Health Plans 101
Understanding Health Care Expenses
Understanding Your Plan
Most health care plans have cost-sharing that you are responsible for depending on the care you receive. These payments are called out-of-pocket expenses. They fall into the following categories:
Deductible – The amount you must pay for covered health care services before your plan begins to pay. For example, if the deductible is $500, your health plan will not pay anything until you have paid out $500. The deductible may not apply to all services.
Coinsurance – The percentage of costs of a covered health care service for which you are liable for after the deductible has been met. For example, if your health plan pays $100 for an office visit, at a 20% coinsurance rate, you would pay $20.
Copayment (or Copay) – A fixed amount you pay for a covered health care service, usually at the time you receive the service. The amount may vary depending on the type of service you receive.
Usual, Customary, and Reasonable Charge (UCR) – The amount your health plan will pay for a medical service in a geographic area based on what other providers in that area usually charge for the same kind of service. You may be responsible for paying charges that are above the UCR and other out-of-pocket costs.
Understanding Your Explanation of Benefits
An EOB is not a bill, but it contains helpful, important information about your plan benefits and Quartz’s share of your medical expenses.
Your coverage through Quartz pays a substantial portion of your family’s medical expenses. Here’s how it works.
When you go to an in-network doctor, we will receive a bill from your doctor’s office and pay our portion. The portion we pay depends on the health care plan you have in place. Once we’ve reviewed the bill and paid our portion, we’ll send you an Explanation of Benefits (EOB) statement.
An EOB lists the total cost of health care services received, the amount Quartz paid, and the remaining amount owed to the provider. An EOB is not a bill — it’s just a notice of what Quartz paid according to your plan benefits. Your health care provider will send you a bill if they require additional payment from you.
Quartz mails an EOB statement to the member who received the health care service, even if the claim is for a child. In many cases, we are required by law to do this in order to protect member privacy.