Insurance Jargon 101

Building generational health by decoding insurance jargon!

What is the number one thing that most people want to know about healthcare services? The cost.

This brief read explains common insurance terms that help you make healthcare decisions and understand your coverage when you need services.

Open/switch enrollment is October 1-16. The APS benefits vendors will be available to answer questions during the Employee Wellness Fair on Wednesday, Oct. 7, and Thursday, Oct. 8, from 2:30-6:00 p.m. Check the Employee Wellness calendar for the event schedule.

What is a premium?

Your premium is the amount you pay for your medical, dental, and/or vision health insurance each month. At APS, we deduct this from your paycheck twice a month. When you enroll in an APS medical plan, you are also covered under the prescription/pharmacy benefits provider, Evernorth/Express Scripts.

What is Copayment?

Or copay, for short, is the amount you pay as your share of the cost at the time of service. This can be for a primary care/doctor visit or other specialty visits like orthopedics, chiropractic/physical therapy, Urgent Care, or the ER. You also have copays on some prescription drugs. Generic medication options will cost you less than brand drugs.

Urgent care and Emergency Room (ER) copays are higher.

Typically, preventive services like vaccinations, annual exams, mammograms, colonoscopies, and mental/behavioral health services listed in your 2027 comparison grids have no copay as long as you use an in-network doctor or medical facility. There is no out-of-network coverage on either medical plan; you will be responsible for paying the total cost if you choose to use an out-of-network doctor or medical facility.

What does deductible mean?

This is the amount you owe for covered health services before your health insurance plan begins to pay. Once you reach your deductible, coinsurance will start.

What is coinsurance?

Your share of the cost of covered health care and prescription drug services once your deductible has been met. This is usually calculated as a percentage of the allowed amount for the service. For example, if you have a covered medical expense from an in-network provider that is $100 and your coinsurance is 20%, then you pay $20, and your employer plan pays $80. With out-of-network providers, you pay the total cost, and it will not count toward your out-of-pocket limit/maximum.

This is an important point to keep in mind when using in-network versus out-of-network doctors, hospitals, and other medical facilities. Depending on the health plan you choose, there may be different access to doctors and medical services available to you. Out-of-network provider or service expenses are not covered under the APS medical benefits plans. (Remember: out-of-state is not always out-of-network. The BCBS medical plan uses the BCBS PPO network of in-network providers and services, a nationwide list that includes out-of-state but in-network options. The Presbyterian Health Plan utilizes the Aetna network to allow for out-of-state but in-network options, but ONLY for enrolled dependents ages 17-26 who live outside New Mexico; the Aetna network is not available to any other members on the Presbyterian plan and is not available to any members who live in New Mexico, regardless of their age.)

What is the out-of-pocket maximum or limit?

This is a cap, or limit, on the amount of money you have to pay for covered health care services, and prescription drug services (separate limit applies), in a calendar year. If you meet that limit, your health plan will pay 100% of all covered health care costs for the rest of the calendar year. Some health insurance plans call this an out-of-pocket limit.

If you have questions about your benefits, please email employee.benefits@aps.edu or submit questions online.

*Sources: healthcare.gov, APS Benefits Enrollment Guide