Claim
A request for payment of medical expenses submitted to your insurer
Coinsurance
In an FFS plan, coinsurance is the percentage of medical expenses that you have to pay for after you have paid your deductible.
Coordination of Benefits
If you are covered by multiple group plans, this institution typically limits the benefits that you can receive to one hundred percent of the claim.
Co-payment
A flat fee that you pay any time you receive certain medical services
Covered Expenses
The medical services and expenses that an insurer agrees to pay for in a given policy
Customary Fee
The maximum fee that an insurance company sees as reasonable and customary for a given medical service in a given area. If your doctor charges more than this, and you get the service from them, you will have to pay the entire difference between the customary fee and what your doctor charges.
Deductible
The annual amount of medical expenses that you must pay before your insurance starts contributing
Exclusions
Specific situations and conditions stipulated in a policy that prevent you from receiving benefits
IPA (individual practice association)
Independent group of doctors contracted with an HMO (or similar organization) to take care of patients
Managed Care
Methods used by health insurance companies to control costs, use, and quality of health care
Maximum Out-of-Pocket Expenses
The maximum dollar value you are required to pay in a given year between your deductible and coinsurance (monthly premiums are excluded from this)
Non-cancellable Policy
Also known as a guaranteed renewable policy, it guarantees that you can receive health insurance as long as you pay the premium.
Pre-existing Condition
A health problem that you suffered from before the day your policy became active.
Premium
The (typically monthly) amount paid for coverage
Primary Care Doctor
A doctor you typically choose from a network who you visit regularly and who treats any minor health complications. Your primary care doctor can refer you to specialists if additional care is needed. This specialist care will probably only be payed for by your policy if your primary care doctor recommended it.
Provider
A person or place that provides health care. This includes but is not limited to doctors, nurses, dentists, optometrists, and hospitals
Third-Party Payer
Anyone or any thing that pays for your health care services that is not you. Examples include insurance companies, HMOs, PPOs, and the government