Some Important Terms

"Coinsurance" means the percentage of eligible costs that you pay for services, after the deductible has been met. No coinsurance is required for KPOS Program referred care. Coinsurance will apply to self-referred benefits. For self-referred care, your coinsurance amount is generally 20% of the reasonable and customary amount. Remember you will also be responsible for the difference between the reasonable and customary amount and the amount billed by the provider, if you use a non-participating provider. “Co-payment”is the flat dollar amount you pay for some medical services when care is received from or referred by your PCP (referred care). Co-payments will not apply toward your calendar year deductible or your annual out-of-pocket limits for self-referred care. “Deductible” means the portion of your covered expenses that you pay before your medical plan begins to pay certain benefits.No deductible is required for KPOS Program referred care. A deductible will apply each calendar year to self-referred benefits. “Primary Care Physician (PCP)” means a doctor who acts as a guide to your total health care by providing, coordinating and referring you (in writing) for all medical care. If you enroll in the KPOS Program, you must choose a PCP at enrollment. “Reasonable and customary” means the amount that is the usual or customary charge for the service or supply as determined by the KPOS Program. The chosen standard is an amount which is most often charged by other providers for similar services or supplies within the same geographic area where the service or supply is provided and who have training, experience and professional standing comparable to those of the actual provider of the service or supply. If no comparison exists, the KPOS Program determines what is reasonable by the severity and/or complexity of the patient’s condition for which the service or supply is provided. “Referred” means you access medical services through or referred by your PCP. You pay less out of your own pocket when you use referred care, and claim forms are not required for most services. If you cannot arrange for direct billing when receiving emergency or urgent care, you will need to pay the charges and then seek reimbursement. You may send Keystone a letter that explains the reason care was needed together with an itemized bill. “Self-Referred” means you choose to use non-participating providers, or a participating provider who is not referred by your PCP. You may pay more out of your own pocket and you must file claim forms.