Glossary of Insurance Terms
Below is a list of common terms members might encounter while utilizing their EHP benefits. Refer to the Explanation of Benefits for more information.
Are you looking for specific information about what’s covered by your plan? Use the EHP Benefits Explorer.
|In-Network Provider||A provider or facility who has contracted with EHP to provide services is considered “in-network.”|
|Out-of-Network Provider||A provider or facility who is not contracted with EHP to provide services is considered “out-of-network.”|
|Hopkins Preferred Provider||A provider or facility in the EHP network that is directly affiliated with Johns Hopkins. Access our Provider Directory.
Hopkins Preferred Providers include:
FACILITIES: The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, All Children’s Hospital (St. Petersburg, FL), and Mt. Washington Pediatric Hospital.
PROVIDERS: Johns Hopkins Clinical Practice Association/School of Medicine, Johns Hopkins Community Physicians, and Johns Hopkins Part-Time Faculty.
|MultiPlan||MultiPlan is an extended provider network consisting of over 600,000 providers nationwide. Multiplan’s PHCS Healthy Directions Network is available for services rendered outside of the state of Maryland (Multiplan is available in the state of Maryland for Suburban members) and is considered the same as EHP in-network benefits. To find a MultiPlan PHCS Healthy Directions network provider outside the state of Maryland, visit www.multiplan.com.|
|In-Network PCP||A primary care provider is an in-network internal medicine or family practice provider or pediatrician regardless of whether he or she is a Hopkins Preferred Provider.|
|Allowed Amount||The maximum amount EHP will allow for the service(s) the patient received. Any copay and/or coinsurance amounts that the member is responsible for paying are deducted from the allowed charge.|
|Allowed Benefit (AB)||For any service or supply, the lesser of (1) the provider’s actual charge or (2) the amount that would be allowed by Medicare, increased by a percentage determined by Johns Hopkins Employer Health Programs, not to exceed 150% of the amount that would be allowed by Medicare. If Medicare does not provide an allowance for a service or supply, then Allowed Benefit means the prevailing, reasonable fee paid to similar providers for the same service or supply in the same geographic area, as determined by Johns Hopkins Employer Health Programs. EHP Network providers (Option 1) will not charge more than the Allowed Benefit, but Out-of-Network providers (Option 2) can charge more and you are responsible for charges above the Allowed Benefit|
|Deductible||The amount that the member must pay within the plan year, before EHP begins to pay benefits. The patient’s Schedule of Benefits or Summary Plan Description (SPD) will advise if he/she has a deductible.|
|Copay||A flat fee the member must pay to the Provider at the time of service. Usually applicable to an office visit or prescription.|
|Coinsurance||Percentage of medical costs that the member shares with EHP. The member’s Schedule of Benefits or SPD will advise if he/she has a copay or coinsurance.|
|Out of Pocket (OOP) Maximum||
The maximum amount the member pays for medical expenses during a plan year. After the member has paid the annual out-of-pocket limit, the Plan pays any additional covered expenses at 100% for the remainder of that plan year. The out-of-pocket maximum includes the deductible, coinsurance, and co-pays; but does not include penalties; prescription drug co-pays and expenses; amounts in excess of the Reasonable and Customary charge; amounts in excess of Plan maximums; or any charges for services which are not covered.
*For Broadway Services Inc.: The maximum amount the member pays for medical expenses during a plan year. After the member has paid the annual out-of-pocket limit, the Plan pays any additional covered expenses at 100% for the remainder of that plan year. The regular out-of-pocket maximum includes the deductible and coinsurance, but does not include copays; penalties; amounts in excess of the Reasonable and Customary Charge (R&C); amounts in excess of Plan maximums; or any charges for services which are not covered.
|Reasonable and Customary (R&C) Charge||The usual fee charged by similar providers for the same services or supplies in the same geographic area. Johns Hopkins Employer Health Programs (EHP) determines what is a Reasonable and Customary Charge. Non-network providers can charge more. For more information, look under the heading “Payment Terms You Should Know” in your Summary Plan Description (SPD). You are responsible for any charges above R&C.|
|Pre-Authorization||Required medical review of requested services before they are rendered.|
|Pre-Determination/Pre-Treatment Review||Designed to give members and their dentist a better understanding of the benefits payable under the Dental Plan before services are provided. A pre-treatment review is recommended if dental services are expected to cost $500 or more, or for certain treatments including bone surgery, bridges, crowns, inlays (post and core) and onlays, and veneers. For any of these treatments, we recommend that the member’s dentist provide a proposed course of treatment and a pre-treatment estimate.|