Common health insurance terms
If jargon and insurance terms have you a bit confused, take a look at our list of the most common health insurance-related terms. Understanding what’s discussed in the health insurance world can go a long way to ensuring that you feel comfortable and empowered when it comes to choosing the right coverage.
Should you have any further questions please do contact us.
An amount considered by a health insurance company to be a reasonable expectation of the cost of a particular medical service or supplies, based on the rates in your area. Also referred to as the “allowable amount”, “maximum allowable” or “usual, customary, and reasonable charge”.
The healthcare elements, procedures, etc. that are covered by your health insurance plan.
The maximum amount an insurer will pay for a covered benefit.
A request by the insured (see Insured below) to seek payment or reimbursement for medical services received/to be received.
The amount of money the insured (see Insured below) will pay for the cost of covered treatment, following the payment of the deductible. The co-insurance is usually charged at a percentage of the costs.
A flat fee payment for certain medical expenses, to be paid by the insured (see Insured below).
The annual amount the insured (see Insured below) must pay to cover eligible medical expenses before the insurance policy becomes effective, and the insurer starts paying.
The term for an individual (spouse, child, or otherwise) who the main policyholder is financially, if not legally, responsible for and is covered under the medical plan.
A common feature of modern health insurance plans. The insurer has an agreement with specific health care facilities (see: In-network below) to be billed first. When you seek care at these facilities, they will bill the insurer first.
A list of the medications that will be covered by your plan.
Exclusion / Limitation
A condition, situation, or treatment that your health insurance plan will not cover.
Group health insurance
The name given to an insurance plan that covers a number of members under a single policy, usually offered to staff by their employers. See also: Individual health insurance.
A healthcare provider - either a hospital, pharmacy, clinic, specialist, etc - that is part of an insurer’s network. These are usually preferred providers who have agreements with insurers to offer reduced fees and charges in exchange for encouraging their clients use their services. Many insurers have also established direct billing with the facilities in their network See also: Out-of-network provider.
Individual health insurance
The name for health insurance plans that cover individual people, and any family dependents as necessary. See also: Group health insurance.
Person or people covered by a health insurance plan.
The group of specialists, professionals, hospitals, and other providers that insurers have contracted to provide medical services at favorable rates. Insurers will often recommend clients use in-network providers for seeking medical attention. See also: In-network provider and Out-of-network provider.
A healthcare provider, either a hospital, pharmacy, specialist, etc. that is not part of an insurer’s network. Seeking treatment from out-of-network providers can often cost you more, or not be covered at all. See also: In-network provider.
The maximum amount of money an insured person will have to pay for coverage during the year. Any covered medical costs incurred beyond this amount will be paid by the insurer.
The term used for the health insurance company that pays for the cost of your care. Otherwise referred to as the “carrier”.
The name of the owner of an insurance policy, whether it be an individual or a company.
A common requirement set by insurers. This means you will need to inform your insurer before any care is received in order for it to be covered.
A health problem or concern that was diagnosed, or was treated, before buying a health insurance plan.
The amount a policyholder pays monthly or annually for health insurance coverage.
The term for any person or institution that provides medical care, such as a doctor, nurse, hospital, or clinic.
A coverage option that can expand your basic insurance plan, but for an additional premium. Common riders include maternity, dental, and pre-existing condition coverage.
The process that insurers follow to determine whether or not an applicant may purchase insurance, and for setting their premium.
A period of time in which insurers may require policyholders to wait before specific coverage benefits will apply. For example, maternity coverage often comes with a waiting period before the insured may be eligible for coverage of costs related to pregnancy. Also referred to as a “moratorium”.