Benefit – A specific cost, fee or procedure covered by a Health Insurance Policy.
Carrier – A health insurance company who provides underwriting for a Health Insurance Policy and backs the provisions of the policy.
Coinsurance – A percentage of costs shared by the health insurance Carrier and health insurance policy holder after the plan Deductible is met. Coinsurance generally ranges from the Carrier paying 100% down to the Carrier and health insurance policy holder splitting the costs 50/50%.
Copay – A flat rate payment made by the health insurance policy holder for treatment from a health professional. Generally the Copay applies to doctor’s office visits and is a maximum fee the health insurance policy holder must pay per visit. Any general costs incurred above the Copay are covered by the health insurance Carrier. In some instances, the Copay does not cover costs incurred from X-rays or laboratory tests.
Covered Expenses – Costs and fees that are incurred by the health insurance policy holder for health care that are included in the health insurance policy benefits.
Deductible – A predetermined amount of covered expenses that the health insurance policy holder must pay for before the health insurance Carrier begins providing either Coinsurance or full coverage of the policy holder’s health costs. Deductibles and Premiums have an inverse relationship; the higher the Deductible the lower the Premium or the lower the Deductible the higher the Premium.
Dependent – Any individual insured under the Health Insurance Policy other than the primary or spouse. Dependents are generally children who are under the age of 24 and a full-time student.
Effective Date – The date the provisions of the Health Insurance Policy become active. Any costs incurred by the Insured before this date are not applied to the terms of the policy.
Exclusions – Specific illnesses or procedures that are not covered under the Health Insurance Policy.
Health Insurance Policy – The agreement between the individual applying for health insurance and the Carrier providing health insurance coverage. The Health Insurance Policy will specify what costs the applicant will be responsible for, what costs the carrier will be responsible for and what health insurance costs will be covered.
Health Savings Account (HSA) – A government approved account that can be used for almost any health related cost that is funded by pre-tax dollars. The individual who establishes the account can remit up to 100% of their health insurance policy deductible into the account every year.
Inpatient Procedure – Any medical procedure that requires a hospital stay.
Insured – An individual (the primary, spouse or dependents) who receives coverage through a Health Insurance Policy.
Medicare – Medicare is a government funded health insurance system for individuals over the age of 65 or that are disabled.
Medicare Supplemental Health Insurance – Medicare only covers a handful of expenses and does not always provide the coverage many individuals desire. Medicare Supplemental Health Insurance provides coverage for many health costs that are not covered by Medicare.
Outpatient Procedure – Any medical procedure which does not require a hospital stay.
Optional Benefit – An Optional Benefit is any Benefit that is not covered by the base Health Insurance Policy, but is available to be selected for coverage for an additional fee.
Out of Pocket Maximum – The health insurance policy Out of Pocket Maximum is the most money an individual or family will be responsible to pay for their health costs in any given year or policy term. To determine the Out of Pocket Maximum for a Health Insurance Policy add the Deductible and Coinsurance that each covered individual will be responsible for (most plans have a maximum of two or three Deductibles per family). This amount does not include Premiums or any applicable fees or charges that may apply.
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 Organization (PPO) – Most Carriers have entered into agreements with organizations of doctors and other health care professionals called PPOs in order to establish fees and rates that are lower than average for their health insurance policy holders. Under a PPO health insurance policy, the health insurance policy holder will be charged a lower rate for treatment from a member of the PPO. However, any health care received from a provider outside of the designated PPO will either not be covered or will be covered at a lower rate from the carrier making the cost for that treatment or service to the health insurance policy holder greater.
Premium – The predetermined amount that is paid by the health insurance policy holder either monthly or up front in return for the policy Benefits provided by the Carrier.
Preferred Rating – Individuals who are in good health and have not had a history of Preexisting Conditions can be eligible for a Preferred Rating. A Preferred Rating generally results in paying a lower Premium for a Health Insurance Policy.
Primary – The individual under whose name the health insurance policy is implemented.
Short-Term Health Insurance – Also referred to as Temporary Health Insurance, is a Health Insurance Policy that provides coverage for a predetermined amount of time, usually less than 12 months. Short-Term Health Insurance is typically utilized for filling short gaps when an individual is not insured. Short-Term Health Insurance is ideal for students or professionals who are mandated to undergo a waiting period before they are covered by their employer’s health insurance.
Temporary Health Insurance – See Short-Term Health Insurance.