This common Health Insurance terms you should now.
The maximum amount that your insurer will pay for covered services.
|Benefit / Plan|
The health care services covered by your health plan, which is the type of coverage you pick.
An entity defined by state law that is authorized to sell health insurance.
The difference between the allowed amount and what your provider charges (what you owe).
How long your benefits are good for, typically one calendar year (January to December).
The demand for payment of services from a medical provider to the insurance company.
Your portion of the bill, which can include coinsurance (a percentage), copayments (fixed dollar amounts),the deductible or other similar charges.
|Coordination of Benefits|
How your insurance gets coordinated if you have more than one insurance provider.
When you can sign up for health insurance (for private plans under the ACA, November through January).
How much you have to pay before your health plan starts to pay its portion of the bill.
What your health insurance provider will not cover under your health plan.
|Explanation of Benefits|
A statement that breaks down a claim, including what the insurer paid and how much you may owe.
The maximum amount that you will have to pay out of pocket for covered services in a plan year.
A list of providers that your plan contracts with, which includes in-network (covered) and out-of-network (sometimes not covered).
Your primary care physician or primary care provider, who oversees your health care.
How much you pay for insurance, typically broken down into a monthly dollar amount.
Also called pre-approval, it’s the determination that a treatment or service is medically necessary.
Examples include HMOs and PPOs, it refers to your plan’s approach to coverage (e.g., flexible vs. strict).
Also called an advance premium tax credit, it’s a dollar amount provided by the government that offsets your monthly premium under Obamacare.
How much your health plan pays for prescription drug coverage (varies by plan).
The medical entity providing your care, which can be preferred (contracted with your health plan) or non-preferred (no contract), the latter being more expensive.