Terms to know

When a provider bills you for the balance remaining on the bill that your plan doesn’t cover. This amount is the difference between the actual billed amount and the allowed amount.

For example, if the provider’s charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider (preferred provider) may not balance bill you for covered services.

A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service (sometimes called “copay”). The amount will vary by the type of covered health care service and health plan.

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. Many times coinsurance will apply after you have satisfied your deductible.

A fixed dollar amount that you must pay out-of-pocket each policy year (calendar year for Klaviyo medical plans) for covered health care services before your plan begins to pay. Depending on the plan you are on there are two different types of deductibles, embedded and non-embedded (also known as aggregate). The deductible resets on January 1 each year.

Klaviyo BCBSMA Medical Plans

PPO and HMO Plan (Embedded Deductible)

The deductible would apply to services such as in-patient hospitalization, outpatient surgery, diagnostic testing, etc. Once you have satisfied your individual deductible, the plan typically pays for these services. Co-pays do not apply to your deductible.

HDHP Saver Plan – HSA Eligible (Non-Embedded Deductible)

The deductible would apply to any service covered under the plan, including prescriptions, except for preventive services. Once you have satisfied your deductible most services will be covered at 100%, and prescription will apply a copay.

Embedded

If on a plan with covered dependents, each person will be capped at the individual deductible amount. Once a person on the plan reaches their individual deductible level that one person will no longer have deductible responsibility until the deductible resets. At the same time, everyone enrolled on the plan will be working towards the total family deductible cap. Once the family deductible is met, the deductible is considered met for everyone on the plan whether they have met their individual deductible cap.

Non-Embedded

If covering dependents on the plan, everyone works towards the family deductible cap, and no one person is capped at the individual deductible level. Once the family deductible cap is met, then services will be covered. If on an individual plan, you will only be responsible up to the individual deductible cap.

The health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the insurance paid for and what portion of the costs you are responsible for.

A list of drugs your plan covers. A formulary may include how much your share of the cost is for each drug. Your plan may put drugs in different cost-sharing levels or tiers. For example, a formulary may include generic drug and brand name drug tiers and different cost- sharing amounts will apply to each tier.

A provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan. You will pay less if you see a provider in the network. Also called “preferred provider” or “participating provider.”

A provider who doesn’t have a contract with your plan to provide services. If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-participating” instead of “out- of-network provider.”

The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit, the plan will usually pay 100% of the allowed amount in-network. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover.