Understanding Health Insurance Terms

Coinsurance: the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage.
Coordination of Benefits: a system 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 percent of the claim.

Copayment: another way of sharing medical costs. You pay a flat fee every time you receive a
medical service. The insurance company pays the rest.

Covered Expenses: most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Covered services are those medical procedures the insurer agrees to pay
for.

Deductible: the amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.

Exclusions: specific conditions or circumstances for which the policy will not provide benefits.

Managed Care: ways to manage costs, use, and quality of the health care system.

Maximum Out-of-Pocket: the most money you will be required to pay in a year for deductibles
and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular
premiums

Preexisting Condition: a health problem that existed before the date your insurance became effective.

Premium: the amount you or your employer pays in exchange for insurance coverage

Primary Care Doctor: usually your first contact for health care. This is often a family physician
or internist. A primary care doctor monitors your health and diagnoses and treats minor health
problems, and refers you to specialists if another level of care is needed.

Provider: any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical
care

Third-Party Payer: any payer for health care services other than you.

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