Insurance Basics
This is the amount a Member pays each month to keep their health insurance active.
This type of provider is often the first stop for routine care, preventive care, and general health concerns.
Primary care provider
This document explains what a health plan covers, what it excludes, and what costs may apply.
SPD (Summary Plan Document)
This is a list of medications covered by a prescription drug plan.
Formulary
This is the process of helping a member understand where to go, what questions to ask, and what next steps to take.
Navigation
This is the amount a Member pays out-of-pocket before the insurance plan starts paying for many covered services.
Deductible
This type of provider focuses on a specific area of medicine, such as cardiology, dermatology, or orthopedics.
Specialist
These are services like annual physicals, vaccines, and screenings that may be covered before a member is sick.
Preventative care
These medications usually cost less because they do not use a brand name, but they have the same active ingredient as the brand-name version.
Generic
This skill helps confirm that the member’s concern was heard and understood before offering solutions.
Reflective listening
This is a fixed dollar amount a Member pays for a covered service, such as a doctor visit.
Co-pay
This term means a provider or facility has a contract with the member’s insurance plan.
In-network
This is approval from the insurance plan before a service is provided.
Prior authorization
This pharmacy option can be helpful for maintenance medications taken regularly over time.
Mail-order pharmacy
This is the safest response when benefits information is unclear, conflicting, or unavailable.
Verify before giving a final answer
This is the percentage of costs a Member pays after meeting the deductible.
Coinsurance
This type of care is for serious or sudden health issues that are not usually life-threatening, such as a sprain or minor infection.
Urgent care
This is a request asking the insurance plan to review and potentially reverse a denied claim or coverage decision.
Appeal
This requirement means the plan may ask the member to try a lower-cost or preferred medication before covering another medication.
Step therapy
This kind of question encourages the member to explain their situation in their own words instead of answering yes or no.
Open-ended question
This is the most a member should have to pay for covered in-network care during a plan year, not including premiums.
Out-of-pocket maximum
This is the best place to go for severe, life-threatening, or potentially disabling symptoms such as chest pain, trouble breathing, or stroke symptoms.
Emergency room
This happens when a member has coverage under more than one health plan and the plans determine which one pays first.
Coordination of benefits
This is a higher-cost medication that may require special handling, monitoring, or prior authorization.
Specialty medication
This is the practice of explaining the next step, who owns it, and when the member can expect follow-up.
Setting expectations