2024 Archdiocese of Atlanta / Lay Employee Quick Guide - Flipbook - Page 27
Glossary of Terms
Ambulatory Surgery
Surgery performed at an ambulatory surgical facility (a licensed public or private facility), which does not provide services or
accommodations for a patient to stay overnight.
Co-payment (Co-Pay)
An amount of money that a participant is required to pay each time he or she visits a healthcare provider, or fills a prescription.
Co-Insurance
The percentage of eligible expenses the Plan and the Covered Person are required to pay once the deductible has been satisfied.
Deductible
The annual out-of-pocket amount that a plan participant is responsible for paying before the health plan covers his or her medical
costs. Until a person meets the annual deductible, he or she pays the full cost of healthcare services received, unless the service is not
subject to the annual deductible as stated in the benefit schedule.
MERITAIN.com
Your online benefits portal and connection to your plan. Here you can order prescriptions, find health care providers, research
health topics and get answers to your questions about healthcare.
Out of Pocket Maximum
An out of pocket maximum is the maximum amount you and/or your family members will pay for eligible expenses incurred during
a calendar year before the percentage payable under the Plan increases to 100%
Point of Service Network (POS)
Specific network of physicians and other care providers a third party organization has negotiated special, low rates for quality
healthcare services. Providers who belong to a POS are called participating or in-network providers.
Preferred Providers Organization (PPO)
Organization that negotiates special, low rates for quality healthcare services provided by physicians and other care providers that
are within the PPO’s network. Providers who belong to a PPO are called participating or in-network providers.
Usual and Customary Charge
Your plan reimburses charges from non-participating or out-of-network providers that are equal to or less than usual and customary
charges. Usual and customary charges are amounts most frequently charged for the same service:
• In the same geographic area; and
• By other providers in the same or similar medical area.
The fees charged by non-participating providers may exceed the usual and customary charges recognized by your plan. In such
cases, Meritain Health will process an amount equal to the usual and customary charge for the healthcare service you received, and
you will be reimbursed for a portion of that amount according to your plan’s out-of-network provider’s fee (sometimes referred to
as “balance billing”). Your payment of this difference does not apply towards your deductible or out-of-pocket maximum.
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