17 msfocusmagazine.org • Coinsurance – Is a percentage of costs that you pay for a covered health service once you have met your deductible. For example, let’s say you have a plan with 20 percent coinsurance and you have met your deductible and are ordered to get an MRI. If the MRI costs $1,000, you would pay $200 and the insurance company is responsible for the remaining $800. If you haven’t met the deductible, you would be responsible for the full cost of the MRI or $1,000. • Copayment – Is a fixed amount that you pay for a covered healthcare service after you've paidyourdeductible. Copayments can vary per health service and the amounts are typically listed on your insurance card. For example, you may have a $20 copay for doctor’s visits, $35 copay for a specialist and $100 copay for services like MRIs. If you haven’t met your deductible, you maybe responsible for the full cost. • ExplanationofBenefits(EOB)–Isastatement sent by a health insurance company to the covered individuals explaining what covered health services were paid on the behalf of the insured. It is important to note that the EOB is a statement and not a bill. Physician Types • PrimaryCare Physician (PCP) - Is a medical doctor(MD) ordoctorof osteopathic medicine (DO) who directly provides or coordinates a range of healthcare services for a patient. It is critical to note that your MS treating neurologist is not your PCP and that your PCP may have to write a referral to your neurologist to coordinate MS services. • Specialist – A specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions-like a neurologist to manage your MS. If you have an HMO plan, your MS specialist will need a referral. Administrative • Referral – Is a written order from your primary care doctor for you to see a specialist or get certain medical services like an MRI. Many insurance companies won’t pay for health services without receiving a referral first. • Prior Authorization – Is approval from a health plan that may be required before a medical service or a prescription will be covered by your plan. Prior authorization, however, does not guarantee payment from a health insurance plan. When you provide your referral to the specialist, they will seek prior authorization from your insurer prior to your appointment. • Appeal – Ifyourhealth plan denies a referral, prescription, or other health service, you have the right to request that the health plan review that decision. The appeals process may be started by you or your provider with your consent. The terms of your policy will outline the appeal process. • Grievance – Is a complaint that you communicate to your health insurer or plan. Grievances can be filed after all appeals have been exhausted. Your plan will detail the steps to follow to file a grievance. • Benefits – Refers to all healthcare services that are included in your plan. • Excluded Services – Are healthcare services that your health insurance or plan doesn’t pay for or cover. For example, chiropractic services are excluded from some plans. • Pre-ExistingCondition – Is a health problem, such as MS, that you were diagnosed with