Brush up on your lingo
Learn what insurance terms mean to you
Lost in all the insurance lingo? This glossary can help you navigate through the alphabet soup of insurance terms.
The percentage of eligible claims you pay after you meet your deductible. For example, if your health plan pays 80% co-insurance, that means you pay the remaining 20% co-insurance plus your deductible.
Maximum Out of Pocket (MOOP) — The most you will have to pay in a year in co-insurance for covered benefits after you meet your deductible. Once you reach your MOOP, you will still pay office visit and prescription co-pays, but your health plan will pay 100% of eligible claims.
The fixed, up-front dollar amount you pay for certain covered expenses. You don’t have to meet your deductible for services such as office visits where you only pay a co-pay. These co-pay amounts don’t apply toward your deductible but they do apply towards your Maximum Out of Pocket. For traditional PPO plans, most routine care — such as doctor visits or prescription drugs — will be covered under the co-pay.
The up-front, out-of-pocket expense you pay before insurance kicks in. You must meet your deductible with eligible charges before claims will be paid. For most traditional PPO plans, treatments that are subject to the deductible include hospital care, screenings and inpatient treatments for mental health and substance abuse.
Family deductible — For most traditional PPO plans, when you and your dependents use enough health care services to meet the family deductible, then your health plan will begin paying claims for your family at the co-insurance level. One person cannot meet the full family deductible alone. It must be a combination of claims from two or more family members.
Individual deductible — For most traditional PPO plans, when you — the policy holder — meet your own deductible, your health plan will begin paying claims for you at the co-insurance level.
A doctor, hospital or other health care facility that has entered into a contract to provide medical services or supplies at agreed upon rates to you or your covered dependents under the plan. Using doctors and hospitals that are “in-network” saves you money.
Any physician not considered a primary care physician, such as an anesthesiologist, cardiologist, radiologist or orthopedic surgeon. You pay a higher co-pay for health care services provided by a specialist than by a primary care physician.
For more insurance terms regarding your health plan — or dental, term life and accident, or disability — check out our comprehensive insurance glossary.