Allowable charge
This is the maximum amount a medical insurance company will pay for a covered health care service.
Benefit
This is an entitlement made under a health insurance policy. Usually, it entails the services health insurance plans must cover.
Claim
A claim is an elaborate invoice that a health care provider sends to a medical insurance company asking for payment based on the terms of the insurance policy.
Coinsurance
The amount you pay to share the cost of covered services after you have paid your deductible. The coinsurance rate is usually a percentage.
Copayment
A copayment is a fixed amount you pay for covered health care services after you have paid your deductible.
Deductible
The amount you pay for covered health care services before your insurance plan starts to pay.
Dependent
A dependent is an individual who is eligible for health insurance coverage. Dependents include all those people whom the insured person is under a legal obligation to support, such as children and spouse.
Drug formulary
Refers to a list of prescription medications that a health insurance plan will cover.
Exclusion or limitation
An exclusion or limitation is a provision within a health insurance plan that eliminates coverage for certain expenses, as disclosed on the Certificate of Insurance.
Group health insurance
This is an insurance plan that provides health care coverage to a specific group of people. These plans offer uniform benefits the select members of the group.
Health maintenance organization (HMO)
A type of health insurance plan that provides health coverage with providers under contract. HMO plans do not cover out-of-network care except in emergency situations.
Health savings account (HSA)
This is a tax-exempted savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. This account can only be used if you have a High Deductible Health Plan (HDHP).
In-network provider
In-network provider are medical care providers that an health insurance company has contracted with to provide medical care for pre-negotiated rates.
Individual health insurance
This is coverage that is purchased on an individual or family basis, and not offered by an employer or an association.
Medicaid
This is a joint state and federal program that provides low-cost or free health coverage to millions of Americans. This program provides coverage for families and children, low-income people, pregnant women, disabled people and the elderly.
Medicare
This is a federal health insurance program that covers people aged 65 years and above, or those under 65 with disabilities, as well as people with End-Stage Renal Disease.
Medicare supplement plans
These are plans that provide coverage for some of the health care costs that Original Medicare does not cover, including deductibles, copayments, and overseas emergency coverage.
Out-of-network provider
An out-of-network provider does not have a contract with your medical insurance company for reimbursement at negotiated rates.
Out-of-pocket maximum
This is the maximum amount a health insurance policyholder will pay for health care services over the course of the policy year. Once the policyholder has reached their out-of-pocket maximum, the plan begins to pay 100 percent of the allowed amount for covered health care.
Pre-existing condition
This is a condition where, according to the health insurance carrier, the signs and symptoms of that condition were existing at any particular time during the period of six month ending on the day the person took an insurance cover under the policy.
Preferred provider organization (PPO)
This is a type of health plan that contracts with medical care providers to create a network of participating providers. In most PPO plans, the policyholder pays less if they use providers belonging to the plan network.
Premium
The amount you pay for your health insurance every month.
Provider
Refers to health professionals who provide health care services.