Learn the lingo

This is your guide to some common terms you’ll see and hear that are related to your coverage. Review your plan’s Benefit Handbook for the definitions that apply to your specific policy.

Activity Summary

An Activity Summary, also known as an explanation of benefits or EOB, is a monthly summary that lists the services you received, the amount the provider charged, and the amount Harvard Pilgrim paid or denied. The Activity Summary is not a bill, but it will tell you if you owe your provider money. A new Activity Summary will be posted each month to your online account. We will also mail you an Activity Summary when you are responsible for a deductible, coinsurance or an amount not covered by your plan.

Allowed amount

Generally, this is the maximum amount that Harvard Pilgrim will pay a provider for covered services. If you have a POS or a PPO plan and you see a non-participating provider, it’s possible that the provider will charge more than the allowed amount for the care you received. In that case, you would be responsible for paying the difference between the provider’s charges and Harvard Pilgrim’s allowed amount. This is sometimes called “balance billing.” 1 

Balance billing

Balance billing is something that can happen when POS and PPO members see non-participating providers for covered services. Non-participating providers sometimes charge more than Harvard Pilgrim’s allowed amount for the care they provide. After Harvard Pilgrim pays the non-participating provider’s claim, you would be responsible for paying any balance on the provider’s bill over and above what Harvard Pilgrim paid. That amount would not count toward your out-of-pocket maximum.1

Claim

A claim is a provider’s request to be paid for your care. When providers send claims to Harvard Pilgrim, we will look at your benefits and figure out who needs to pay the provider and how much. If you need to pay, you will receive a bill from the provider, which you should compare against the Activity Summary you receive from Harvard Pilgrim.

Coinsurance

This is a fixed percentage of costs that you pay for covered services. For example, if you have a plan with coinsurance, you may have to pay 20% of a provider’s bill for your care, while Harvard Pilgrim pays 80%. Coinsurance is usually something you pay after you have paid an annual deductible.

Copayment

This is a flat dollar amount you pay for certain services on your plan. You may have different copayments for different services (e.g., primary care visits, specialist visits and prescription drugs). Copayments are normally due when you have your appointment or when you pick up prescriptions from the pharmacy. Your Plan Benefits page will tell you what your copayments are for different services.

Cost sharing

Cost sharing is what you pay for specific health care services (e.g., office visits, X-rays and prescriptions). Coinsurance, copayments and deductibles are all examples of cost sharing.

Covered

Being covered for something means that it’s part of your benefits package. You still may need to pay copayments, coinsurance or a deductible. If something is “covered in full,” that means there’s no charge to you.

Deductible

This is a set amount of money that you have to pay out of your own pocket for certain services. If you have a $2,000 annual deductible, for example, you will have to pay $2,000 worth of charges before Harvard Pilgrim helps pay. If you receive care for services that fall under the deductible, your provider will send you a bill. If prescription drugs fall under your plan’s deductible, you’ll need to pay for them when you pick them up from the pharmacy. Copayments do not count toward your deductible.

Explanation of benefits

At Harvard Pilgrim, we refer to an explanation of benefits as an Activity Summary. Please see Activity Summary for more information.

Formulary

If your plan includes Harvard Pilgrim prescription drug coverage, your formulary is the list of drugs that are covered under your plan. Different Harvard Pilgrim plans offer different formularies, so your coverage may change if you switch plans. You can see all the drugs covered under your formulary in the drug lookup.

HMO (health maintenance organization)

An HMO is a type of insurance plan that requires you to get your care from a primary care provider (PCP) who belongs to your plan’s provider network. You will need your PCP’s referral for most kinds of specialty care.

HRA (health reimbursement arrangement)

This is an account, set up by an employer, that can help you pay for your plan’s deductible costs.

HSA (health savings account)

This is an account that can help you pay for qualified health care expenses. You need to have a federally qualified high deductible health plan, such as the Best Buy HSA HMO or HSA PPO, to be able to open an HSA. These accounts may be available through employers or through a bank.

In-network

Generally, this describes coverage for care that POS and PPO members receive from participating providers in the Harvard Pilgrim network. In-network coverage typically costs less than out-of-network coverage. In most cases, if you have a POS plan, you need to have a referral from your primary care provider (PCP) to another participating provider in order for in-network cost sharing to apply.

Non-participating providers

These are health professionals and hospitals that do not have contracts with Harvard Pilgrim to care for our members and are therefore not in our network. Harvard Pilgrim will not pay for care that HMO members receive from non-participating providers, except in a medical emergency. POS plan and PPO members can see these providers for covered services, but they usually pay higher cost-sharing amounts. Also, it’s possible that non-participating providers will charge more than Harvard Pilgrim’s allowed amount for the care they provide. In that case, you would be responsible for paying the difference between the provider’s charges and Harvard Pilgrim’s allowed amount.

Out-of-network

Out-of-network coverage applies only to POS and PPO plans. Harvard Pilgrim will cover care that POS and PPO members receive from non-participating providers, but it usually costs more than in-network coverage. In addition, if you have a POS plan, you will — in most cases — have out-of-network coverage when you receive care for covered services from participating providers without your primary care provider’s referral.

Out-of-pocket maximum

This is a limit on the total amount of cost sharing you have to pay annually for covered services. This generally includes copayments, coinsurance and deductibles. After you meet your out-of-pocket maximum, Harvard Pilgrim will pay all additional covered health care costs.

Participating providers

These are health professionals and hospitals that have contracts with Harvard Pilgrim to care for our members and are therefore in our network. Not all Harvard Pilgrim plans have the same participating providers. Be sure to check your plan’s provider directory.

PCP (primary care provider)

This is the medical professional (e.g., doctor, nurse practitioner or physician assistant) you see for routine care and when you are sick. PCPs are usually in specialties such as internal medicine, family practice or pediatrics. If you are covering family members on your policy, everyone can have a different PCP. HMO members need a PCP’s referral for most kinds of specialty care. Likewise, POS plan members need a PCP’s referral to participating providers for in-network coverage.

POS (point-of-service plan)

This is a type of insurance plan that allows you to see participating providers and non-participating providers. Be sure to get your primary care provider’s (PCP’s) referral to participating providers for in-network coverage and lower out-of-pocket costs. You’ll have out-of-network coverage — and higher out-of-pocket costs — when you get covered services a) from participating providers without your PCP’s referral and b) from non-participating providers.

PPO (preferred provider organization)

This is a type of insurance plan that allows you to see participating providers as well as non-participating providers. You have in-network coverage when you receive care for covered services from participating providers and out-of-network coverage when you receive care for covered services from non-participating providers. You do not need a primary care provider, but we encourage you to have one.

Premium

This is the monthly cost of your health insurance coverage.

Provider network

This is the group of health professionals and hospitals that have contracts with Harvard Pilgrim to care for our members. Some of our plans have select or defined provider networks. That means only some of our providers are available to care for members who have that particular plan.

Surprise bill

You might receive a “surprise bill” (or unexpected bill) if: (1) you obtain services from a non-participating provider while you were receiving a service from a participating provider or facility, or (2) you obtain services from a non-participating provider during a service previously approved or authorized by Harvard Pilgrim where you did not knowingly select a non-participating provider.

Tier

Generally, this means “category.” Our prescription drug plans put medications into different tiers with different cost-sharing amounts. Some of our medical plans also put providers into tiers with different cost-sharing amounts.

Disclosures

1 If you have an HMO plan, except in an emergency, there is no coverage for care you receive from non-participating providers.