Common Medical Insurance Terms
Annual Out of Pocket Maximum - A dollar amount set by the plan which puts a cap on the amount of money the insured must pay out of his or her own pocket for covered expenses over the course of a calendar year.
Benefits - The services or items covered under a health insurance plan.
Claim - A request for payment that you or your health care provider submits to insurer.
Coinsurance - A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the policy's deductible has been met.
Copayment - (1) A fee that many insurance plans require an insured to pay for certain medical services (such as a physician's office visit). (2) An amount that the insured must pay toward the cost of each prescription under a prescription drug plan.
Deductible - A flat amount of covered medical expenses that an insured must incur before the insurer will make any benefit payments under a medical expense policy.
Effective Date - The specified date of when the health insurance policy is to begin.
Enrollment or Eligibility Period - The time during which a new group member may first enroll for group insurance coverage.
Exclusions and Limitations - Specific conditions, situations and services not covered by the health plan.
Explanation of Benefits (EOB): The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.
Health Care Provider - A doctor, hospital, laboratory, nurse or anyone else who delivers medical or health-related care.
In-Network (Preferred Provider) - A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Medically Necessary - Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Out-of-Network (Non-preferred Provider) - Health care services received outside the HMO, POS or PPO network.
Referral - A written order from your primary care doctor for you to see a specialist or get certain medical services.
Pre-Admission Certification - A component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.
Premium - A specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group.
Preventive Services - Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Information from UnitedHealthcare StudentResources Glossary and Healthcare.gov Glossary
