Basic Terms
What is a premium?
This is what you pay every month for insurance
What is a claim?
This is the bill you get for medical services.
What is in-network?
This means your doctor is covered by your plan.
What is preventive care?
This includes checkups and screenings to stay healthy.
What is a formulary?
A list of drugs covered by insurance.
What is a deductible?
This is the amount you must pay before insurance starts helping.
What is a balance?
This is the part of the bill you still owe after insurance pays.
What is out-of-network?
This means the doctor is not covered and may cost more.
What is emergency care?
care for sudden, serious health problems.
hat are generic drugs?
Lower-cost versions of brand-name drugs.
What is an out-of-pocket maximum?
This is the most you pay in a year before insurance covers 100%.
What is cost-sharing
This term means your insurance pays part and you pay part.
What is a referral?
Some plans require this to see a specialist.
What is outpatient care?
Care you get without staying overnight in a hospital.
What are specialty drugs?
Higher-cost drugs often placed in special tiers.
What is a copay?
This is a fixed amount you pay for a doctor visit.
What is an out-of-pocket maximum?
This is a yearly limit on what you must pay yourself.
What is a primary care physician (PCP)?
This is a doctor who focuses on general health care.
What is inpatient care?
care that requires staying in the hospital.
What are drug tiers?
Levels that determine how much you pay for medications.
What is coinsurance?
This is the percentage of costs you pay after your deductible
What is an allowed amount?
This is the amount providers agree to charge insurance members.
What is an HMO (Health Maintenance Organization)?
This type of plan usually requires referrals and staying in-network.
What is the Affordable Care Act?
This law requires many plans to cover essential health benefits.
What is prior authorization?
Approval needed before insurance covers certain medications.