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Health Insurance Terminology

Health Information

  • Accident: An unexpected event that causes injury.
  • Allowable Charges: The charges agreed to by the Preferred Provider Organization (PPO) for specified covered medical treatment, services and supplies.
  • Benefits: The money the insurance company pays the health care provider for medical services provided to you if you become ill or injured.
  • Claim: A request by you for the insurance company to pay medical expenses that are covered under the insurance policy. If the provider of a medical service is in network, they will file the claim for you.
  • Coinsurance: A provision of the insurance by which the covered person and the insurance carrier share in a specified ratio of the eligible hospital or medical expenses resulting from a sickness or accident, (e.g. 80%:20%; the insurance carrier paying 80%, the insured person paying 20%). Coinsurance typically comes after the deductible, but not always.
  • Coverage: The conditions for which the insurance company will pay.
  • Copayment: A specified dollar amount a Covered Person must pay for specified services, typically for office visits, urgent care, and ER visits.
  • Covered Person: A Covered student and his or her dependent(s) insured under the Policy.
  • Deductible: The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a "$250 deductible," the insurance company pays as agreed after you pay the first $250.
  • Provider: A licensed practitioner providing medical expertise and services within the scope of his or her license and practice.
  • Effective Date: The date insurance coverage begins.
  • Eligible Expenses: An expense defined in a health plan as being covered and not listed in the exclusions section.
  • Essential Health Benefits: A set of health care service categories that must be covered by certain plans, starting in 2014. The complete list of categories can be viewed at - Essential Health Benefits.
  • Exclusions: Specified conditions or circumstances for which a policy does not provide benefits.
  • Expiration Date/ Termination Date: The date that insurance coverage ends.
  • Explanation of Benefits (EOB): The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.
  • Identification Card: A card given to you that identifies you as a member of a particular health insurance plan. The card must be presented when seeking treatment, as it contains identifying information specific to you and your plan in order to process claims.
  • Insurance: A system under which individuals, businesses and other organizations, in exchange for a premium, are promised payments for losses resulting from certain dangers as specified in a contract.
  • Insurance Policy: The legal document issued by the company to the policyholder, which outlines the terms and conditions of the insurance; also called a "contract."
  • Insured: A person or organization covered by an insurance policy.
  • In-Network: Defines providers or health care facilities that are contracted with a particular network and have negotiated discounts with the participants of that network.
  • Major Medical: A plan that provides basic medical coverage, typically with a high deductible.
  • Medical Necessity/Medically Necessary: Services, supplies, or treatment for particular diagnoses that are within the standard of care in the medical community and/or as defined by CDC.
  • Open Enrollment: Time period when students are eligible to enroll or change coverage for any reason.
  • Out-of-Pocket Costs: The total you pay out of your pocket for a policy year. These costs include the deductible, co-insurance and amounts considered by the insurance company to be above the "Usual and Customary charges.”
  • Out-of-Network: Defines providers or health care facilities that are not contracted with a particular network and do not have negotiated rates or discounts with that particular network.
  • Pharmacy: A business where drugs approved by a doctor are legally sold.
  • Pre-existing Condition: A medical condition that was diagnosed and/or required treatment during a fixed period of time, usually 3 or 6 months, before you purchased your insurance policy.
  • Preferred Provider Organization (PPO): A type of managed care health insurance plan that utilizes a network of physicians and facilities contracted by the insurance carrier to provide services for a negotiated price bound by contract. Utilizing PPO providers helps to keep the out of pocket costs lower to you overall and claims costs lower to the insurance plan.
  • Policy Term: The length of time a health policy provides benefits to a covered person.
  • Premium: The price you pay for your insurance policy.
  • Usual and Customary Charge/Reasonable and Customary: The routine charge for a medical service by similar professional medical providers in the same geographical area. You may be required to pay an amount above the Usual and Customary charge for an out-of-network provider, if that provider charges more than other providers for the same service.