TERMS TO KNOW
COPAYMENT (COPAY) – A fixed-dollar amount you will pay out of pocket for a doctor office visit or prescription
Ex: Your plan may require a $20 copay for a doctor visit and a $10 copay to have a prescription filled.
COINSURANCE – The percentage of the medical bill you are required to pay for a medical service after meeting the deductible
Ex: If your plan’s deductible is $100 a year with 10% coinsurance, you will
pay the first $100 in medical expenses out of pocket. After meeting the deductible, you will be responsible for 10% of any new charges.
COVERED EXPENSES – Medical services that are eligible for payment under your plan
DEDUCTIBLE – The amount you pay out of pocket for medical services each calendar year before the plan shares in the cost. This applies to services with coinsurance.
Ex: You have an outpatient medical procedure that costs $2,000. You are responsible for first paying the $100 deductible; then you’ll pay 10% of the remaining balance, or $190. The next time you have medical services, you will only pay the coinsurance, since your deductible is paid for the rest of the calendar year.
FULLY INSURED PLANS – An insurance plan purchased by the employer from an insurance company in which the employer is responsible for paying a monthly premium, and the health plan carries the risk for the cost of claims. Marvell’s Kaiser HMO plan, life insurance and AD&D plans are fully insured.
OUT-OF-POCKET MAXIMUM (OOP) – The most you pay in a calendar year for covered expenses. Your deductible, copays and coinsurance count toward your out-of-pocket maximum. Once you meet the OOP maximum, the plan will pay 100% of covered expenses for the rest of the calendar year. Separate OOPs are in place for the prescription drug benefit and the medical plan (Anthem EPO and PPO).
SPECIALIST – A physician who is not a general practitioner, internist, family practitioner, pediatrician, gynecologist or obstetrician.
SELF-INSURED PLANS – A health plan in which the employer collects premiums from enrollees and takes on the responsibility of paying for all the covered enrollees' medical claims. Marvell is self-insured for the Anthem PPO and EPO plans, dental plan and vision plan. Every time you go to the doctor, Marvell pays the full cost of the claim. Marvell also pays Anthem an annual fee to use its network, billing services and customer service and to take advantage of its negotiated rates.
USUAL, CUSTOMARY, REASONABLE (UCR) – This is the amount paid for a medical service based on what providers in the geographic area typically charge for a similar medical service. This applies to out-of-network expenses under the Anthem PPO, Delta Dental PPO and VSP plans. Anthem, Delta Dental and VSP do not pay for the cost of services that exceed the UCR level. Your expenses above UCR do not apply toward the out-of-pocket maximum.
EVIDENCE OF INSURABILITY (EOI) – An assessment of your current and past health conditions that determines your eligibility for insurance.
GUARANTEED ISSUE (GI) – A base amount of insurance provided by Lincoln Financial Group without having to complete an EOI.