Insurance Glossary

Balance Billing – The amount of a claim you are liable for due to care you receive out of network, since your insurance company has no contract with them, or the amount not covered by your plan.

Coinsurance – The percentage you pay for covered services after you meet your deductible. (See How Deductibles and Coinsurance Work on the FAQ page)

Copayment – “Copay” – A fixed-dollar amount that is payable at the time a covered service is provided, such as a doctor’s appointment or Emergency Room visit.

Deductible – The annual amount you pay for covered services before your health insurance plan pays for all or part of the remaining covered services. (See How Deductibles and Coinsurance Work on the FAQ page)

Dependent – A person (a spouse or a child) other than the subscriber/primary insured who is covered under a health insurance plan.

Network – The facilities, doctors and other health care professionals who have agreed to offer care to a plan’s members at a specified (lower) cost. Use of a provider that is not in-network can result in more expense including higher deductibles, coinsurance and balance billing (paying the part billed by the provider that the insurance company won’t pay)

  • In-Network – Refers to the use of providers who participate in the health plan’s provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee’s out-of-pocket expense.
  • Out-of-Network – Services performed by a provider who has not signed a contract with the member’s health plan to be part of a provider network.

Pre-Existing Condition – A condition, disease, illness or injury for which medical advice, diagnosis, care or treatment was received or recommended within a specified time period prior to enrolling in a health plan. Pregnancy and genetic information are not considered pre-existing conditions. The new health plans for 2014 do not exclude pre-existing conditions.

Premium – The amount paid to keep an insurance policy active. This term is used in most types of insurance contracts.

Preventive Care – Medical services related to the prevention of disease, provided by or upon the direction of a doctor or other provider.

Primary Care Physician (PCP) – A doctor selected by the member to be the first physician contacted for any medical problem. The doctor acts as the member’s regular physician and coordinates any other care the member needs, such as a visit to a specialist or hospitalization.

Provider – A hospital, non-hospital facility, doctor or other provider, accredited, licensed or certified where required in the state of practice, performing within the scope of license or certification. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Provider Network – A set of providers contracted with a health plan to provide services to the enrollees. Many affordable health insurance plans use a provider network to help control costs.