Terms to Know: Insurance Definitions

Insurance policies can use words that are not always clear. This fact sheet defines various insurance-related terms.

Appeal When your health insurance denies a form of medical care, you may request your health insurer to review the decision again.

Claim A claim is a bill from your health care provider (doctor or hospital). Your health care provider sends a claim to your insurer to be reimbursed for the service provided.

COBRA (The Consolidated Omnibus Budget Reconciliation Act) COBRA is a law that lets you keep your insurance for up to 18 months or more after leaving your job, usually paying the full cost of the plan.

Co-payment or Co-pay Out-of-pocket cost you are expected to pay when you receive medical care or a prescription; this is after your insurance has been applied.

Co-insurance A percentage difference between what your insurance pays for and what you pay for. The amount you are responsible to pay after the deductible is met.

Deductible A fixed dollar amount that you are expected to pay out-of-pocket towards your health care before your health care insurer pays. For example—If your deductible is $3,000, you are expected to pay the first $3,000 towards your health care expenses. Your insurance will cover expenses after you have paid $3,000.

Flexible Spending Account A flexible spending account, or FSA, allows you to set aside money from your paycheck before it is taxed into a special account that later can pay for certain medical expenses, such as co-pays. You can decide how much money per paycheck will go into your FSA account. It is important to figure out your medical expenses throughout the year, because this money is usually lost at the end of the year.

In-Network or Network Provider A health care provider selects health care professionals or hospitals to be a part of their insurance plan or network. These preferred health care providers or institutions cost less than others who are out of network.

Out-of-Network or Non-network provider Health care professionals or hospitals not a part of a health care provider’s insurance coverage. Going out-of-network generally costs more.

Medicaid Medicaid is a social health care program that provides health insurance for individuals with limited resources. Visit www.medicaid.gov for more.

Medicare Medicare provides health insurance for those 65 or older. Visit www.medicare.gov for more information.

Network A network is a large group of health care professionals, pharmacies and hospitals that are selected and preferred by an insurance company to provide care.

Open enrollment Open enrollment is the time period each year when you’re allowed to start, stop or change your health insurance plan. Normally, you sign up around the end of one calendar year for coverage that lasts the next full year.

Preauthorization At times, your health insurance may require their approval before you receive some health care services. This is not a guarantee that they will automatically cover the cost. It is sometimes called ‘prior authorization’ or ‘precertification.’

Premium What an individual pays each month to have insurance coverage. This amount is paid even if an individual does not receive medical care that month.

Provider A provider is a health care professional (doctor, nurse, surgeon, etc.) or institution (hospital) that provides care.

Edited by Melisa Celikoyar, LCSW

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