What Do These Common Health Insurance Words Mean?

Health insurance can be confusing, including some of the words you may read or hear. But the more you know, the better you can manage your health. Find out more now!

September 28, 2016 | HF Healthy Living Team

How many of these words do you know? Learning what these terms mean can help you understand how health insurance works and can keep you focused on staying healthy.

Annual or Open Enrollment Period

The period each year during which eligible individuals may choose to keep their existing health insurance plan or enroll in a new one. This time period varies by plan or program.

If you need a health insurance plan outside of this time period and are not eligible for a health plan that allows enrollment all year round, you may still be able to get a health plan if you’ve had a Qualified or Qualifying Life Event (QLE). These events include birth of a child, marriage, loss of employment, loss of coverage, change in place of residence, and more. Learn more about Qualifying Life Events here.

Coinsurance

The fee you owe a provider for your care after you meet your annual deductible. The amount you owe is part of the cost of your care. Your insurance company pays the rest. For example, your coinsurance amount might be 20%. In this case, after you meet your deductible, your health insurance plan will pay 80% of the remaining cost. You will pay 20% of the remaining cost.

Copayment (or Copay)

The fee that you pay each time you go to the provider, get a prescription drug filled, or get other services. For example, if your health plan has a $20 PCP copayment, you must pay $20 for a checkup with your Primary Care Provider (PCP).

Deductible

The amount of money you must pay in covered expenses each year before your plan or program pays anything for certain covered services. The deductible may not apply to all services. Not all plans require deductibles.

For example, if your deductible is $500, you need to spend $500 for covered healthcare services within one year before your plan or program will start paying for your health services. Your deductible resets once every year.

Dependent

An individual who is legally eligible for health plan benefits because of his or her association with the insured subscriber (the insurance policy holder). Usually a dependent is a member of the subscriber’s family.

Formulary

A list of prescription drugs (both generic and brand name) covered by your health plan. This may also be called a Preferred Drug List.

Maximum Out-of-Pocket (MOOP)

The amount of money you have to pay each year for expenses covered by your plan (i.e., the sum of the deductible, copay, and coinsurance amounts). Once you reach this amount, you do not pay anything for most services. This does not include your monthly premium costs, any charges from out-of-network healthcare providers, or services that are not covered by the plan.

Out-of-Network

A healthcare provider (doctor or hospital) that is not a part of a plan network. You will typically pay more if you use a provider that is not in your plan network.

Preauthorization/Precertification

Some health insurance plans require you to check with them before you get certain services. This is to make sure that these healthcare services are covered before you get them, so that you will not be responsible for the entire cost.

Premium

The amount of money you must pay monthly, quarterly, or twice a year to be covered by a health insurance plan or program.

Preventive Care Services

The services you receive from your provider that help prevent disease or to identify disease while it is more easily treatable. Under Healthcare Reform, most of these services are 100% covered by your health insurance plan, which means that you will not have to pay for them.

Primary Care Provider (PCP)

Your PCP provides you with basic healthcare and preventive services to help make sure you stay healthy. Your PCP coordinates most of your care, authorizes treatment, and may refer you to specialists.

Subsidy

Monetary assistance to help pay health insurance expenses, provided in the form of a refundable tax credit.

 

© 2016 HF Management Services, LLC.

Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

This health information or program is for educational purposes only and not intended to treat, diagnose, or act as a substitute for medical advice from your provider. Consult your healthcare provider and always follow your healthcare provider’s instructions.

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