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Glossary
Confused about health insurance terms? Check out these helpful definitions.
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Benefits—Services covered by a health care plan, like doctor visits or prescription coverage.
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Brand-name drug—A medication sold by a company under patent protection, which makes it more expensive than its generic equivalent.
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COBRA (Consolidated Omnibus Budget Reconciliation Act)—A government ruling that requires businesses with 20 or more employees to offer employees and their families a temporary extension of health insurance coverage after a voluntary or involuntary loss of a job.
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CDHP (Consumer-Directed Health Care Program)—Health insurance plan that puts you at the center of decision-making, giving you control over how you use your benefit dollars.
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Coinsurance—The percent of the bill you have to pay yourself. For example, a 25 percent coinsurance for drugs means you pay 25 percent of the costs and your health care plan pays 75 percent.
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Copay—A small, flat fee you pay for a specific health care service—like a doctor visit.
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Deductible—The amount you have to pay for health care expenses before your insurance starts to cover the costs.
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DOI (Department of Insurance)—The DOI protects your insurance rights and monitors insurance companies.
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Effective date of enrollment—The date your membership in a health insurance plan begins.
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Emergency services—Treatment you receive at an emergency room to evaluate or stabilize an emergency medical condition.
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Exclusion—A medical service that a health care plan won't cover. (For example, cosmetic surgery is often not covered.)
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(FFS) Fee-for-Service plan—A type of health insurance that lets you choose any doctor, hospital or other provider—as long as it accepts your plan.
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Formulary—A list of drugs covered by a health insurance plan. If a drug is on the plan's formulary, it costs less than a non-formulary drug.
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Generic drug—A copy of a brand-name drug that offers the same safety, quality and performance at a lower price.
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Group health care plan—A plan you can enroll in through your job, a union or a professional association (like the Writer's Guild).
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Health education—Educational programs that teach you how to take better care of your health.
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Health insurance—A plan that pays for some or all of your medical costs.
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Health Savings Account—A tax-free account opened by you or your employer to save money for your medical expenses. Any money not used for expenses may be rolled over to the next year.
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HMO (Health Maintenance Organization)—A form of managed care plan that charges a low monthly rate with no deductibles. However, only visits to professionals in the plans' network are covered.
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Indemnity plan—An indemnity plan pays for your medical expenses no matter which doctors or hospitals you use.
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Individual health plan—An insurance plan you enroll in on your own, not through your job. It's often used by self-employed or unemployed workers, or employees with no group health insurance for themselves or their families.
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Inpatient services—Medical treatment you receive while you're staying overnight in the hospital.
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Insurance Store Advisor—A representative who answers your questions and helps you enroll in a health care plan from The Insurance Store.
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Managed care—A type of health care plan that uses a network of doctors, hospitals and other providers. If you're a member, you may have to use a doctor or hospital that belongs to the network.
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Multi-specialty group—A doctors' practice that several different types of specialists belong to.
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Network—A group of doctors or other professionals who provide treatment at a reduced rate through a contract to a health care plan.
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Optional benefits—Extra benefits that don't automatically come with your plan. You pay an additional fee to add them to your coverage.
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OOP (Out of pocket)—The charges you must pay for services after your coverage runs out.
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Out-of-pocket limit—The maximum amount of medical charges you and your family will have to pay each year.
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Outpatient services—Medical treatment that doesn't require an overnight stay at a hospital or clinic.
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(PBM) Pharmacy benefit manager—A third-party administrator of a prescription drug program that processes and pays prescription drug claims.
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Plan premium—The amount you pay each month for your health insurance coverage.
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POS (Point of Service)—A type of managed care plan that allows you to go to any doctor or medical facility without restrictions. However, you must pay coinsurance and an annual deductible.
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PPO (Preferred Provider Organization)—A type of managed care plan that lets you choose doctors and other providers outside of its network, although you'll have to pay more for services than if you stay in-network.
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Pre-existing Condition—A sickness or injury for which you were treated prior to your plan's effective date of coverage.
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Preventive care—An approach to health care that emphasizes taking care of small conditions before they become more serious and expensive to treat. Preventive care benefits include routine check-ups and flu shots.
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PCP (Primary care physician)—Doctors that provide a full range of basic health services to their patients. General practitioners, pediatricians, family practice physicians and internists are primary care physicians.
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Short-term health care—A type of individual health insurance that covers you from 1 to 12 months only.
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Specialist—A doctor who provides health care services for a specific disease or part of the body. Examples include oncologists (care for cancer patients) and cardiologists (care for the heart).
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Urgent care—Care you receive for a sudden illness or injury that needs medical treatment right away, but is not life threatening.
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