Health Insurance Glossary of Terms

As with any genre, health care insurance is filled with jargon exclusive to its field. The following is a list of health insurance terms and their meanings that will hopefully give you good grasp of what these health insurance terms mean.

COINSURANCE
The percentage of medical costs you have to paying after meeting the deductible amount that is attached to your plan.

CO-PAYMENT
This occurs under an HMO plan and requires a specified dollar amount be paid to the health insurance provider on each visit.

COVERED BENEFITS
A covered benefit must always be a medical necessity. The determination of whether something is a medical necessity or not is made by the health insurance company.

DEDUCTIBLE
The amount you must pay in medical expenses before your health insurance company will begin to cover your medical bills.

DEPENDENT
A dependent is someone other than yourself who is covered under your health insurance plan. This could include a spouse, child, unmarried partner. For children there are age limits at which they are no longer covered under a parent’s health policy.

DISABILITY
In the event that you are unable to work for an extended period of time due to an injury or a medical condition, disability insurance provides funds to cover your living expenses in a specified amount.

GATEKEEPER
Another title for your Primary Care Provider (PCP)

GROUP INSURANCE
Employers often offer group insurance plans. Under group insurance an employee can generally obtain a much more affordable plan.

IN NETWORK/OUT OF NETWORK
In network refers to those physicians who have been contracted under a health care plan to provide services to their members. Staying in network allows lower charges and a smaller percentage of out of pocket expenses. Conversely, going out of network generally means charges are higher and you will have to pay a greater percentage of out of pocket expenses.

GRACE PERIOD
This is a specified period past the due date of a premium during which coverage may not be canceled. This prevents health insurance companies from canceling your policy if payment should arrive a few days late.

OPEN-ENROLLMENT PERIOD
Generally, this is a once-a-year period of time that allows you to make changes to your existing health insurance coverage. (A change in marriage status or the birth of a child also allows you to modify your health insurance plan.

PRE-CERTIFICATION(Pre-authorization)
Before surgery or hospitalization, the insurance company must be contacted to get approval for a medical service to take place. Failure to do so typically means the insurance company will NOT pay for the service. This does not apply in an emergency situation, although the insurance company should be contacted as soon as possible.

PRE-EXISTING CONDITION
A medical condition that existed before an insurance policy became effective. Most insurance companies require a three month to one year waiting period before a pre-existing condition can be covered under their plan.

PREMIUMS
Monthly payments made to the health insurance company for health insurance coverage.

REFERRAL
A written form from your Primary Care Provider to another Dr. (usually a specialist) giving consent for you to go to them for medical services.

SECOND SURGERY OPINION
On occasion an insurance company will ask you to be seen by a second Dr. to determine if the recommended procedure is necessary or if an alternate method could accomplish the same result.

URC (Usual, reasonable, and customary)
URC refers to the dollar amount an insurer will usually pay for a service or procedure based on what is customary for the area in which you live. An insurance company will not pay $800 for a procedure that costs only $300.