Basic Health Benefits Terminology

The following sections define benefits and benefit terms to help you better understand your Basic Health medical benefits.

Copay

A set dollar amount you pay when you get specific services. Copays are not subject to a deductible and do not apply toward your deductible, coinsurance, or out-of-pocket maximum.

Deductible

A deductible is the amount you pay before Community Health Plan starts to pay for some covered medical services.

You are responsible for paying the first $250 of some covered medical costs before Community Health Plan pays the 80% coinsurance. The $250 deductible has to be met for each family member enrolled in Basic Health.

For more information about whether there is a deductible for a specific service:

In "Your Basic Health Benefits," see Benefits and Services Not Subject to Deductible and Coinsurance and Benefits and Services Subject to Deductible and Coinsurance.
See the Basic Health Benefit Table.
Call the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.

If you change plans at any time during the year, the amount you have paid toward your deductible for family members covered by Community Health Plan will start over with your new health plan.

Coinsurance

Coinsurance is a percentage you pay for covered medical services after you have paid your annual deductible.

You pay 20% of the cost of medical services that have a coinsurance, up to your out of pocket maximum of $1,500.

For more information about what you pay for medical services:

In "Your Basic Health Benefits," see Benefits and Services Not Subject to Deductible and Coinsurance and Benefits and Services Subject to Deductible and Coinsurance.
See the Basic Health Benefit Table.

Out-of-pocket maximum

The most coinsurance you will have to pay for each year for each covered family member—$1,500 per member per year. Only your coinsurance costs apply toward your out-of-pocket maximum. After you have paid the out-of-pocket maximum, you do not have to pay coinsurance costs for the remainder of the calendar year.

For more information about what you pay for medical services:

In "Your Basic Health Benefits," see Benefits and Services Not Subject to Deductible and Coinsurance and Benefits and Services Subject to Deductible and Coinsurance.
See the Basic Health Benefit Table.

Explanation of Benefits (EOB)

Each time you get medical services, Community Health Plan will send you a detailed explanation.

The EOB explains:

Which procedures and services you got
The allowed amount for each service
How much Community Health Plan pays
How much you are responsible to pay

Your Explanation of Benefits will also track each covered family member's annual deductible and out-of-pocket maximum.

Important Note:
If you change health plans at any time during the year, the amount you have paid toward your deductible and out-of-pocket maximum for family members covered by Community Health Plan starts over with the new plan.