Glossary of Health Insurance Terms

Understand the terms the industry uses so you can get the most out of your health insurance.

If you do not understand your health insurance documents, contact your insurance provider for further assistance.

Important Insurance Terms You Should Know

A request to be paid by a health plan for health services given. An example would be the claim your doctor sends to your health plan after an office visit.
The amount you are required to pay for medical care after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the coinsurance is 20%, then you pay 20% of the medical bill and your insurance company pays 80%.
A flat fee you must pay every time you receive a medical service (for example, $15 for every visit to the doctor). The insurance company pays the rest after you pay the deductible.
The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying. Low deductible plans are more expensive and high deductible plans are cheaper.
Specific conditions or services your health plan will not cover. It is extremely important to read the exclusions of an insurance plan before purchasing it.
Service provided after you are admitted to the hospital. Inpatient stays are those lasting 24 hours or longer (at least one night).
Maternity Care
Services that generally include prenatal care, normal childbirth/delivery services, and routine newborn nursery care.
The select doctors, clinics, hospitals, and other medical providers your insurance company contracts with to provide health care to its members at negotiated rates.
Out-of-Pocket Maximum
The maximum amount you will be required to pay each year for deductibles and coinsurance. This is a stated dollar amount set by the insurance company, in addition to regular premiums.
Service provided at a hospital, physician's office, or other health facility without you being admitted overnight to the facility. The term "ambulatory" is often used to describe outpatient care.
Preexisting condition
A health problem that existed before the date your insurance became effective.
Preferred Provider
A doctor who is referred by your insurance company. (Sometimes called a “network provider”.) When you use the doctors and hospitals that are preferred providers, a larger part of your medical bills are covered. You can use other doctors, but at a higher cost.
Primary Care Doctor
Usually your first contact for health care, this is often a family physician, although some women use their gynecologist. A primary care doctor monitors your health and diagnoses, treats minor health problems, and refers you to specialists if you need another level of care.
Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Urgent care
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care and cannot be postponed. An urgent situation requires prompt medical attention to avoid complications, unnecessary suffering, or severe pain.
Usual, customary and reasonable
The amount charged or the amount determined to be the reasonable charge, whichever is less, for a particular covered service in the geographical area where it is performed.