Insurance Glossary
1. Premium
The amount you pay every month (or year) to keep your health insurance active.
2. Deductible
The amount you must pay out of pocket for medical care before your insurance starts paying.
3. Copayment (Copay)
A fixed amount you pay for a covered healthcare service (like $25 for a doctor visit).
4. Coinsurance
The percentage of costs you pay after you’ve met your deductible (for example, 20% of the bill).
5. Out-of-Pocket Maximum
The most you’ll have to pay for covered services in a year. After that, your insurance covers 100%.
6. Network
The group of doctors, hospitals, and other providers your insurance company has contracts with.
7. In-Network Provider
A doctor or facility that’s part of your plan’s network and usually costs less to visit.
8. Out-of-Network Provider
A doctor or facility not contracted with your insurance company, often resulting in higher costs.
9. Primary Care Physician (PCP)
Your main doctor who handles general health needs and referrals to specialists.
10. Specialist
A doctor who focuses on a specific area of medicine (like a cardiologist or dermatologist).
11. Referral
A written order from your primary doctor to see a specialist or get special services.
12. Preventive Care
Routine checkups, screenings, and vaccines that are often covered at no cost.
13. Explanation of Benefits (EOB)
A statement from your insurance company explaining what was covered, what they paid, and what you owe.
14. Preauthorization (Prior Authorization)
Approval from your insurance company before getting certain procedures or prescriptions.
15. Claim
A request your provider or you send to the insurance company asking for payment.
16. Dependent
A family member (like a spouse or child) covered under your health insurance plan.
17. Open Enrollment
The yearly period when you can sign up for or change your health insurance plan.
18. Qualifying Life Event (QLE)
A major change (like marriage, having a baby, or losing a job) that lets you enroll outside Open Enrollment.
19. Marketplace (Exchange)
The government website where individuals can compare and buy health insurance plans.
20. Subsidy
Financial assistance from the government that helps lower your insurance costs if you qualify.
21. HMO (Health Maintenance Organization)
A type of health plan that requires you to use doctors and hospitals within its network. You usually need a referral from your primary care doctor to see a specialist.
22. PPO (Preferred Provider Organization)
A flexible health plan that lets you see any doctor, but you’ll pay less if you use doctors within the plan’s network.
23. EPO (Exclusive Provider Organization)
A plan that only covers services from doctors and hospitals in its network, except in emergencies. No referrals are usually needed.
24. POS (Point of Service Plan)
A plan that combines features of an HMO and PPO. You need referrals for specialists but can see out-of-network doctors at a higher cost.
25. COBRA
A federal law that allows you to keep your employer’s health insurance for a limited time after losing your job, though you pay the full premium.
26. FSA (Flexible Spending Account)
An account where you can set aside pre-tax money to pay for eligible medical expenses within the plan year.
27. HSA (Health Savings Account)
A tax-free savings account you can use to pay for medical expenses. It’s available if you have a high-deductible health plan (HDHP).
28. High-Deductible Health Plan (HDHP)
A plan with lower monthly premiums but higher out-of-pocket costs before insurance begins to pay.
29. Formulary
A list of prescription drugs covered by your health insurance plan. Drugs not on the list may cost more or not be covered.
30. Generic Drug
A medication that has the same ingredients and effects as a brand-name version but usually costs less.
31. Brand-Name Drug
A medication sold under a specific company name, typically more expensive than generic alternatives.
32. Preexisting Condition
A health issue that you had before your new insurance coverage started. Under current law, most plans cannot deny coverage for preexisting conditions.
33. Lifetime Maximum
The most your insurance company will pay for your care over your lifetime. This limit is no longer allowed under most ACA-compliant plans.
34. Medical Necessity
A term used by insurance companies to decide if a treatment or service is needed to diagnose or treat a medical condition.
35. Outpatient Care
Medical treatment or procedures that do not require an overnight stay in a hospital.
36. Inpatient Care
Care that requires you to be admitted to a hospital for at least one night.
37. Urgent Care
Medical attention for conditions that are not life-threatening but need quick treatment, such as minor injuries or infections.
38. Emergency Room (ER)
A hospital department that treats severe or life-threatening conditions and emergencies.
39. Telehealth
Healthcare services provided remotely by phone or video instead of in person.
40. Out-of-Pocket Costs
Any medical expenses you pay directly, such as deductibles, copayments, and coinsurance, that are not reimbursed by insurance.