Glossary of Insurance Terms

Usual, Customary and Reasonable (UCR) Fee

  • UCR is the amount established by insurance companies to determine the maximum amount they will consider eligible for reimbursement.
  • Your provider may charge substantially more than the UCR and you will be responsible for the difference.

Co-pay

  • A co-pay is a set fee that you will pay to providers at the time of service.
  • Co-pays are applied to emergency department visits, hospital admissions, office visits, etc.
  • The cost is usually minimal.
  • You should be aware of the co-pay amount prior to receiving services.
  • You can call the 800 number on your insurance card to inquire about your specific co-pay responsibility, or it may be printed on the back of your insurance card.

Calendar Year Deductible

  • Deductibles are provisions that require you to accumulate a specific amount of medical bills before benefits are provided.
  • For example, if your policy contains a $500 deductible, you must accumulate and pay $500 out-of-pocket before the insurance carrier will pay benefits.
  • Once you have met your deductible, the insurance company usually pays a percentage of the bill.
  • You are responsible for the unpaid percentage.
  • Deductibles are yearly, usually starting in January.

Co-Insurance

  • Co-insurance is a form of cost sharing.
  • After your deductible has been met, the insurance company will begin paying a percentage of the bills.
  • The remaining amount, known as co-insurance, is the portion that you must pay; it represents the percentage of the UCR amount you pay.

Difference Between “In Network” and “Out-of-Network” Providers?

  • Many managed care plans pay different amounts for health care services, depending on whether a provider is considered in network or out-of-network.
  • These companies will pay a higher percentage of the costs for an in network hospital or physician.
  • If you choose to receive care from a provider that is out-of-network, your insurer will pay a lower percentage of the costs and you may be responsible for a higher amount of out-of-pocket payment.