Insurance Shopping Made Easy

Get a Free Instant Quote:

Health Insurance Glossary

Allowable Charge – the highest amount the insurer will pay to the healthcare provider for a medical service.

Ambulatory Care – outpatient care or treatment provided without hospital admission.

Ambulatory Surgery – outpatient surgery performed without requiring an overnight stay in the hospital.

Ancillary care – additional healthcare services such as lab tests, X-rays, and physical therapy.

Anniversary date – the day after the coverage ends.

Behavioral care services – evaluation and treatment for mental health issues and substance abuse.

Benefits – healthcare services included in your health plan’s coverage that you don’t have to pay for out-of-pocket.

Board-certified – the physician has passed an exam demonstrating mastery in their field of specialization.

Brand-name drug – a medication produced and sold by a pharmaceutical company and protected by a patent.

Carrier – a health insurance company that provides coverage.

Claim – a formal request for payment for a medical service covered by the health plan’s benefits.

Coinsurance – the portion of the cost of a medical service that the member pays as a percentage after reaching the deductible amount.

Consolidated Omnibus Budget Reconciliation Act (COBRA) –  a Federal law that requires employers (provisions apply) to allow their members to continue their coverage even after they have lost their job or their work hours have been reduced. COBRA coverage usually lasts for 18 months but may be longer for some.

Coordination of Benefits – This occurs when the insured has multiple group health insurance plans. The plans work together to prevent duplicate payments for the same benefit. One plan is designated as the primary, and the other becomes the secondary plan.

Co-payment (copay) is a set dollar amount the member pays for healthcare benefits after the deductible is reached.

Deductible – is the amount a member has to reach through accumulated out-of-pocket payments for medical services. Those enrolled in plans that have a deductible need to reach their deductible before their coverage kicks in.

Durable medical equipment – equipment used for a patient’s medical needs at home. Can range from simple canes, crutches, and walkers, to hospital beds and diabetic equipment.

Exclusive Provider Organization (EPO) – a type of health plan where care is exclusively received from in-network providers; no need to elect a primary care physician (PCP); and no need to get a referral to see a specialist. There is a deductible and copayments apply.

Explanation of benefits (EOB) – a statement sent to members who filed a claim. providing detailed information on claims payment. It includes the date of service, provider’s name, billed amount, amount paid by the insurer, and the member’s portion of the cost.

Formulary – a list of prescription drugs approved and covered by the plan’s benefits.

Gatekeeper – the primary care physician (PCP) responsible for coordinating a patient’s care. Some health plans require members to obtain a referral from their PCP before seeing specialists, hence the term “gatekeeper.”

Generic drug – is identified solely by its formula name rather than a brand name. The Food and Drug Administration monitors generic drugs to ensure they are as good as brand-name drugs.

Health Maintenance Organization (HMO) – a type of health plan where care is provided through a network of health care providers.

Health Reimbursement Arrangement (HRA) – is a setup in which an employer contributes to a fund designed to reimburse covered employees for their healthcare expenses.

HIPAA – the Health Insurance Portability and Accountability Act of 1996, permits individuals to retain their health coverage when transitioning jobs, even if they have a pre-existing condition. Additionally, HIPAA safeguards the privacy and security of individuals’ medical records.

Home Health Care – refers to healthcare services provided by medical professionals within a patient’s own residence.

Indemnity plan – also known as a fee-for-service plan, permits the insured individual to receive healthcare from any chosen provider. Initially, the insured pays for the services out of pocket, after which the insurer reimburses a portion or all of the covered service costs.

In-Network Provider – a group of healthcare professionals and facilities that have entered into a contractual agreement with a health insurance company to offer medical services to the company’s members.

Inpatient Care –  all forms of medical treatment provided by a healthcare facility to an admitted patient.

Managed Care – a managed system of health care delivery to reduce cost and get the necessary medical care. HMOs, POSs, PPOs are examples of managed care plans.

Non-Participating Provider – any healthcare professional or facility that offers medical services but lacks a formal contract with an insurance plan.

Occupational Therapy – activities focused on rehabilitating a person’s physical abilities necessary for everyday tasks such as bathing, walking, or eating using utensils.

Out-of-Network Provider – refers to health care providers and facilities that are not part of your insurer’s contracted network.

Out-of-Pocket – the portion of the cost of a medical service that is not covered by your health insurance policy and thus needs to be paid by you directly. Examples include deductibles, co-insurance, and co-payments.

Out-of-Pocket Maximum -is the highest total amount that a member will have to pay for their medical expenses over the course of their coverage.

Outpatient Care – also known as ambulatory care, this refers to medical care a patient receives without being admitted to a facility.

Participating Provider -a healthcare professional, doctor, or health facility that is part of a health insurance network. They offer medical services within the network in exchange for a predetermined fee as outlined in their contracts.

Point-of-Service (POS) plan – a type of health insurance plan that permits members to seek care outside of the network, albeit with a higher copayment. However, members are mandated to select a primary care physician within the network.

Precertification – the process of obtaining approval from the patient’s health plan before medical services are administered. A healthy policy can specify services which need prior approval before administration.

Pre-Existing Condition – any medical condition that has been diagnosed or treated within a defined time period before the commencement of health coverage.

Pre-Existing Condition Limitations – the insurer withholds coverage for medical services towards a pre-existing condition until after the waiting period.

Preferred Provider Organization (PPO) Plan – this plan offers its members the power to choose between getting medical services within the network or outside the network. Going outside the network will cost more. Members of this plan do not require a referral from a primary care physician to visit a specialist.

Preventive care – consists of tests and medical services intended to detect and prevent diseases at an early stage.

Primary Care Physician (PCP) – is your main healthcare provider who offers a comprehensive range of medical services. Your PCP also coordinates referrals to specialists and any other necessary care.

Urgent Care – involves addressing illnesses or injuries requiring medical attention within  24 hours. It’s distinct from emergency care.

Usual, Customary or Reasonable (UCR) – refers to the amount reimbursed to healthcare providers, which is determined based on the prevailing rates in the area.


"Vista Health Solutions" Tel (888)215-4045 Email [email protected]