Health Insurance Basics
The amount you pay every month to maintain your health insurance coverage.
What is a premium?
Under this type of plan, you typically must choose a primary care provider (PCP) and get a referral to see a specialist.
What is a Health Maintenance Organization (HMO)?
This federal program provides health insurance for Americans aged 65 and older.
What is Medicare?
A person who has this is entitled to receive benefits according to their health insurance policy.
What is an eligible individual or beneficiary?
This is the network of hospitals, doctors, and other providers that contract with a health plan to offer services to members.
What is a provider network?
The amount you must pay out-of-pocket for covered services before your plan begins to pay.
What is a deductible?
This plan offers more flexibility, allowing you to see both in-network and out-of-network providers, though at a higher cost.
What is a Preferred Provider Organization (PPO)?
This part of Medicare covers hospital insurance, including inpatient stays and skilled nursing facility care.
What is Medicare Part A?
This law ensures that an employer must continue to offer health coverage to former employees for a limited period.
What is the Consolidated Omnibus Budget Reconciliation Act (COBRA)?
This is the process of getting pre-approval from your insurance company for certain medical services, procedures, or prescriptions.
What is preauthorization or prior authorization?
This is the specific, flat dollar amount you pay for each medical service, like a doctor's visit or prescription.
What is a copayment or copay?
This plan combines elements of an HMO and a PPO, allowing you to choose a PCP who then makes referrals to a network of specialists.
What is a Point-of-Service (POS) plan?
A joint federal and state program, this insurance primarily helps low-income individuals and families.
What is Medicaid?
This federal act was signed into law in 2010 to expand access to health insurance and reform the American healthcare system.
What is the Affordable Care Act (ACA)?
The formal document sent from a doctor to your insurance company detailing the services and charges for a medical procedure.
What is a claim?
The percentage of covered medical expenses you pay after meeting your deductible.
What is coinsurance?
This consumer-driven plan features a high deductible and is often paired with a Health Savings Account (HSA).
What is a High-Deductible Health Plan (HDHP)?
This term refers to private insurance plans, like Medigap, that can help cover costs not paid by Original Medicare.
What is a Medicare Supplement Policy or Medigap?
Often associated with the ACA, this term describes the list of services that all health plans sold on the Marketplace must cover.
What are Essential Health Benefits?
For health plans with prescription coverage, this term refers to the list of covered medications.
What is a formulary?
The maximum amount you will have to pay for covered medical expenses during a policy period before your insurance covers 100% of the cost.
What is the out-of-pocket maximum?
Under this plan, the insured must pay for a service at the time of care and then submit a claim for reimbursement from the insurance company.
What is an indemnity plan?
Encompassing vision, dental, and prescription drug coverage, these are benefits often included in many Medicare Advantage plans.
What are Medicare Part C plans?
A clause that prevents duplication of payments by ensuring that if an individual has more than one health plan, the two plans work together to determine how much each will pay.
What is Coordination of Benefits?
An insurance company's refusal to cover a particular medical service or procedure, often because it is not considered medically necessary.
What is an exclusion?