Here are some common terms that can help you understand your deductible plan.
A plan that has 1 deductible and 1 out of pocket maximum for everyone in the family. Once you reach your family deductible, everyone will start paying less than the full charges for covered services - just a copay or coninsurance for the rest of the year. See your Evidence of Coverage for your plan details.
A percentage of the charges that you pay for covered services. For example, a 20 percent coinsurance on a $200 procedure means you pay just $40.
The set amount you pay for covered services - for example, a $10 copay for an office visit. For example, a $10 office visit copay means you'll pay $10 for each office visit.
The amount you pay for covered services each year before Kaiser Permanente starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible. Until you reach the deductible, you'll pay the full charges for most services.
A family plan with 2 kinds of deductible and out-of-pocket maximums - 1 for each individual and 1 for the whole family. When you reach your individual deductible, you'll start paying less than the full charges for covered services - just a copay or coinsurance for the rest of the year. It works the same way for each member of your family, until your family deductible is met. When you reach the family deductible, everyone in your family will pay less for covered services.
A document that shows detailed information about your benefits and coverage. Your employer's human resources department should be able to provide you with a copy. If you have a direct-pay plan, the EOC is included with your plan welcome materials.
A summary of services received, including dates received and the provider's name. An EOB is not a bill, but it can help you keep track of your health care expenses. There may be times when you receive an EOB rather than a Summary of Accumulation (SOA) — for example, if your employer's plan is self-funded or you received emergency care from a non-Kaiser Permanente provider.
An account offered by your employer. It lets you set aside money to pay for care. You won't pay taxes on the money you put in your account. You can use your FSA to pay for qualified medical expenses, which are described in IRS Publication 502, Medical and Dental Expenses, available at irs.gov publications.
An account funded by your employer that gives you money to pay for care. Your employer sets up an account and puts money into it. Because the money isn't part of your wages, you won't pay taxes on it. You can use this money to help pay your health care costs. For more information on qualified medical expenses, refer to IRS Publication 502, Medical and Dental Expenses, available at irs.gov publications.
An account you can set up and put money into. You won't pay federal taxes on this money, and you can use it anytime to pay for care. Your account may earn interest, and you can take your money with you if you change jobs or retire. You can use your HSA to pay for qualified medical expenses, which are described in IRS Publication 502, Medical and Dental Expenses, available at irs.gov publications.
If you have symptoms of a condition, this kind of service can help figure out what the condition is or help treat it. There is little or no cost for most preventive care services, but you'll have to pay more if you have any non-preventive services.
The most you'll pay for covered services each year. For a small number of services, you may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum.After you reach your out-of-pocket maximum, we'll provide most covered services at no cost to you for the rest of the year.
What you pay when you come in for care. This may only cover part of what you owe for your visit. If so, you'll get a bill for the difference later.
The amount you pay for your health plan coverage, usually each month.
Services you get when you're healthy so you can stay that way. These services can help you find problems before they get serious, so you can deal with them as soon as possible.
Medical costs that you can pay with money from your HRA, HSA, or FSA. For a list of qualified medical expenses, download a copy of IRS Publication 502, Medical and Dental Expenses at irs.gov/publications.
If you have an HRA and your employer offers the rollover option, you can use funds left over from one year to pay for qualified medical expenses the next year, as long as you’re still a member of the plan. How funds roll over — including how much can roll over from year to year — will depend on your plan details.
This is how you prove expenses were eligible to be paid with money from your HRA, HSA, or FSA. Be sure to keep your bills, receipts and Summary of Accumulations or Explanation of Benefits. You may need them to validate your expenses. Check with your HRA or FSA administrator for specific requirements.
A statement that tracks the care you've received and how close you are to reaching your deductible and out-of-pocket maximum. Your SOA is not a bill, but it can help you keep track of whether you’ve met your deductible or out-of-pocket maximum for the year.
*The tax references on this website relate to federal income tax only. Consult with your financial or tax adviser for information about state income tax laws. Federal and state tax laws and regulations are subject to change. If tax, investment, or legal advice is required, seek the services of a qualified professional.