Glossary of eligibility and benefits terms

coinsurance
A percentage of the charges that you pay for covered services. For example, a 20 percent coinsurance for a $200 procedure means you pay just $40.

copay
The set amount you pay for covered services — for example, a $10 copay for an office visit.

deductible
The amount you pay for covered services each year before Kaiser Permanente starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.

Evidence of Coverage (EOC)
A detailed description of benefits, cost sharing, and other terms and conditions of coverage for your plan type. If you get your health coverage through your job, then your EOC can be obtained from your employer. If you have an individual plan, then the booklet is mailed to you when you join the plan. If you do not have your EOC, check with your employer or contact Member Services.

group
The name of the entity through which you are enrolled such as an employer "group" or an individual plan.

in network provider
A participating, contracted doctor, hospital, pharmacy, or other provider offering covered health services within Kaiser Permanente.

level
If your plan’s benefits differ according to which providers you see, the “level” shows your copayment or coinsurance associated with each provider. Benefits can also differ by level depending on the amount of services you use.

limit
The maximum number of visits or the maximum dollar amount allowed for the covered service.

health plan
Your health plan gives you a wide range of care and support to help you stay healthy.

Maximum Out-of-Pocket (MOOP) expenses
The most you’ll pay for covered services each year. For a small number of services, you may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum.

out-of-network provider
A doctor, hospital, pharmacy, or other provider that has not contracted with Kaiser Permanente to provide health services to its members at negotiated rates.

payor
The insurance program or company that pays for the member’s covered services.

referral required
The term used when a member must obtain a referral for a service. Referrals can be internal (from one provider in the network to another provider within the network) or external (from a provider in the network to a provider outside of the network).

start date
This is when your health plan starts or renews.

subscriber
The person who’s responsible for paying your health plan premiums — usually the same person who bought your plan.

type of service
Benefits and services covered under your plan, such as office visits, Emergency Department care, and prescription drugs.