HEALTH INSURANCE GLOSSARY

Terminology to know

  • the name of the health care reform law finalized in March 2010 that allowed people to purchase their own insurance as individuals, regardless of pre-existing conditions

  • The negotiated rate and maximum amount your insurance company and provider have agreed upon for a covered health care service. Your copayments and coinsurance will be based on this amount. This may also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference.

  • The amount an insurance plan will pay in total benefits over a year. Once you hit this cap, your policy will not pay again until the next year. The ACA prohibits annual limits on essential health benefits, except for grandfathered plans.

  • When a provider bills you for the difference between the provider’s charge and the allowed amount

    For example, if the provider charges $100 and the insurance’s allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider (in-network provider) may not balance bill you for covered services. Balance billing typically occurs when a provider is out-of-network.

  • The healthcare items or services covered under a health insurance plan

  • The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

  • The amount you pay when you receive care. The co-pay amount is set by the insurance company, not the provider’s office. This can be a percentage or flat rate amount.

    For example, the amount you pay to see a provider may be $30.00 each visit, with the insurance company covering the rest of the cost.

  • The amount you pay after you meet the plan’s deductible

    For example, an 80/20 co-insurance rate means the insurance company pays 80% and you pay the remaining 20%. Co-Insurance usually does not start until you pay an amount equal to the deductible.

  • The amount you pay out-of-pocket for medical expenses before your plan pays anything for the healthcare services you received

    For example, if your deductible is $1,000, your plan won’t pay their portion for a covered service until you’ve hit your $1,000 limit. Monthly premiums do not count toward meeting your deductible.

  • Services your health insurance company, or specific plan, doesn’t pay for

  • This plan’s services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency). Unlike HMOs, you do not need to select a PCP or need a referral to see a specialist.

  • An EOB is created after a claim payment has been processed by your health care plan. It explains the actions taken on a claim such as the amount that will be paid, the benefits available, discounts, reasons for denying payment, and the claims appeal process. EOBs are available both as a paper copy and online.

  • A list of prescription drugs your health plan covers. Generic medications are typically covered in a formulary, whereas only some brand names are not.

  • A benefit program that gives employees a choice between cash, life insurance, vacations, retirement plans, and childcare. Although there are usually some requirements, flexible benefit plans offer a choice for the remaining benefits.

  • A contract that requires your health insurer to pay for a portion (or all) of your healthcare services in exchange for a premium

  • website where individuals, families, and businesses based in the US can research, compare, and choose a health insurance plan

  • This plan usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care, except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. You must select a PCP on an HMO. You will need a referral from your PCP to see a specialist.

  • A physician, healthcare provider or healthcare facility that has a contract with your plan to provide their members services at a lower cost to the insurance company.

  • Standards used by health plans to decide whether treatments or health care supplies recommended by your mental health provider are reasonable, necessary, and appropriate. If the health plan decides the treatment meets these standards then the requested care is considered “medically necessary”.

  • Item descriptionthe contract between your health insurance and your healthcare provider

  • The annual period in the fall when you can enroll in a health insurance plan via the Insurance Marketplace on healthcare.gov for the next calendar year

  • A physician, healthcare provider or healthcare facility that does not have a contract with your plan. Using healthcare services that are not covered in your plan will greatly increase the amount you have to pay.

  • The amount you pay out of your own pocket when treatment or services are not covered by your plan

    For example, some plans do not cover laboratory tests, x-rays, medications, Nutrition Therapy, etc.

  • The highest amount of money a person will have to pay during their plan period. It includes the money spent within the deductible amount, co-insurance, and copays. Once you reach this limit, the insurance company will pay 100% of the allowable amount of costs for all covered benefits. Out-of-pocket maximum is higher than your deductible and does not include medication costs or services that are listed as excluded within your plan language. Today, most plans have separate medication and medical out-of-pocket maximums.

  • this plan allows you to pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor to see a specialist.

  • An insurance plan may require prior approval for certain services, drugs, or equipment to consider any charges. Preauthorization is not a guarantee that the insurance plan will cover the cost of the service; however, this is generally the first step for those requiring certain services, such as eating disorder IOP, PHP, and Residential.

  • This plan will allow you to pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

  • The amount you pay monthly, quarterly, or yearly for your health insurance plan. If you have insurance through the workplace, your employer may pay a portion of your premium on your behalf as part of your employee benefit package

  • A physician, healthcare provider or healthcare facility licensed, certified or accredited as required by law

  • This type of provider focuses on a specific area of medicine or illness. Some specialists may not be in-network with your plan

  • • The provider cannot or does not submit out-of-network claims to a client’s payer

    • The client does not have health insurance

    • A client is self-pay for any reason, such as:
    • Benefits do not include medical nutrition therapy (MNT)
    •There are no (eating disorder) specialized providers within the payor’s network
    • Their diagnosis is not a covered benefit

    A superbill may be used by clients for Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs), tax purposes, or to try to obtain reimbursement from their health plan.

    A superbill does not guarantee an insurance provider will reimburse the client for the services provided. The ability of a health plan member to obtain reimbursement from a health plan is dependent on individual member benefits and coverage, as well as health plan policies regarding member reimbursement.

    Medicare beneficiaries are unable to submit superbills for nutrition therapy provided by an out-of-network provider. For Medicare plans, outpatient nutrition sessions are only covered for diabetes, kidney disease, and three years following a kidney transplant.

  • Health insurance policies can be overwhelming and tricky. There is a lot of different information that varies by policy, and it can be confusing to understand what your plan does and does not cover, how much the cost is per service, etc.