A Deductible is a cost sharing feature in which the Member pays a fixed dollar amount prior to being eligible for payment of some or all covered services.

Hospital, Medical and other health care services and supplies provided to a Member for which benefits are paid under a Contract.

A cost sharing feature in which the Member pays a fixed percentage of the cost of medical care after the deductible has been satisfied.

A cost sharing feature where the Member pays a fixed dollar amount for the
cost of medical care.

The maximum amount that a Member will have to pay for covered services under the Health Benefit Plan. The maximum is typically the sum of all deductibles and coinsurance amounts paid by the Member.

A form that may be sent to the Member after a claim has been processed by The Health Benefit Plan. The form explains the action taken on that claim.

A type of health benefit plan designed to give Members incentives to use health care providers designated as Network Providers, but that also provide reduced benefits for covered services received from Non-Network Providers.

The doctors, clinics, hospitals and other medical providers with whom the carrier contracts to provide health care to its Members.

A physician or hospital in the Network.

A medical provider who has not contracted with a carrier to participate in the Network. Also known as a non-participating provider or out of network provider.

A person (e.g. a spouse or child) other than the subscriber who is covered Under the Subscriber’s Contract. Also called a “Member”.

For newborns, an enrollment application must be received with in 30 days.

The enrollment application must be received within 30 days of the date of the qualifying event.

Dependent cancellations can be submitted at any time.