Premium
The amount paid regularly to maintain insurance coverage. It may be paid monthly quarterly or yearly.
Deductible
The amount a person must pay out of pocket before insurance begins to cover costs. Higher deductibles often mean lower premiums.
Copayment
A fixed amount paid for a service such as a doctor visit. It helps share costs between the person and the insurer.
Coinsurance
A percentage of costs paid after the deductible is met. It varies by plan.
Out of Pocket Maximum
The most a person will pay in a year for covered services. After reaching it insurance pays all remaining costs.
Network
A group of providers who contract with an insurance plan. Staying in network usually costs less.
Preauthorization
Approval required before receiving certain services. It ensures the service is medically necessary.
Claim
A request for payment submitted to insurance. It covers services already provided.
Coverage
The services and treatments included in an insurance plan. Coverage varies widely.
Exclusion
A service not covered by insurance. It must be paid fully out of pocket.
Benefit Period
The time frame during which coverage applies. It is often one year.
Provider
A healthcare professional or facility that delivers services. Providers may be in or out of network.
Primary Care Provider
A main doctor who coordinates care. Some plans require choosing one.
Specialist
A doctor with advanced training in a specific area. Visits may require referrals.
Referral
A written order to see a specialist. Some plans require referrals to cover costs.
Formulary
A list of medications covered by insurance. It may include different cost levels.
Enrollment Period
The time when people can sign up for insurance. Missing it may delay coverage.
Explanation of Benefits
A document that shows what insurance paid. It is not a bill.
Preventive Services
Care that helps avoid illness. Many plans cover these at no cost.
Appeal
A request to review a denied claim. It allows people to challenge insurance decisions.