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Plan

A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

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Physician Services

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

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Payment Frequency

You can choose how often you would like to pay your insurance premiums. If you choose “monthly,” your premium payments will be due every month.

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Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count …

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Out-of-Pocket Costs

An out-of-pocket expense is any cost or fee for medical services paid by the patient such as copayment or coinsurance. Out-of-pocket expenses will not be reimbursed by the insurance plan.

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Out-of-network Copayment

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

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Out-of-network Coinsurance

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

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Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your …

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Network

The list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that hasn’t contracted with the plan is called an “out-of-network provider.”

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Navigators

Navigators deliver in-person outreach, education, and enrollment in both qualified health plans and public insurance options. Consumers can get one-on-one assistance from our statewide network of navigators and assisters.

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