This glossary explains what the words and phrases mean for health insurance. Knowing these terms can help you choose a plan that meets your needs.
Premium: The amount you will pay (usually shown as monthly or yearly) for the insurance plan. Payments are usually due monthly. Remember to factor this amount into your decision when choosing an insurance plan.
Provider: A licensed physician, nurse practitioner, physician’s assistant, dentist, or other health care practitioner; also a hospital or other health care facility.
PPO: Preferred Provider Organization. This can refer to a plan, or to a doctor, group of doctors, or other healthcare provider, a hospital, or a healthcare facility. Normally, PPO refers to a contract that one of these entities has with the insurance company. In this contract, health care providers agree to a lower rate. What this means to you: if you go to a PPO provider, they can only charge the contracted fee; and not the provider’s actual fee. You can go to a non-PPO provider (called going “out-of-network”), but you will end up paying more for services.
HMO: Health Maintenance Organization. This also refers to a plan, or to a doctor, group of doctors, another healthcare provider, a hospital, or a healthcare facility. If you chose an HMO plan as your insurance, you can ONLY go to a network provider (the insurance company will give you a list of providers to choose from). HMO plans often have lower premiums and co-payments (see below), but your choice of providers is limited and you may have a longer wait for an appointment.
Deductible: This is the amount you will have to pay before the insurance will pay. The amount is dictated by the plan you have chosen and is usually charged annually. You only pay this if you use your insurance, and normally this is an annual deductible (meaning you are responsible for this once per year). Typical medical insurance deductibles can range from 0-$4,000.00. Remember to factor this amount into your decision when choosing an insurance plan.
Co-payment: (Sometimes called co-pay or co-insurance).This is the amount you will owe the doctor or other provider for your care (after you have “met”, or paid, your deductible). This will be based on a percentage of the total charge for the services you receive.
For example (just for demonstration purposes-these are not actual fees):
Let’s say you have an x-ray that costs 100.00, and it is the first procedure you have done for the year. If your deductible is 75.00 and the co-payment is 10%, here’s how the insurance company figures out what you owe:
100.00
-75.00: deductible
25.00
x .10:10% co-pay
2.50
75.00 (deductible)
+2.50 (co-pay after deductible)
77.50 Total co-payment (amount you will owe) for the x-ray
Excluded services: Services the insurance will not pay for.
Preauthorization: Sometimes, insurance will require your provider to send in paperwork and evidence (x-rays, lab tests) to prove that a procedure is medically necessary.
Primary Care Physician (PCP): A physician who directly provides or coordinates your health care. Some insurance plans require that your primary care physician give you a referral to a specialist before you can go to them.
Specialist: a provider who is specially trained to diagnose & treat certain conditions (i.e. a dermatologist for skin-related issues, a cardiologist for heart-related issues).
Referral: sometimes required by your insurance before you can go to a specialist. Your primary care physician’s office will take care of this.
Emergency room vs. urgent care coverage: Some insurance plans will only pay for an emergency room visit if your condition is life-threatening, you will need to be admitted to the hospital, or urgent care facilities in the area are not available. You will need to use your best judgment for this, but urgent care facilities can handle almost every situation: fevers, broken bones, etc. (generally anything that you can be treated for & then go home to recover).
Need more help? Here’s a more detailed glossary of health insurance terms.
