Do you know the ABCs of health insurance? Claims, premiums, deductibles copayments and coinsurance? It’s OK, we know as well as anyone that the language of health insurance can be hard to understand. Yet every day, it’s becoming more and more important for health care consumers to have at least a basic knowledge of the industry’s terminology.
Here, you’ll find plain-English definitions for some of the most common insurance terms.
Allowable charge – sometimes known as the “allowed amount,” “maximum allowable,” and “usual, customary, and reasonable (UCR)” charge, this is the dollar amount considered by a health insurance company to be a reasonable charge for medical services or supplies based on the rates in your area.
Benefit – the amount payable by the insurance company to a plan member for medical costs.
Benefit level – the maximum amount that a health insurance company has agreed to pay for a covered benefit.
Benefit year – the 12-month period for which health insurance benefits are calculated, not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year.
Claim – a request by a plan member, or a plan member’s health care provider, for the insurance company to pay for medical services.
Coinsurance – the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
Coordination of benefits – a system used in group health plans to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100% of the claim.
Copayment – one of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.
Deductible – the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
Dependent – any individual, either spouse or child, that is covered by the primary insured member’s plan.
Effective date – the date on which a policyholder’s coverage begins.
Exclusion or limitation – any specific situation, condition, or treatment that a health insurance plan does not cover.
Explanation of benefits (EOB) – the health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.
In-network provider – a health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.
Network – the group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.
Out-of-network provider – a health care professional, hospital, or pharmacy that is not part of a health plan’s network of preferred providers. You will generally pay more for services received from out-of-network providers.
Out-of-pocket maximum – the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.
Payer – the health insurance company whose plan pays to help cover the cost of your care. Also known as a carrier.
Premium – the amount you or your employer pays each month in exchange for insurance coverage.
Provider – any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.
Waiting period – the period of time that an employer makes a new employee wait before he or she becomes eligible for coverage under the company’s health plan. Also, the period of time beginning with a policy’s effective date during which a health plan may not pay benefits for certain pre-existing conditions.
