Health Insurance Terms

Below are some common health insurance terms.  For more information contact us.  We are here to work for you!

• COINSURANCE:  The percentage of covered expenses under a major medical plan that will be paid once a deductible is satisfied OR a cost-sharing arrangement under which a covered person pays a specified percentage of the cost of a specified service, such as 20% of the cost of a doctor’s office visit.
• COPAY:  A set fee for medical expenses that is required to be paid by the insured for specific services such as doctor’s office visits.
• DEDUCTIBLE:  The initial amount of medical expenses an individual must pay before he/she will receive benefits under a medical expense plan.
• HMO:  Health Maintenance Organization.  Insureds are required to use a primary care physician in order to receive ANY benefits and there is a network to use.
• LIMITS:  Maximum amount of benefit payable for a given situation or occurrence.
• OUT-OF-POCKET  MAXIMUM (OOP):  A present amount that the plan participant must pay before the insurance company pays 100% of the expenses.
• NETWORK:  List of providers that a carrier has contracted to provide services to its insureds, at negotiated prices.
• OPEN ENROLLMENT:  A period of time when eligible subscribers may enroll in, or transfer between, available programs providing health care coverage.
• OUTPATIENT SERVICES:  Non-inpatient services, i.e., no overnight stay, provided by a hospital or other qualified facility, such as a mental health clinic, rural health clinic, mobile X-ray unit or free-standing dialysis unit. Those services include physical therapy, diagnostic X-ray and laboratory tests. Also included are doctor visits.
• PREFERRED PROVIDER ORGANIZATION (PPO):  A health care arrangement between purchasers of care such as employers and insurance companies and providers offering benefits at a reasonable cost using incentives, such as lower deductibles and copays to get members to use providers within a network. Use of non-preferred physicians would involve a higher cost. Preferred providers must agree to specified fee schedules and are required to comply with certain utilization and review guidelines.
• PRIMARY CARE PHYSICIAN (PCP):  Primary care physicians deliver basic or general care that is intended to be the patient’s first level of contact with the medical care system.