Glossary of Terms

Affordable Care Act: A federal law enacted by the Obama Administration in 2010. It is most known for enacting a health insurance requirement and expanding Medicaid eligibility.

Claim: A request for payment of services or treatment rendered under the terms of an insurance policy.

Claims Company: The company that processes claims from providers and distributes payment on behalf of the insurance plan, also called the third-party administrator (TPA).

Coinsurance: Your share of the cost of a covered healthcare service. For example, if the plan covers 90% of a service, you would be responsible for 10%. Coinsurance differs between in-network and out-of-network providers. You pay coinsurance plus any deductibles you owe. Your plan’s schedule of benefits will show the coinsurance percentage.

Copayment/Copay: A flat fee that you must pay upfront for services, generally including office visits, emergency room visits, urgent care, and prescription drugs.

Deductible: A set amount that you must pay before the plan will pay any coinsurance. Deductibles can be annual or per condition.

Insurance Company: The company that assumes the risk and payment of the claims under a policy, also called the underwriter or carrier.

Network: A group of doctors, hospitals, and other healthcare providers contracted to provide services at a negotiated rate. Provider networks can exist in a local or regional area, as well as nationally. You will generally pay less for using a network provider.

Out-of-Network: Providers who do not belong to the specified network and do not offer pre-negotiated rates. Out-of-network costs are generally higher. For some types of plans, out-of-network providers are not covered at all.

Out-of-Pocket Maximum: The total amount you are required to pay. Once you reach (have paid) the out-of-pocket maximum, the plan will pay 100% (up to plan maximum). The out-of-pocket maximum does not include copays.

Premium: The amount you pay for the insurance plan. This may be annually, monthly, quarterly, by semester, or term.

Provider: A doctor, hospital, pharmacy, laboratory, other ancillary facility, or licensed supplier that provides healthcare services.