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Health Insurance Terms**
**The following definitions are provided to help clarify terminology you might see in quotes or proposals and do not replace or supercede terms within actual carrier policies.
Coinsurance: The amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
Coordination of Benefits: A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
Copayment: The amount you will be required to pay for most office visits and consultation services only. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). Eligible expenses for other covered charges provided at the time of the office visit will be subject to the deductible and coinsurance amount. In a prescription drug program, the copayment will be the fixed amount you pay for each prescription dispensed or refilled by the participating pharmacy.
Covered Expenses: Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures and drugs the insurer agrees to pay for. They are listed in the policy.
Deductible: The amount of money you must pay each year to cover your eligible medical care expenses before your insurance policy starts paying.
Emergency Care: Health care services provided in a hospital emergency or comparable facility to evaluate and stabilize severe medical conditions.
Exclusions: Specific conditions or circumstances for which the policy will not provide benefits.
Experimental/Investigational: The use of a treatment, procedure, facility, equipment, drug, device or supply not accepted as the standard (and in some instances Federal or governmental agency approved) medical treatment of the condition.
Generic Drug: Drugs which are pharmaceutically and therapeutically equivalent to the brand name drug prescribed.
Generic Drug Copayment: The fixed amount you will pay when a generic drug is dispensed. Generic drug copayments are less than preferred drug copayment amounts.
Home Health Agency: A business that provides home health care and is licensed by the Department of Health.
Home Health Care: Skilled health care services provided at a patient's home by a Home Health Agency on an intermittent, part-time basis.
HMO (Health Maintenance Organization): Prepaid health plans. You pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO.
Hospice: A facility or agency who provides skilled nursing or therapeutic services for terminally ill patients. Hospices are licensed by state law and require certification by Medicare as a supplier of hospice care (to be eligible for Medicare coverage).
Hospice Care: Skilled health care services provided by a Hospice to terminally ill patients.
Hospital: Short term acute care facility which is licensed in the state in which it is located, provides inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of patients under the supervision of physicians. Hospitals have organized departments of medicine, diagnostic, major surgery and maintain clinical records on all patients.
Hospital Admission: The period of time between when a patient is admitted into a hospital as a bed patient and when they are discharged by the admitting physician or other professional provider.
Identification Card: The card issued by an insurance company to their subscriber showing the policy coverage information, copayment details, and deductibles.
Independent Laboratory: Medicare certified laboratory providing technical and professional anatomical and/or clinical laboratory services.
Inpatient Hospital Expense: Charges for services or supplies provided by a hospital and incurred while a patient is admitted under a physicians direction. Typical examples are items such as room and board charges.
Managed Care: Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.
Maximum Out-of-Pocket: The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
Medical-Surgical Expense: Charges for medically necessary services or supplies provided by a hospital and incurred while a patient is admitted under a physicians direction. Typical examples are physician services, physical medicine services, diagnostic x-ray and laboratory procedures, radiation therapy, dietary formulas, rental of durable medical equipment, ambulance services, and other services/supplies deemed medically necessary.
Network: A group of physicians, specialists, hospitals or other health care facilities who have executed a managed care agreement to provide heatlh care services.
Network Benefits: The benefits available for services and supplies that are provided by a network provider.
Network Physician: A physician or other professional provider who has a managed care agreement to provide health care services.
Network Provider: A hospital, physician or other provider who has executed a managed care agreement to provide health care services or supplies.
Non-Participating Pharmacy: A pharmacy which does not have an agreement to provide prescription services under a prescription drug program.
Non-Preferred Brand Name Drug: A brand name drug which does not appear on the preferred brand name drug list but is therapeutically equivalent to a drug on the preferred drug list.
Non-Preferred Brand Name Drug Copayment Amount: The copayment amount applicable to a prescription for a non-preferred brand name drug. This copayment is generally higher than either the generic or preferred brand name drug copayments.
Noncancellable Policy: A policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.
PPO (Preferred Provider Organization): A combination of traditional fee-for-service and an HMO. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered. You can use other doctors, but at a higher cost.
Preexisting Condition: A health problem that existed before the date your insurance became effective.
Premium: The amount you or your employer pays in exchange for insurance coverage.
Primary Care Doctor: Usually your first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed.
Proof of Loss: Written evidence of a claim including a claim form and bills or statements showing amounts charged for services/items and correct dignosis and prodecure code(s) for services/items performed.
Provider: Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Skilled Nursing Facility: A facility which provides skilled nursing or other therapeutic services and is either stated licensed or Medicare or Medicaid elegible to supply skilled inpatient nursing care.
Third-Party Payer: Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government. | 
