Sometimes it seems like health coverage comes with its own language! Use this mini-glossary to learn more about your choices.
Benefits (also called covered services): The healthcare services that are covered by your health plan, such as office visits, X-rays, preventive care, laboratory tests, etc.
Coinsurance: Your share of the costs of a covered healthcare service. It is calculated as a percentage. Let’s say the coinsurance is 20% and the medical bill is $100. You would pay $20 and the health plan would pay the rest.
Copayment (also called copay): Your share of the costs of a covered healthcare service, set at a fixed amount. For a doctor visit that might cost $150, you might pay $15 and the health plan pays the rest. Copayments vary by plan.
Cost-sharing: The amount of money you pay out of your own pocket for services covered by your health plan. Deductibles, coinsurance and copayments are examples of cost-sharing.
Deductible: The amount you owe for some covered services before your health plan begins to pay. For example, if your deductible is $1,000, you must pay for the healthcare services you use up to this amount. The deductible may not apply to all services.
Dependents: Spouse, domestic partner or children of the primary member.
Excluded services: Healthcare services that your health coverage doesn’t pay for or cover.
Member: The person who receives benefits under the plan.
Network: The doctors, hospitals and other healthcare providers that your health plan has contracted with to provide healthcare services.
Out-of-pocket maximum: The most you pay during a policy period (usually a calendar year). After you pay the out-of-pocket maximum, your health plan will begin to pay 100% of the allowed amount for covered services. This limit never includes your premium or charges for services your health plan doesn't cover.
Premium: The amount you pay every month to maintain your coverage.
Preventive care: Routine healthcare that includes screenings, checkups and patient counseling to prevent illnesses, disease or other health problems.
Primary care physician (PCP): A doctor who gives or coordinates healthcare services for a patient. A PCP can be a medical doctor (M.D.) or Doctor of Osteopathic Medicine.
Prior Authorization: Approval from the health plan for certain treatments and medications. In some cases, the medical group may give approval instead of the health plan. Several terms mean the same as "prior authorization" including Preauthorization, Preapproval, and Precertification.
Subscriber: The name of the primary member.