Health Insurance Glossary
Additional Insured: Anyone covered under your health plan that is not named as "insured" in your documentation from the insurance company.
Benefit: The dollar amount your insurance carrier will pay when you file a claim for a covered loss.
Benefit Period: The interval during which you will be eligible for benefits. Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days.
Carrier: The insurance company you receive your health plan from.
Certificate of Insurance: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It spells out precisely what will be covered, what won't, and the dollar maximums.
Claim: This refers to any request to your insurance company for benefits.
COBRA: This acronym refers to the Consolidated Omnibus Budget Reconciliation Act of 1985. This law requires group medical plans with twenty employees or more to offer participants the option to receive continued healthcare benefits for 18-36 months after the cancellation of their coverage due to loss of job.
Coinsurance: The amount you will be required to pay for a particular medical expense. Coinsurance is measured as a percentage of the total medical bill.
Co-payment: This is a cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($20.00 per office visit, or $10.00 per generic prescription).
Covered Expenses: The various medical procedures that your insurer has agreed to provide you coverage for.
Deductible: A deductible is part of the cost of health insurance that needs to be paid by an individual before insurance covers any medical expenses. The amount of the deductible that is paid by an individual can have an effect on the amount of premium that is paid for a health insurance policy.
Exclusion: A specific circumstance or condition that is not covered by your policy.
Effective Date: This refers to the date on which your insurance coverage will actually begin to cover you.
HMO: Health Maintenance Organization. HMO's are popular health benefit programs in which you'll pay monthly premiums in return for managed coverage for your checkups, hospital stays, doctors' visits, surgery, emergency care, preventive care, lab tests, and X-rays. If you join an HMO, you will have to select what's called a "Primary Care Physician" who will be responsible for coordinating your healthcare and making any referrals to specialists that you require. You'll also have to use doctors, hospitals and clinics who are members of your HMO plan's network.
In-network: Healthcare facilities or providers who are members of your health plan.
LOS: This is an acronym for the term "length of stay". It's used by insurance carriers, case managers, and other healthcare professionals to describe the length of time any individual spends in a hospital or an in-patient care facility.
Maximum Out-of-Pocket Expenses: The most you will have to pay during one year — in the form of deductibles and coinsurance fees.
Medicaid: This is a joint state/federal health insurance program that is administered by the state. It provides health coverage for low-income individuals, especially pregnant women, children and the disabled.
Medicare: This is a federally-sponsored healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65.
Network: This refers to the groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurance carrier's customers.
Out-of-Network: This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO or PPO). Depending on your plan's guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.
Pre-existing Conditions: This refers to any healthcare issues you had prior to your insurance plan's effective date. Many policies will refuse to cover pre-existing conditions, while others do so only for a short time.
PPO: Preferred Provider Organization. PPOs are networks of healthcare providers who have negotiated discount contracts with health insurance carriers. Your healthcare provider decisions will be up to you, but there are generally financial incentives for you to select providers within your PPO network.
Preventative Care: Health services that focus solely on preventative care measures such as physical exams, immunizations, diagnostic tests and mammograms.
Premium: The dollar amount you'll pay on a monthly basis in exchange for your insurance coverage.
Primary Care Physician: Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health, treat most of your health problems, and refer you to specialists when necessary.
Provider: This term refers to any individual (nurse, physician, or specialist) or institution (clinic, hospital, or laboratory) that provides you with care.
Rider: This refers to any policy attachment that makes additions or changes to your original insurance plan.
Short Term Health Insurance: This type of healthcare plan is purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you're traveling overseas.
Small Business Health Insurance: This is a type of healthcare coverage that is available to businesses employing between two and fifty employees. It offers discounted premiums to employees and tax advantages to small business owners; also in most cases, the coverage cannot be denied.
Travel Health Insurance: This insurance is purchased to provide you with coverage when you're traveling abroad.
Waiting Period: This refers to a pre-specified time period during which you will not be covered by your insurance (for a particular healthcare issue).