Health Insurance Terms

Agent -a licensed individual who represents several insurance companies and sells their products. Benefit -reimbursement for covered medical expenses as specified by the plan.

Brand-Name Drug – prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on some health plans. (see “generic.”)

Broker – a licensed insurance professional who obtains multiple quotes and plan information in the interest of his client.

Carrier – insurance company insuring the health plan.

Certificate Booklet – the plan agreement. A printed description of the benefits and coverage provisions intended to explain the contractual arrangement between the carrier and the insured group or individual. May also be referred to as a policy booklet

Claim – a formal request made by an insured person for the benefits provided by a policy.

COBRA – (Consolidated Omnibus Budget Reconciliation Act)- Federal legislation that requires group health plans to provide health plan members the opportunity to purchase continued coverage in the event their insurance is terminated. Applies only to employer groups with 20 or more employees. Learn more about COBRA at the Department of Labor’s website. – Please note this may take a few minutes to appear.

Co-insurance – the percentage of covered expenses an insured individual shares with the carrier. (i.e., for an 80/20 plan, the health plan member’s co-insurance is 20%.) If applicable, co-insurance applies after the insured pays the deductible and is only required up to the plan’s stop loss amount. (see “stop loss.”)

Copay/copayment – the amount an insured individual must pay toward the cost of a particular benefit. For example, a plan might require a $30 copay for each doctor’s office visit.

Deductible – the dollar amount an insured individual must pay for covered expenses during a calendar year before the plan begins paying co-insurance benefits.

Dependents – usually the spouse and/or children. Effective date – the date insurance coverage begins.

Exclusions – expenses which are not covered under an insurance plan. These are listed in the Certificate Booklet.

Explanation of Benefits (EOB) – a carrier’s written response to a claim for benefits.  This document explains how the claim has been processed in accordance to the plan’s coverage.

Generic drug – the chemical equivalent to a “brand name drug.” These drugs cost less, and the savings is passed onto health plan members in the form of a lower copay.

Group insurance – an insurance contract made with an employer or other entity that covers individuals in the group.

Health Maintenance Organization (HMO) – A plan where you will typically only have “in network” coverage.  Typically HMOs require enrollees to see a particular primary care physician (PCP) who will refer them to a specialist if deemed necessary.  No coverage would be provided if you decide to go to a physician outside of their network.

HIPAA – Health Insurance Portability and Accountability Act of 1996, P.L. 104-91. This law relates to underwriting, pre-existing limitations, guaranteed renewal, COBRA and certification requirements in the event someone terminates from the plan. The new law, commonly known as the “Kennedy-Kassebaum Bill,” establishes new requirements for self-funded, fully-insured group plans (including church plans) and Individual Health policies.

Pre-certification – an insurance company requirement that an insured obtain pre-approval before being admitted to a hospital or receiving certain kinds of treatment.ID card/identification card -card given to insured individuals showing that a patient is covered by a particular health insurance plan.

In-network – describes a provider or health care facility which is part of a health plan’s network. When applicable, insured individuals usually pay less when using an in-network provider.

Lifetime Maximum Benefit – the maximum amount a health plan will pay in benefits to an insured individual’s lifetime. Network – a group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees.

Provider networks can cover large geographic markets and/or a wide range of health care services. If a health plan uses a preferred provider network, insured individuals typically pay less for using a network provider.

Out-of-network – describes a provider or health care facility which is not part of a health plan’s network. Insured individuals usually pay more when using an out-of-network provider, if the plan uses a network.

Out-of-pocket maximum – the total of an insured individual’s co-insurance payments and sometimes deductible.

Pre-certification – Pre-admission review and approval of appropriateness and medical necessity of hospitalization or other medical treatment.

Pre-existing condition – an illness, injury or condition for which the insured individual received medical advice, treatment, services or supplies; had diagnostic tests done or recommended; had medicines prescribed or recommended; or had symptoms of typically within 12 months (time periods may vary depending on state laws) prior to the effective date of insurance coverage.

Preferred Provider Organization (PPO) – A network or panel of physicians and hospitals that agrees to discount its normal fees in exchange for a high volume of patients. The insured individual can choose from among the physicians on the panel.Premium -payments to an insurance company providing coverage.

Rider – a modification to a Certificate of Insurance regarding clauses and provisions of a policy. A rider usually adds or excludes coverage.

Risk – uncertainty of financial loss.

State mandated benefits – specific benefits which are required to be covered in a policy, designated by each State’s laws.

Stop-loss – the dollar amount of claims filed for eligible expenses at which the insurance begins to pay at 100% per insured individual. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.

Third Party Administrator (TPA) – An organization responsible for marketing and administering small group and individual health plans. This includes collecting premiums, paying claims, providing administrative services and promoting products.

Waiver of coverage -a section on the enrollment form which states that an employee was offered insurance coverage but opted to waive this coverage.

Worker’s Compensation Insurance – insurance coverage for work-related illness and injury. All states require employers to carry this insurance.