Navigating the world of health insurance can feel like learning a new language. Understanding the key terms is crucial for making informed decisions about your coverage and healthcare. This glossary will help you decipher the jargon and gain confidence in managing your health insurance.
A
- Annual Limit: The maximum amount an insurance company will pay for covered expenses in a year.
- Appeal: A formal request to your insurance company to reconsider a denial of coverage.
B
- Beneficiary: The person designated to receive benefits from an insurance policy.
- Benefits: The services covered by your health insurance plan.
C
- Claim: A request for payment submitted to your insurance company for covered medical expenses.
- Coinsurance: The percentage of costs you share with your insurance company after meeting your deductible.
- Copayment (Copay): A fixed amount you pay for a covered healthcare service, like a doctor’s visit or prescription.
- Covered Services: The specific healthcare services and treatments that your insurance plan will pay for.
D
- Deductible: The amount you pay out of pocket for covered health services before your insurance starts to pay.
- Dependent: A spouse, child, or other individual who is covered under your health insurance policy.
E
- Exclusions: Specific services or treatments that are not covered by your health insurance plan.
- Explanation of Benefits (EOB): A statement from your insurance company explaining what services were covered, how much was paid, and your responsibility.
F
- Formulary: A list of prescription drugs covered by your insurance plan.
G
- Grace Period: A period of time after your premium is due during which your coverage will remain active if you pay.
H
- Health Maintenance Organization (HMO): A type of health insurance plan that typically requires you to choose a primary care physician (PCP) and get referrals for specialists.
- Health Savings Account (HSA): A tax-advantaged savings account used to pay for qualified medical expenses.
I
- In-Network Provider: A healthcare provider who has contracted with your insurance company, typically resulting in lower out-of-pocket costs for you.
N
- Network: A group of healthcare providers who have agreed to provide services to members of a particular health insurance plan.
O
- Out-of-Network Provider: A healthcare provider who is not contracted with your insurance company, often resulting in higher out-of-pocket costs for you.
- Out-of-Pocket Maximum: The most you will have to pay for covered services in a year. Once you reach this limit, your insurance company will pay 100% of covered expenses for the rest of the year.
P
- Pre-Existing Condition: A health condition that existed before you enrolled in a health insurance plan.
- Premium: The amount you pay, usually monthly, to keep your health insurance coverage active.
- Preferred Provider Organization (PPO): A type of health insurance plan that offers more flexibility in choosing healthcare providers, with lower out-of-pocket costs for in-network providers.
- Preventive Care: Healthcare services focused on preventing illness and disease, often covered in full by health insurance plans.
R
- Referral: A written order from your primary care physician (PCP) to see a specialist.
U
- Usual, Customary, and Reasonable (UCR): The amount that your insurance company considers to be the standard charge for a particular healthcare service.
Remember, this glossary is just a starting point. If you have questions about specific terms or your coverage, don’t hesitate to contact your insurance company for clarification.