Glossary of Insurance Terms

  • Beneficiary. An individual eligible to receive health care coverage and benefits. See also Enrollee, Covered person.

  • Calendar year. The 12-month period between January 1 and December 31. Most insurance plans calculate a patient’s deductible and out-of-pocket expenses with reference to the calendar year.

  • Capitation. A health care delivery system by which health care providers receive a fixed per-capita amount for each patient served in a group plan.

  • Co-insurance. A shared cost provision by which covered members of a health plan pay for a percentage of billed services, usually applied after the deductible has been met and in addition to any co-payment.

  • Comprehensive. Major medical plan. See Indemnity plan.

  • Consultation. A patient visit to a specialist requested by a primary care physician for purposes of diagnosis and treatment.

  • Co-payment (co-pay) . A fixed amount that a subscriber to a medical insurance plan pays for a specified service, usually assessed on a per-visit basis.

  • Covered charges. Fees for medical care deemed payable subject to the terms of the insurance carrier or health care plan.

  • Covered person. An individual entitled to benefits under terms of an insurance policy or health care plan. See also Beneficiary, Enrollee.

  • Deductible. Fixed amount that a member pays for health care, in addition to premiums, before insurance coverage or reimbursement is calculated.

  • Eligible expenses. Medical expenses deductible for tax purposes.

  • Enrollee. The person in whose name health coverage is issued.

  • Established patient/new patient. For administrative purposes, an established patient is one who has received services from a particular physician within the past three years. A new patient has not received services within the past three years.

  • Exclusion period. A period that begins when coverage starts during which an insurer may deny benefits for a pre-existing condition, established through previous diagnosis, care, or treatment. The exclusion period is not allowed for certain conditions, such as pregnancy, and may not be imposed if the covered person has previously had continuous health coverage for at least two years without a break longer than 63 days. See Pre-existing condition.

  • Exclusive provider organization (EPO) . A health care plan in which a group of providers contract as a fixed, comprehensive network to provide care to subscribers through an insurer, generally without provision for out-of-network coverage.

  • Explanation of benefits (EOB)/explanation of payment (EOP) . A statement for patients that lists services rendered, amounts billed, and payments received.

  • Fee maximum. The highest dollar amount that an insurance plan will pay a participating health care provider for a specific service or procedure.

  • Health maintenance organization (HMO) . A managed care consortium in which members of a voluntary group, usually in a circumscribed geographic location, pay a fixed, prepaid amount in return for comprehensive medical services.

  • In-plan services. Health care services furnished within a managed care network.

  • Indemnity plan. A traditional fee-for-service medical insurance plan that charges patients a fixed rate and reimburses them in accordance with a schedule for reasonable and customary charges. Also called comprehensive major medical plan.

  • Managed care. A system of health care delivery that actively reviews and controls services and utilization, and measures performance, with the aim of providing quality, cost-effective health care. Also known as managed health care.

  • Medical necessity. Medical services that have been established as safe and effective for treating specific conditions, consistent with diagnosis or accepted treatment parameters. Medical necessity is consistent with national medical practice guidelines and will vary among health care contracts.

  • New patient. See Established patient/new patient.

  • Nonparticipating provider (non-par provider) . A health care provider who has not contracted with a carrier or health plan. Non-par providers may bill patients without balance billing limits typically agreed to by participating providers. Also known as out-of network provider.

  • Out-of-network coverage. In an HMO or PPO, benefits for treatment obtained from a non-participating provider. Typically, out-of-network coverage has a deductible, higher co-payments, and/or co-insurance.

  • Out-of-pocket costs. All non-reimbursed expenses for health care required to be paid by the enrollee or insured person, including co-payments, co-insurance, deductibles, and services not covered by the plan.

  • Participating provider (par provider) . A provider or group of providers that contracts with a health plan to deliver medical services to persons covered under the terms of that plan. The provider may be a physician, nurse practitioner, hospital, pharmacy, or other facility.

  • Point of service (POS) plan. A health benefits plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with varying levels of benefits based on use of par or non-par providers.

  • Pre-certification. An authorization provided by an insurer after a review of diagnosis and proposed treatment plans prior to treatment or admission to an inpatient facility or for certain outpatient procedures.

  • Pre-existing condition. Any medical condition diagnosed or treated within a specified period, preceding the effective date of insurance coverage. See Exclusion period.

  • Preferred provider organization (PPO) . A provider network that requires deductibles and co-insurance and allows covered persons to choose to receive health care from participating providers or, at higher cost, to non-participating providers.

  • Primary care physician. A physician trained in family medicine, internal medicine, pediatrics, or OB/GYN who provides initial consultation and care for most health problems. Many HMO models require patients to first see their primary care doctor for a referral to specialists.

  • Reasonable and customary (R & C) . Commonly charged or prevailing fees for health services within a geographic area. Patients may be responsible for portions of fees in excess of those deemed reasonable and customary should they use out-of-network services.

  • Referral. An authorization by a covered person’s primary care physician to see another physician or specialist or to receive certain services. In many commercial, Medicare-managed, and Medicaid-managed plans, a referral is required before covered care can be dispensed by anyone besides the primary care physician. Failure to obtain a referral before seeing a specialist may cause the insurance plan to deny a claim for service.