| Auto insurance |
Insurance billed due to an auto accident or a theft
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| Bad Debt |
A person or persons whose account that has been sent to a collection agency for further action
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| Balance statement |
A statement that shows a balance on an account which has not been paid
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| Benefit coverage |
Services provided to plan members as described by insurance policy
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| Claim |
A demand for payment in accordance with an insurance policy
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| Co-insurance |
The percentage of treatment cost for which the consumer is responsible on an insurance claim
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| Co-pay/Co-payment |
The fixed dollar amount the consumer must pay for each visit to a doctor’s office
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| Deductible |
The annual amount the consumer must pay for medical services (excluding premiums) before the insurance plan begins covering costs
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| Exclusions |
Medical services not covered by an insurance policy
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| Fee for service |
A plan in which the insurance company and consumer share the cost of treatment according to a fixed ratio. (For example, the company might pay 80 percent, while the consumer pays 20 percent in co-insurance)
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| Formulary |
A list of medications covered by an insurance plan
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| HDHP/High-deductible health plan |
A plan that offers lower monthly premiums but much higher deductibles (often more than $2,000 for individuals and $5,000 for families) than typical managed-care plans
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| HMO/Health Maintenance Organization |
A health maintenance organization, or HMO, offers insurance plans in which the consumer pays a modest co-payment for doctor and hospital visits, but coverage is restricted to participating doctors. Specialist care requires a referral from a primary care provider
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| HSA/Health Savings Account |
A tax-free, portable savings account that is used to pay medical expenses. Unused funds can be carried over from year to year. Requires enrollment in a high-deductible health plan (HDHP).
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| In-network |
A term that refers to the fact that a doctor or hospital is part of the group (network) whose services are covered by an insurance plan at the maximum rate
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| Insurance company |
A financial institution that sells insurance
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| Insured |
A person or persons who is a policyholder of an insurance policy. Also known as the subscriber, policyholder, cardholder, beneficiary or consumer
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| Medicaid |
A federal and state-funded program that pays for medical care for those who cannot afford it
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| Medicare |
A federal program that helps pay for medical care for people age 65 and older, or who have certain disabilities. Those enrolled are responsible for premiums, deductibles and co-payments
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| Medigap |
Private insurance used to fill gaps in Medicare coverage
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| Out-of-network |
A term that refers to the fact that a doctor or hospital is not part of the group (network) whose services are covered by an insurance plan at the maximum rate
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| Outpatient |
A patient who is admitted to a hospital or clinic for treatment that does not require an overnight stay.
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| PCP/Primary Care Physician |
A doctor chosen by a patient in a managed-care plan to provide routine care, as well as referrals to medical specialists
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| POS/Point-of-service plan |
An option, also called a point-of-service plan, offered with certain health maintenance organizations (HMOs) allowing for some coverage for out-of-network treatment. Consumer often can visit specialists without a referral from a primary-care physician
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| PPO/Preferred Provider Organization |
An insurance plan in which the consumer pays a co-payment for visits to in-network doctors. PPOs partially cover treatment by out-of-network doctors
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| Personal injury |
When a person has suffered some form of injury, either physical or psychological, as the result of an accident
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| Plan |
A program or policy stipulating a service or benefit
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| Policy |
A written contract or certificate of insurance
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| Pre-authorization |
An insurance plan requirement that you or your primary doctor need to notify the insurance in advance of certain medical procedures or inpatient stays
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| Pre-existing condition |
A medical condition not covered by an insurer because the consumer is believed to have had the condition prior to obtaining the policy
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| Premium |
A fee paid by the consumer for participation in a health plan
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| Prescription |
A written order, especially by a physician, for the preparation and administration of a medicine or other treatment.
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| Referral |
The recommendation of a medical professional
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| Secondary claim |
A request for payment after a primary insurance has processed a claim
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| Self Pay |
Uninsured patient who has no third party insurance coverage
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| Stop-loss |
The point at which a consumer has fully paid the deductible and reached the maximum amount of co-payment required by an insurance policy. Insurance covers 100 percent of additional costs for the remainder of the year
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| Worker's compensation |
Payments required by law to be made to an employee who is injured or disabled in connection with work
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