Member resources
Check my benefits.
Log in to see what your own plan covers and where you stand for the year. If you are still decoding a benefits summary, this page explains what each number means and what to check before an appointment.
The vocabulary
Six terms decide what you pay.
These definitions are the same across plans and insurers. The amounts attached to them are what differ, and those live in your own plan documents.
- Premium
- What you pay every month to keep the plan, whether or not you use any care. It does not count toward your deductible or your out-of-pocket maximum.
- Deductible
- The amount you pay for covered services before the plan starts paying its share. Preventive care from an in-network provider is covered before the deductible, and many plans also cover some office visits and generic drugs first.
- Copay
- A flat amount for a specific service, for example a set dollar amount for a primary care visit. Copays are predictable and are usually collected at the time of the visit.
- Coinsurance
- A percentage of the cost you pay after the deductible is met. If your coinsurance is 20 percent, the plan pays the other 80 percent of the allowed amount for that service.
- Out-of-pocket maximum
- The most you pay in a plan year for covered in-network care. Once you reach it, the plan pays 100 percent of covered in-network services for the rest of the year. Premiums and non-covered services do not count toward it.
- Allowed amount
- The price your plan has negotiated for a service. Your share is calculated from this number, not from the provider list price, which is why an in-network bill is often far lower than the amount first charged.
Reading a benefits summary
Three passes through the document.
Work through it in this order and you will know what a visit is likely to cost before you book it.
01
Start with the Summary of Benefits and Coverage.
Every plan has to give you one, in the same format, so you can compare plans side by side. The first page carries your deductible, out-of-pocket maximum, and whether there is a separate deductible for prescriptions. The back has coverage examples that show how the plan would handle a typical birth or a diabetes year.
02
Check the network column, not just the price.
Benefit tables list an in-network and an out-of-network amount for the same service. The out-of-network column is where surprise costs come from, and on many plans out-of-network care has its own, much higher deductible or is not covered at all except in an emergency.
03
Look for prior authorization and the drug list.
Some services need approval before you get them, and some drugs are only covered at certain tiers or after trying an alternative first. Both are listed in your plan documents, and skipping the approval step is a common reason a claim gets denied for care that would otherwise have been covered.
Before an appointment
A short checklist worth running.
Five minutes here prevents most of the bills people are surprised by later.
- Confirm the provider is in network for your specific plan, not just that the office accepts the insurer
- Ask for the procedure code if a test or procedure is planned, then check how your plan covers that code
- Check whether the service needs prior authorization, and who is responsible for requesting it
- See where you stand against your deductible and out-of-pocket maximum for the year so far
- For a hospital stay, confirm the anesthesiologist, radiologist, and lab are in network as well as the facility
- Ask about a good faith estimate if you are paying without insurance or the service is not covered
Good to know
Benefits questions.
Where do I find my exact benefits?
Why did I still get a bill after paying a copay?
What counts toward my deductible?
Do my benefits reset every year?
What if a covered service is denied?
Comparing coverage
Want benefits that fit the way you use care?
Enter your ZIP code to compare deductibles, copays, and networks on the plans available where you live.