What is a lifetime maximum
A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Some plans have different lifetime maximums for different services, or for in-network and out-of-network services and supplies. Once you reach the lifetime maximum, you pay all expenses over that amount
What are covered services
Covered services are services covered by the plan. No vision plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services. Also, note that some medical procedures associated with the eyes may be covered by another health care plan, in which case they are not eligible for coverage under this vision plan. See your plan materials for a complete list
What is an "allowable amount" (also referred to as "U&C amount" or "R&C amount")
With a plan designed to cover a percentage of eligible expenses, you need to know about the allowable, U&C or R&C amount. Plans use these different terms, but they mean the same thing. This is the amount usually charged for a given service by most providers in your area. This amount is determined by your vision care plan. If your provider charges you more than this amount, you will not only be responsible for any deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept may not apply to out-of-network care, because in-network providers have agreed to negotiated fees that are by definition allowable amounts. For example, suppose you receive a service for which the "U&C amount" is $100 but your provider charges you $110. The vision care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C)
What is a copayment
If your plan is designed so you pay a fixed amount at the time you receive services, that amount is called your copayment
What is coinsurance
When you and the plan each pay a percentage of eligible expenses, the percentage you pay is called your coinsurance. With coinsurance, after you satisfy any deductible, the plan will reimburse you for the plan’s share of your eligible expenses and you will pay the balance
Are there expenses that don't count toward my deductible
Yes. Some expenses will not count toward your deductible. For example, amounts your care provider charges above the plan's allowable amount for a given service or supply will not count toward your deductible. Neither will services or supplies that aren’t covered by the plan at all
What is a deductible
A deductible is the part of your eligible expenses you must pay each year before the plan begins to pay benefits. For example, if your annual deductible is $50 and the cost of your first eligible expense for the year is $200, you are responsible for the first $50 and then the plan covers the appropriate portion of the remaining $150
When do I need to file a claim form
You generally don't need to file a claim form when you see a network provider. In most cases, if you go out-of-network for care, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for the plan’s part of the bill, after you've met any deductible. To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another plan, be sure to include a copy with your claim form. Depending on the type of care you need, you may want to call both your vision plan and any medical plan if you need care while traveling
How does the vision plan work when I go out-of-network
When you go out-of-network, you may use any covered vision provider you choose. However, your cost will generally be higher and you will have certain added responsibilities. For example
• You may need to pay a deductible before the plan begins to pay benefits. Or, your deductible may be higher for out-of-network expenses than for in-network expenses.
• After you satisfy any deductible, the plan will reimburse you for the plan’s share of your eligible expenses and you will pay the balance.
• You must complete claim forms and file claims to receive payment of benefits.
• The plan will not cover any charges above the allowable amount.
What are the advantages of seeing a network provider
There may be several advantages when you go in-network
• If your plan features a deductible (the flat amount of eligible expenses you pay before the plan begins to pay benefits), you may not need to pay a deductible for in-network services and supplies, or your deductible may be lower in-network than for out-of-network expenses.
• Your provider may submit claim forms for you.
• Your provider agrees to accept negotiated fees for certain services, which are generally lower than standard fees.
• Your plan may provide some services in-network that are not available out-of-network.
What is the vision plan and how does it work
The vision plan encourages you and eligible family members to take care of your eyesight. It helps cover preventive services, such as eye exams, as well as the cost of certain qualified treatments
The plan works for you in two ways:
• When you use a network provider, this is considered "in-network."
• When you go to a non-network provider, this is "out-of-network."
You choose whether to go in-network or out-of-network each time you need care. However, if you choose to go out-of-network, you will generally pay a larger share of the cost.
