Simplifying Healthcare Coverage—Vocabulary You Should Know

1. Deductible
Deductibles are the amount a member needs to pay out of their own pocket before a plan begins to pay for covered medical services. 
Deductible amounts are generally accumulated over the benefit year. The deductible amount is described by documents when a subscriber enrolls in the plan.
Once the deductible is reached, the member may still be responsible for other cost-sharing medical expenses, including coinsurance, copays, and more. o, remember to drink lots of water! 
2. Network, National Network, and Out-of-Network providers
SmartHealth has tiers of healthcare providers.
Ascension Network (Tier 1) providers are the clinicians, doctors, hospitals, nurses, and other medical personnel and health services contracted with SmartHealth to meet members’ medical needs. Ascension Network (Tier 1) providers offer better coordination of care for members. Ascension Network (Tier 1) providers and medical services will cost members less than National Network (Tier 2) and Out-of-Network (Tier 3) providers. 
National Network (Tier 2) providers are available to SmartHealth members through the Blue Cross Blue Shield Network. Their services cost members more than Ascension Network (Tier 1) providers, and they offer limited coordination of care for SmartHealth members.
An Out-of-Network (Tier 3) provider is a provider who does not have a contract with the SmartHealth healthcare plan to provide services. Out-of-Network (Tier 3) providers will cost members more than any other healthcare provider option.
3. Self-funded
A self-funded plan is a type of healthcare plan funding. The employer provides health benefits to their employees using their funds instead of paying for health insurance. Although employers often use a third-party administrator (TPA) to process claims, the responsibility of claim payments falls on the employer. SmartHealth is a self-funded healthcare plan.
4. Out-of-pocket costs
Out-of-pocket costs are any costs for covered services that are the responsibility of the member. These include deductibles, coinsurances, and copays. The health plan generally sets an out-of-pocket limit for each benefit year. At this point, a plan begins to pay 100 percent of the allowed amount for covered services.
5. Allowed amount
The allowed amount is the maximum amount your plan will pay for a covered service. Network providers have agreed to bill for the allowed amount. Suppose an Out-of-Network provider charges an amount greater than the allowed amount. In that case, you may be responsible for the balance. This is called balance billing.

With these terms in your lexicon, you are on your way to being a healthcare expert. 

If you want to learn more healthcare terms or more about your SmartHealth coverage, you can find more answers on’s Information Center