Common health insurance terms

Commonhealth insurance terms

COVERAGE

COST

ADMIN

Carrier

allowed amount

benefit / plan

An entity defined by the state law that is authorized to sell health insurance plans (insurance company)

The maximum amount your insurer will pay for covered services.

The healthcare services covered by your health plan, which is the type of coverage you pick.

CLAIM

balance billing

benefit year

The demand for payment of services from a medical provider to the insurance company.

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)

enrollment period

COST SHARING

Coordination of benefits

Your part of the bill, which can include coinsurance (%), copayment (fixed amount), deductible or other similar charges.

When you can sign up for health insurance (Usually initial, open or special enrollement)

How your insurance gets coordinated if you have more than one insurance provider.

deductible

excluded services

explanation of benefits

A statement that breaks down a claim, including what the insurer paid and how much you may owe.

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.

pcp

out-of-pocket limit

network

A list of providers that your plan contracts with, which includes in-network (covered) and out-of-network (may not be covered)

The maximum amount that you will have to pay out of pocket for covered services in a plan year

Your primary care physician or primary care provider, who oversees your healthcare.

plan type

premium

pre-authorization

How much you pay for insurance, typically broken down into monthly dollar ($) amount.

Example include PPOs and HMOs, it refers to your plan's approach to coverage (flexible vs strict)

Also called pre-approval, it's the determination that a treatment or service is medically necessary.

provider

subsidy

rx coverage

Or advance premium tax credit, it's dollar amount provided by the government that offsets your monthly premium under ACA.

An entity providing your care, which can be preferred or non-preferred.

How much your health plan pays for your prescription drug coverage.