Health insurance can feel confusing, especially when you’re trying to figure out what’s covered. Maven can help you understand these terms and how they may show up in your coverage, so you feel more confident when navigating your benefits.
Here are some common terms you may see from your insurance provider—and what they really mean.
In-network vs. out-of-network
- In-network: A doctor or facility that has a contract with your health plan, usually at a lower cost to you.
- Out-of-network: A doctor or facility with no contract. Seeing them often means higher costs.
Out-of-pocket (OOP)
The amount you personally pay for medical care that your insurance doesn’t cover.
Annual or lifetime cap
The maximum amount your insurance plan will pay for certain benefits in a year—or over your lifetime.
Diagnosis of infertility
Some insurance plans require an official infertility diagnosis before you can use fertility benefits.
Examples include:
- Trying to conceive for 6–12 months (depending on age) without success
- Ovulation disorders
- Blocked fallopian tubes
- Low sperm count
Learn more about infertility here.
Primary vs. secondary infertility
- Primary infertility: Trouble conceiving your first child.
- Secondary infertility: Trouble conceiving another child after already having one.
Pre-authorization (or prior authorization)
Approval your insurance plan requires before it will cover a certain treatment, medication, or service.
Policy Basics to Confirm
Every plan is unique, but most follow a similar structure. When speaking with your insurance provider, you may want to ask about these key terms:
- Cost share: The part of your health care costs that you pay out-of-pocket for covered services or prescriptions. Cost sharing usually includes co-pays, deductibles, and co-insurance. It does not usually include your monthly premium or the cost of services your plan doesn’t cover.
- Co-pay: A set amount you pay for a covered service (for example, $20 for a doctor’s visit).
- Deductible: The amount you pay out-of-pocket before your insurance starts covering costs.
- Co-insurance: A percentage of the cost you pay after your deductible is met (for example, 20%).
- Out-of-pocket maximum: The most you’ll pay in a plan year for covered services. After that, insurance pays 100%.
- Premium: The amount you pay each month for your health insurance coverage.
Tip: Start any call with your insurance provider by confirming your deductible, co-pay, co-insurance, and out-of-pocket maximum. This can give you a clearer picture of what your care will cost.
For information on how your insurance works alongside Maven, please review one of these articles:
- If you have access to Maven or are a Maven Green member: Maven Is Not Insurance: Understanding the Difference
- If you’re a Maven Gold member: How Insurance Works For Maven Gold Members With The Maven Benefit
- Not sure if you’re Green or Gold? Check out this article: How does Maven Wallet work?
Still have questions? The Maven Care Team is here for you 24/7.
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