is the facilities, providers, and suppliers your health insurance carrier or plan has contracted with to provide services.

are health care services that your health insurance or plan doesn’t pay for or cover. These are services such as cosmetic or elective surgeries.

the covered health care services from providers who contract with your health insurance carrier or plan network. Examples may include exams, surgeries, stitches, etc.

the health care services from providers who do not accept our insurance or plan. Under the Risas medical plan(s), out-of-network services are excluded and not covered. If you have out of network medical expenses, you will be fully responsible for the entire cost. So, it is important to make sure your doctor is in network and ask questions to ensure any procedures/facilities will be covered as well. The exception is for emergency situations, something that is life or limb-altering.

A virtual visit is when you see your regular doctor, or PCP, virtually. Teledoc is a separate service that gives you access to many doctors so you can be seen right away. Appointments are done usually through Facetime or a webcam. Before starting the visit there is a brief questionnaire to be sure your symptoms can be treated virtually. Teledoc is a great way to be seen quickly, without being exposed to other patients, while keeping your medical expenses low. It has our lowest copay.

is the amount of money you pay each pay period to have insurance coverage. While you are employed with Risas it will be deducted from each paycheck. It is important to note that the premium does not cover all medical costs. It gives you access to the level of insurance you choose. If you think of it like car insurance. You pay your premium each month to have car insurance. It covers some things at no additional cost to you. But if you get into a car accident, you may have to pay extra (usually called a deductible) for the insurance company to cover the cost of fixing your vehicle.

is a set amount of money you pay for certain medical services. Your insurance will then cover the remaining cost. For example, if you visit the doctor for a sore throat, they may charge $150 for the exam. If you have a copay of $25 to see your primary care doctor, you only pay $25 and the insurance provider pays $125 for the exam. The next time you come to your doctor for a sore throat you will again pay $25. A copay is a great way to minimize your medical expenses. But keep in mind, only the Choice Plus plan offers copays and not all medical services are covered by a copay. For example, if you are in the hospital for a few days to recover from surgery, it would not be covered by a copay.

is the amount you will pay out of your own pocket (when there is no option for a copay) each year before your insurance begins to cover medical expenses. Under Risas’ medical insurance we offer two plans. The HSA plan will cover 100% of your expenses after reaching the deductible. The Choice Plus plan, once you hit the deductible, will cover 80% of your medical expenses until you hit the out of pocket maximum limit and then it covers 100% of the remaining expenses. For example, if you have knee surgery for $12,000. You will be billed for the amount of your deductible. Then depending on the medical plan you chose, you will either pay 20% of the remaining cost until you hit the out of pocket limit or no additional cost.

When choosing your insurance plan, the deductible is one of the most important factors.

Under the HSA plan, the deductible is non-embedded. This means that if you have family coverage, the full family deductible amount must be met before the plan will begin paying 100% of covered services. For example, if you, your spouse, and three children each have $12,000 in medical expenses for the year, you would pay up to the $5,000 family deductible, then the plan would cover the additional covered expenses at 100%.  

Under the Choice Plus plan, the deductible is embedded. This means that if you have family coverage, any combination of covered family members may help meet the maximum family deductible, however, no one person will pay more than the individual deductible amount. For example, if you, your spouse, and three children each have $12,000 in medical expenses for the year, each individual will not pay more than the $750 individual deductible before the 80% coinsurance would apply, and once the family deductible of $1,500 has been met, every family member’s covered services will be covered at 80%

Please note: the amount you spend in copays goes towards your out of pocket maximum, it does not count towards your deductible.

is the maximum amount of money you will pay in covered medical expenses each year. The limit is set to help protect people from large medical bills. For example, if you had $100,000 in medical expenses (which is very possible) and insurance covers 80% you could still be stuck with a bill of roughly $20,000 if you did not have an out of pocket limit.

These tiers refer to the types of drugs and their cost level. Often a drug will have a generic version which is cheaper. This would be a tier one drug. A tier two drug would usually include more name brand drugs, but at more affordable prices. Tier three will have the most expensive brand name drugs.