Capitation: A flat monthly fee that HMO (health maintenance organization) plans pay to your primary care physician (PCP) for prescribed medical services. A capitated site refers to the location of your PCP's designated x-ray or lab sites.
You should always confirm all capitated sites with your PCP before using them. Any service provided at a location other than your physician's capitated site will not be covered by your medical plan.
Co-insurance: After you meet the deductible, your health plan pays a specified percentage of the charges for you covered services. You pay the remaining charges, called co-insurance.
Co-payment/Co-pay: A flat per-service charge that you pay for services such as doctor visits or prescriptions.
Deductible: The dollar amount you must pay each year before your medical and/or dental plan begins to pay benefits for certain covered expenses. The amount of the deductible depends upon the plan you select.
Imputed Income Tax: Imputed income refers to the value the government attaches to life insurance coverage in excess of $50,000 when paid by your employer. This value is determined by age-related rates established by the Internal Revenue Service. Generally, the imputed income tax that you pay is not a significant amount, but it does increase as age and salary increase.
Out-of-Pocket Maximum: The highest amount you have to pay out of your own pocket for eligible medical expenses each year, as long as your providers accept your plan's UCR. Once you reach the out-of-pocket maximum, your eligible medical costs are covered at 100% of UCR for the rest of that plan year. For the HMO plans, the out-of-pocket maximum applies only to copays. For the UPHS POS and PennCare/Personal Choice PPO plans, you have a copay maximum and a separate coinsurance/deductible maximum. Each covered individual will not pay more than the individual out-of-pocket maximum. If multiple dependents are covered, the aggregate total of the out-of-pocket costs paid by all covered members will not exceed the family maximum.
PennChoice: Penn provides a flexible benefits package called PennChoice which lets you select the medical, dental, life insurance coverages and pre-tax expense accounts that best meet your needs and those of your family. In addition, Penn offers several other benefits and programs to promote the well being of the members of the Penn community.
UCR or R&C: refers to the usual, customary and reasonable fees that physicians, health care facilities or other health care providers in the same geographical area charge to similar services. Plans that pay 100% of UCR or R&C pay 100% of the usual, customary and reasonable fess for that service. If providers have an affiliation with the Plan, they are obligated to accept the Plan's UCR or R&C as payment in full. However, if providers are not affiliated with the Plan, they are not obligated to accept the UCR or R&C, and you may have to pay any charges in excess of the payment made by the Plan.