Health Insurance Glossary of Terms
Actuary – An insurance mathematician who calculates rates, statistics, and reserves.
Agent – A qualified representative of one or more insurance companies licensed to sell insurance.
Benefit – The amount an insurance company pays to a policyholder when a loss occurs.
Brand-Name Prescription Drug – Drugs developed, manufactured, and marketed with a brand name by a pharmaceutical company. Brand name drugs are typically more expensive that generic drugs.
Broker – An insurance salesperson that searches for quotes and plan options for individual clients.
Carrier – A company that provides insurance plans.
Case Management – A management system in which case managers monitor patients’ health care, to improve quality, reduce cost, and ensure the patient receives appropriate care.
Claim – A request to an insurance company for payment of a service received.
COBRA (Consolidated Omnibus Budget Reconciliation Act) – Legislation allowing employees to keep their group health coverage temporarily after they leave the job.
Coinsurance – A portion of a single medical bill, expressed in a percentage, the insured is responsible for paying.
Copayment – A portion of a single medical bill, expressed in a dollar amount, the insured is responsible for paying.
Deductible – The yearly amount an insured must pay out-of-pocket before insurance coverage begins.
Dependents – Any person directly financially relying on insured. Usually includes spouse and unmarried children.
Effective Date – The date when insurance coverage begins.
Exclusions – Any medical or health care services not covered by an insurance plan.
Fee For Service (FFS) Plan – Also known as traditional “indemnity” coverage, FFS plans reimburse policyholders for the care they receive, as long as it’s covered, from any health care provider.
Flexible Spending Account (FSA) – A savings account in which income can be deposited tax-free for health care expenses. At the end of the year, any unused funds in an FSA are forfeited.
Formulary – The list of all covered prescription drugs.
Generic Drug – Duplicates of brand-name drugs made after the patent expires of the company who developed the drug. Typically, generic drugs are much less expensive than brand-name drugs. And they’re just as safe and effective.
Group Insurance – Health insurance coverage offered for employees of a business.
Guaranteed Issue – Law, varying by state, requiring all insurance applicants to be accepted regardless of health condition, health history, age, or any other factor.
Health Insurance Quote – Health plan options provided by an automated quoting service, an agent, or an insurance company.
Health Maintenance Organization (HMO) – A managed care plan in which members must receive care from the network of doctors, hospitals, and other care providers. They must also choose a Primary Care Physician (PCP) from the network to be their “first-line-of-defense” doctor, and to provide referrals to specialist care.
Health Reimbursement Arrangement – A designated amount of money determined by an employer to spend on their employees’ health care expenses.
Health Savings Account (HSA) – A bank account where tax-free income can be saved for health care expenses. Each year unused HSA funds grow in interest. To be eligible to open an HSA, you must first enroll in a high-deductible health plan.
High-Deductible Health Plan (HDHP) – Plans with a deductible of at least $1,100 for individuals ($2,200 for families). Enrollment in an HDHP makes you eligible to open a Health Savings Account (HSA).
HIPAA (Health Insurance Portability and Accountability Act) – Legislation that allows people to change jobs and be accepted into their new company’s group health insurance plan regardless of pre-existing conditions or health history.
Indemnity Health Plan – See Fee For Service (FFS) plan.
Individual Health Insurance – A health plan purchased by an individual from an insurance company, not through an employer. Individual coverage can include your spouse and dependent children.
Individual Retirement Account (IRA) – An account to save money for retirement. Funds from an IRA can be moved to a Health Savings Account (HSA).
In-Network Care Providers – Any health care professional that agrees with a health plan to discount their medical services in exchange for patient referrals.
Inpatient Care – Care in which patients must stay overnight in a medical facility.
Insurability – The factors that determine if an applicant will be accepted into a health plan, including age, health history, and current health conditions.
Limitations – A specified limit on the benefits paid for a certain medical cost.
Long-Term Care – Care intended to nurse a patient back to health over an extended period of time. Can include unskilled care, skilled nursing care, and custodial care.
Major Medical Insurance – Insurance that provides coverage for major and catastrophic medical care.
Managed Care – A type of health insurance that creates an agreement with a “network” of doctors, hospitals, and other care providers. The health plan provides patient referrals in exchange for discounted medical services.
Maximum Dollar Limit – The maximum dollar amount of benefits and claims that an insurance company will pay in a certain period of time.
Maximum Lifetime Benefit – The maximum dollar amount of benefits and claims an insurance company will pay in the insured’s lifetime.
Medicaid – A government-sponsored program that provides health care for low-income Americans.
Medicare – A government-sponsored program that provides health care for Americans over the age of 65 and those with end-stage renal disease.
Medicare Advantage Plans – These plans provide Medicare benefits that can be purchased and received through private companies. They can also include prescription drug coverage.
Medicare Supplement (Medigap) Insurance Plans – Extra insurance coverage purchased through private insurance companies to cover some of the health care costs regular Medicare does not.
Mutual Insurance Company – Insurance companies that have no public stock and are owned by the wholly by the policyholders.
Network – The group of doctors, physicians, hospitals, clinics, and specialists that agree with a health plan to discount their medical services in exchange for patient referrals.
Out-Of-Pocket Maximum (Limit) – The maximum amount of health care costs that an insured must pay out of their own pocket per year. After the out-of-pocket max is met, the plan will cover 100% of any remaining costs for the year.
Outpatient Care – Care that does not require a patient to stay overnight in a medical facility.
Point of Service (POS) Plan – A managed care plan that combines the benefits of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Like an HMO, POS plans require members choose a Primary Care Physician (PCP). Like a PPO, they provide coverage with any in or out-of-network health care providers.
Pre-Admission Review and Certification – Approval by a health care professional to be admitted into a medical facility.
Pre-Existing Conditions – Any health condition before coverage starts can be considered a pre-exiting condition. Insurance companies may require a waiting period before they cover costs related to that condition.
Preferred Provider Organizations (PPO) – A managed care plan in which members have insurance coverage with in and out-of-network doctors, hospitals, and other health care providers. Typically, members save the most on care with in-network providers.
Premium – The payment that must be made to an insurance company monthly to keep a health insurance policy in effect.
Preventive Care – Health care intended to prevent serious (or more serious) illness through routine doctor’s check-ups, physicals, well-baby care, and immunizations.
Primary Care Physician (PCP) – Can include family doctors, pediatricians, internists, general practitioners, and OB/GYNs. Members of a Health Maintenance Organization (HMO) or Point of Service (POS) plan choose a PCP as their “first-line-of-defense” doctor. They also can provide referrals for specialist care.
Provider – Includes doctors, physicians, hospitals, clinics, specialists, or any health care professional.
Quote – Insurance plan options provided by an automated quoting service, an agent, or an insurance company.
Rider – An addition or exclusion included on an insurance policy.
Risk – An insurance company’s chance of loss. Also refers to the chance of an individual becoming ill or having an accident.
Short-Term Disability – An illness or injury that prevents an employee from working for a period of time.
Short-Term Medical Insurance – An insurance plan that provides insurance coverage for a designated period of time — usually between one month and one year. Many individuals who purchase short-term coverage include recent college graduates and people in-between jobs.
Travel Insurance – Health plans that provide coverage for people while during a trip to another country.
Underwriter – An insurance professional that determines the premiums for applicants.
Underwriting – The process in which an insurance company or underwriter determines the amount the premiums will be for applicants.
Usual, Customary, and Reasonable Fees – The standard amount that is usually covered or charged for medical services and supplies, as recommended by health care professionals.
Utilization Review – The process in which the care of patients are monitored for cost-effectiveness, efficiency, and quality.
Waiting Period – Also known as the elimination period, it refers to the temporary amount of time an insured will not be covered for certain health care costs.
Waiver of Premium – An additional insurance policy that can be purchased. It waives premiums for a period of time if the insured becomes totally disabled and cannot make monthly payments.