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Common Terms & Definitions

 

Coinsurance – The percentage amount you and the insurance company will pay for covered medical services after you have met your deductible.

Copayment – (Copay) The dollar amount you pay to network providers for a specific medical service or supply.

Deductible – The amount the individual must pay for health care expenses before insurance covers the rest.

Out-of-pocket Maximum – A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company will pay 100 percent for an individual’s health care expenses.

Preexisting Condition – Any medical ailment other than routine illness that the health insurance policy holder has been treated for by a health professional in the past. Most carriers have different qualifications to determine what a Preexisting Condition is (generally any condition that has required treatment in the previous 12 months) and in most cases, will not provide coverage for any costs related to that condition in the future.

Preferred Provider Organizations (PPOs) – A health organization composed of physicians, hospitals or other providers which provide healthcare services at a reduced fee.

Usual, Customary and Reasonable – An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.