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” & “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.