INSURANCE BASICS
What is a policy?
This is the agreement between a member and an insurer outlining covered services
What is an HMO?
A plan that requires members to choose a primary care physician.
What is Medicare?
Federal insurance program primarily for people age 65 and older.
What is a premium?
The amount paid monthly to keep coverage active.
What is a claim?
A request for payment submitted to the insurer.
Who is the insured
The person who receives health insurance benefits.
What is a PPO?
A plan that allows out-of-network care at a higher cost.
What is Medicaid?
Joint federal and state program for low-income individuals.
What is a copayment?
A fixed amount paid for a covered service.
What are covered benefits?
Services that are included under the policy.
What is a provider network?
Doctors, hospitals, and facilities that contract with an insurer
What is an EPO?
A plan combining features of HMOs and PPOs.
What is Medicare Part A?
The part of Medicare that covers hospital services.
What is coinsurance?
The percentage of costs a member pays after meeting the deductible.
What is a denial?
A claim that the insurer refuses to pay.
What is out-of-network care?
Care received outside the insurer’s contracted network.
What is an HDHP?
A high-deductible plan often paired with an HSA.
What is Medicare Part B?
The part of Medicare that covers outpatient and physician services.
What is a deductible?
The amount a member must pay before insurance starts paying.
What is an appeal?
The process of asking the insurer to review a denied claim.
What is a Summary of Benefits and Coverage (SBC)?
The document explaining what the plan covers and what it doesn’t.
What is group health insurance?
This plan is typically offered through an employer.
What is Medicare Part D?
The program that provides prescription drug coverage under Medicare.
What is an out-of-pocket maximum?
The maximum amount a member pays in a year for covered services.
What is an Explanation of Benefits (EOB)?
This explains how a claim was processed and paid.