Understanding Health Insurance Terminology
Primary Care Provider (PCP) -
health care at a basic rather than specialized level for people making an initial approach to a doctor or nurse for treatment.
Specialist - A licensed physician that is someone other than a family doctor, internal medicine, or pediatrician is considered a specialist.
Copay - A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.
Deductible - The amount an individual must pay for certain covered expenses before insurance covers the costs.
Coinsurance - a type of insurance in which the insured pays a share of the payment made against a claim. (70/30, 60/40, 50/50)
Maximum Out-Of-Pocket- MOOP - A predetermined limited amount of money that an individual must pay out, before an insurance company or will pay 100 % for an individual's health care expenses.
In-network refers to providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount.
Out-of-Network - refers to
physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan
HMO - Health Maintenance Organization - Members go to participating providers for covered services. No Out-of-Network benefits.
EPO – Exclusive Provider Organization - Members go to participating providers for covered services. No Out-of-Network benefits.
POS - Point of Service – Like PPO plans, POS plans have In-Network & Out-of-Network benefits. Some may or may not have referrals
PPO - Preferred Provider Organizations - No referrals. The member usually receives better benefits when they utilize services from participating providers. If you use a physician outside the PPO plan, you would be utilizing the Out of Network benefit.
Health Savings Accounts / High Deductible Health Plans – a savings account used in conjunction with a high-deductible health insurance policy that allows users to save money tax-free against medical expenses abbreviation HSA.
Explanation of Benefits (EOB) - a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
Pre-Certification / Pre-Approval - The carrier requires that the member obtains pre-approval for coverage of a specific medical procedure or prescription drug (Diagnostic testing, MRI, Surgical procedures, and Rx).
Prescription Tiers - A typical drug benefit includes three or four tiers: Tier 1 usually includes generic medications. Tier 2 and Tier 3 usually includes preferred brand name medications.
Generic Drug - A
drug product that is comparable to a brand/reference listed drug product
in dosage form, strength, route of administration, quality and performance characteristics, and intended use.
Preferred Name Brand - Prescription drugs marketed with a specific brand name by the company that manufactures and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies.
Non-Preferred Name Brand - These name brand medications often have a generic equivalent or a preferred brand alternative.
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