Glossary of Health Insurance Terms:
ACA: Piece of legislation that refers to the Patient Protection and Affordable Care Act.
Additional Insured: Anyone covered under your health plan that is not named as “insured” in your documentation from the insurance company.
Benefit: The dollar amount your insurance carrier will pay when you file a claim for a covered loss.
Benefit Period: The interval during which you will be eligible for benefits. Generally, your benefit period will begin with the first medical service you receive for a specific illness and end after you have not been treated for that condition for 60 days.
Carrier: The insurance company you receive your health plan from.
Certificate of Coverage: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It spells out precisely what will be covered, what won’t, and the dollar maximums.
Claim: This refers to any request to your insurance company for benefits.
COBRA: This acronym refers to the Consolidated Omnibus Budget Reconciliation Act of 1985. The law requires group medical plans covering twenty employees or more to offer participants the option to receive continued healthcare benefits for up to eighteen months after the cancellation of their group plan.
Coinsurance: The amount you will be required to pay for a particular medical expense. Coinsurance is measured as a percentage of the total medical bill.
Co-payment: This is a cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($20.00 per office visit, or $10.00 per generic prescription).
Covered Expenses: The various medical procedures that your insurer has agreed to provide you coverage for.
Deductible: The amount you’ll be required to pay for healthcare expenses before your insurance plan will begin to reimburse you. Typically co-payments will apply prior to a deductible having to be reached, unless otherwise state in the Certificate of Coverage.
Exclusion: A specific circumstance or condition that is not covered by your policy.
Effective Date: This refers to the date on which your insurance coverage will actually begin to cover you.
Fee-for-Service: This is a payment system for healthcare where your provider is paid for each service after it is performed. You receive reimbursement after you file a claim.
Group Health Insurance: This is a type of healthcare coverage that is available to businesses employing employees. It offers the ability to combine members for discounted premiums to employees and tax advantages to small business owners.
HMO: Health Maintenance Organization. HMO’s are popular health benefit programs in which you’ll pay monthly premiums in return for managed coverage for your checkups, hospital stays, doctors’ visits, surgery, emergency care, preventive care, lab tests, and X-rays. If you join an HMO, you will have to select what’s called a “Primary Care Physician” who will be responsible for coordinating your healthcare and making any referrals to specialists that you require. You’ll also have to use doctors, hospitals and clinics who are members of your HMO plan’s network.
In-Network: Healthcare facilities or providers who are members of your health plan.
Maximum Out-of-Pocket Expenses: The most you will have to pay during one year — in the form of deductibles, co-payments and coinsurance fees.
Managed Care: This term refers to an increasingly broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and POS (Point-Of-Service plans).
Medicaid: This is a joint state/federal health insurance program that is administered by the state. It provides health coverage for low-income individuals, especially pregnant women, children and the disabled.
Medicare: This is a federally-sponsored healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65.
Network: This refers to the groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted health care services to your insurance carrier’s customers.
Out-of-Network: This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO). Depending on your plan’s guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.
POS: Point-of-Service Plan. A POS is a managed healthcare plan that combines the features of a Health Maintenance Organization and a Preferred Provider Organization. These plans allow you to decide whether or not you’ll use an in-network provider or an out-of-network provider.
Pre-existing Conditions: This refers to any healthcare issues you had prior to your insurance plan’s effective date. Permanent plans issued after 2014 no longer can exclude pre-existing conditions.
PPO: Preferred Provider Organization. PPOs are networks of healthcare providers who have negotiated discount contracts with health insurance carriers. Your healthcare provider decisions will be up to you, but there are generally financial incentives for you to select providers within your PPO network.
Preventative Care: Health services that focus solely on preventative care measures such as physical exams, immunizations, diagnostic tests, colonoscopy and mammograms. Permanent plans, individual and group, are required to cover preventative care at $0 cost to all members covered by the policy.
Premium: The dollar amount you’ll pay on a monthly basis in exchange for your insurance coverage. This amount is not considered part of the maximum out of pocket.
Primary Care Physician: Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health, treat most of your health problems, and refer you to specialists when necessary.
Provider: This term refers to any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.
Short Term Health Insurance: This type of healthcare plan is purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you’re traveling overseas.
Travel Health Insurance: This insurance is purchased to provide you with coverage when you’re traveling abroad.