Understanding your Health Plan Payment Summary

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Understanding your Health Plan Payment Summary

04/12/2022

When you get care or send us a claim for services you got as a plan member, we send you a Health Plan Payment Summary. It is also sometimes called an Explanation of Benefits (EOB).

The Summary shows what was billed, what we paid, and what you have to pay, if anything. It is not a bill. Match this information to any health care bill you get to compare charges.

Definition

Amount billed: The amount billed by the health care professional or facility (physician, hospital, etc.) for services that you or your covered dependents received.

Amount not covered: Any part of the amount billed that was not eligible for payment based on the rules of your plan. For example, if the charges were for services or products that are not covered by your plan, if the health care professional or facility billed us more than once for the same service, or for charges submitted that are above the maximum amount your plan covers for out-of-network care. Some of these charges will not be your responsibility, but you may have to pay for others.

Coinsurance: After you pay your deductible, you and your plan may share the cost of your care. The percentage you pay is called coinsurance.

Copay: The flat fee you pay for certain services such as doctor visits or prescriptions.

Deductible: The amount you have to pay before the plan starts to pay for certain services.

EmblemHealth discount: The amount you save by using a health care professional or facility (doctor, hospital, etc.) that is part of an EmblemHealth network. EmblemHealth has contracts with its in-network doctors, hospitals, and other facilities to help you save money.

In-network: A group of health care professionals and facilities (doctors, hospitals, labs, etc.) that contract with EmblemHealth. They provide covered products and services to members. Using in-network services usually means you will pay a lot less.

Maximum out-of-pocket: The most you will pay for covered health services from in-network providers in any year. After that, we’ll pay for all your covered in-network health care.

Other insurance: You may have other insurance that is responsible to pay for a portion of this claim. The amount they owe or have paid is included on the claim detail page.

Out-of-network: Health care professionals and facilities (doctors, hospitals, labs, etc.) that do not contract with EmblemHealth. Depending on your plan, you may be able to use out-of-network services, but you may pay more for the same services, and you might have to file a separate claim for us to pay you back.

What EmblemHealth paid: The portion of the amount billed that was paid by your health care plan.

What you owe or may have already paid: The portion of the billed amount that you have to pay. This amount might include your deductible, coinsurance, copay, any amount over the maximum reimbursable charge, or charges for products or services not covered by your plan. Remember that you may have already paid some of this amount. For example, your doctor may have collected your copay at the time of the visit.

Unless you decide to go paperless, your EOB will be mailed to you. This information is also available under Claims when you sign in to your myEmblemHealth account.