Questions Regarding Insurance Terms & Basics
Unable to find the answer you are looking for?
You may want to try a different FAQ topic or ask us through our
general questions form. If you have a question pertaining to Customer Service, please email a Customer Service Representative directly via My Health Plan.
Please Note: Only Customer Service is able to answer specific coverage questions via email.
Return to Top
What is Coinsurance?
Coinsurance is a cost-sharing requirement under certain health insurance policies, which requires the insured and insurer to pay a portion or percentage of the costs for covered services. A typical coinsurance plan might be referred to as "80/20"; which means the insurer pays 80 percent of the allowable amount and the insured pays 20 percent.
Return to Top
What is Traditional Amount?
Traditional Amount is the maximum amount determined and allowed by Medical Mutual for a covered service based on factors including the following:
- The amount billed by a Provider for a given service
- Centers for Medicare and Medical Services (CMS)'s Resource Based Value Scale (RBRVS)
- Input from participating physicians and wholesale prices (where applicable)
- Geographic considerations
- Other economic and statistical indicators and applicable conversion factors
Return to Top
What is non-SuperMed co-insurance or non-network coinsurance?
Non-SuperMed/non-network coinsurance is a percentage of the lesser amount for non-SuperMed (or non-network) providers for which you are responsible after you have met your deductible.
Return to Top
What does participating mean?
A physician or other professional has an agreement with Medical Mutual about payment for covered services.
Return to Top
What is the role of a Primary Care Physician (PCP)?
Under a managed healthcare plan (such as Medical Mutual's SuperMed Select™, SuperMed HMO™, or HMO Health Ohio), a primary care physician (PCP) is responsible for providing, arranging and authorizing a patient's care.
HMO plans emphasize the importance of a collaborative relationship between members and their PCPs. These physicians are specifically trained to help their patients maintain good health, to identify and effectively treat routine health problems, and to refer patients to the appropriate specialist if a more serious problem is identified. Because of their vital role in providing and coordinating care, all care (except emergency and OB/GYN office services) must be performed or authorized by a member's PCP in order to be covered under the HMO system.