Navigating insurance and definitions of items can be overwhelming.
Below you will find commonly used terms and what they mean.
Glossary of commonly used health insurance terms
When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.
The part you pay for a health care service that is covered under some health insurance plans.
This co-insurance amount is a percent of the amount the service costs. The insurance company pays for the rest.
A co-pay is the amount you must pay for a health care service such as an office visit or prescription.You pay this amount at the time of your appointment.The amount will be different for different health insurance plans.
Co-pay is different than coinsurance and deductible. You may have to pay a co-insurance, a co-pay, and part of a deductible for one visit.
Most insurance companies require doctors and other health care providers to collect this payment from the patient.
For services that are not an emergency, some health care providers may refuse to see a patient that does not pay their co-pay.
If you do not pay your co-pay, the health care provider can collect payment for this just like any other money you owe.
A deductible is a fixed amount you must pay for health care services before the insurance will pay for services. This can be an individual amount or a family amount.
Most of the time the deductible is for a fixed period, often for one year. The deductible may not apply to some services.
Health insurance is a health care plan that pays for some or all costs for medical care.
You have insurance if someone else such as your place of work or the government is paying for some or all your healthcare.
Your insurance can be an individual plan that you buy, a plan from your place of work, a plan from a union at your place of work, or a government plan like Medicare or Medicaid.
Managed care is an insurance plan that offers health benefits, but the patient must use a defined network.
For some health services, managed care may require you to get a referral or have the health services approved.
All health care plans work with doctors, hospitals, clinics, and other health care providers. This group of health care providers working together is known as the health plan’s network.
This is a service to prevent you from getting sick or needing more health care later. For example, getting a flu shot is a type of preventative service, because it can prevent you from getting the flu. Another example of a preventive service is a routine dental exam and dental cleaning, which help maintain good oral health.
Payments you make to your insurance provider to keep your coverage. The payments are due at certain times.
Provider (Healthcare Provider)
A hospital, facility, physician or other licensed healthcare professional.
Out-of Pocket Cost
Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost. Consult your health insurance plan for more information as it varies by organizations.