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