Care, Coverage & Billing Terms

Co-insurance: The percentage of covered medical costs you pay after meeting your deductible.

Co-payment (Copay): A fixed amount you pay for a particular health care service, such as a primary care or specialist visit.

Deductible: The amount you pay out of pocket for covered health care services before your insurance plan begins sharing costs.

In-Network: Providers that have contracted with your insurance company. Using in-network providers typically results in lower out-of-pocket costs.

Out-of-Network: Providers that do not have an agreement with your insurance carrier. Members generally pay a larger portion of the cost when using these providers.

Out-of-Pocket Maximum: The most you will pay during a plan year for covered medical services through deductibles, copayments, and co-insurance. Once that limit is reached, the health plan typically pays 100% of covered services for the remainder of the year.

Premium: The amount paid for health insurance coverage, often on a monthly basis.

General Health Insurance Terms

COBRA: A federal law that allows individuals to continue employer-sponsored health insurance for a limited period following certain qualifying events.

Formulary: A health plan’s list of covered prescription medications.

Marketplace: A service that allows individuals and families to compare and enroll in health insurance plans.

Primary Care Physician (PCP): A primary health care provider who delivers routine care, diagnoses common conditions, coordinates treatment, and may provide referrals to specialists.

HMO (Health Maintenance Organization): A health insurance plan that generally requires members to use a specified provider network and typically involves selecting a primary care physician.

PPO (Preferred Provider Organization): A plan that provides greater flexibility to use both in-network and out-of-network providers, generally without referrals.

Summary of Benefits and Coverage (SBC): A standardized document outlining a health plan’s benefits, costs, coverage limitations, and examples of common medical expenses.

FSA (Flexible Spending Account): An employer-sponsored account that allows employees to set aside pre-tax funds for eligible expenses.

HRA (Health Reimbursement Arrangement): An employer-funded benefit that reimburses employees for qualifying medical expenses and, in some cases, health insurance premiums.

HSA (Health Savings Account): A tax-advantaged savings account available to individuals enrolled in a qualifying High-Deductible Health Plan (HDHP).