Insurance Terms Made Simple
Copayments A “co-pay” is a fixed dollar amount you pay for certain covered health expenses, usually at the time you receive services (for example, a $25 copay for an office visit). Co-pays do not count toward your deductible.
Coinsurance Your share of the costs of a covered service, calculated as a percentage of the service cost. For example, if the hospital fee for your stay is $1,000, and your coinsurance is 20%, your share would be $200. The coinsurance usually applies AFTER you hit your plan’s deductible.
Deductible The amount you pay for all your covered health services in a year before your insurance begins to pay for your health care. Depending on your health plan, there may be several benefits the plan provides before hitting your deductible—be sure to check your plan benefits.
Emergency Room A hospital room or stand-alone facility that’s staffed and equipped to treat people requiring immediate or life-threatening medical care.
Formulary A drug formulary is a list of prescription drugs, both generic and brand name, used by medical providers to identify drugs that offer the greatest overall value. A committee of physicians, nurse practitioners, and pharmacists maintain the formulary.
Maximum Out-of-Pocket “Max out-of-pocket” is the most you’ll need to pay during the year for covered health care services. This includes deductibles, copayments and coinsurance. Once you have reached your out-of-pocket maximum, your plan begins to pay 100% for covered services. It does not include your monthly premium.
Medical Emergency This means a sudden and severe medical condition (including severe pain) that can reasonably be expected to result in one or more of the following, if the Enrollee does not seek immediate medical attention:
- Placing the health of the Enrollee (or, with respect to a pregnant woman, the health of the Enrollee or her unborn child) in serious danger;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
Examples: Heart attack, poisoning, loss of consciousness or respiration, convulsions, and excessive uncontrolled bleeding.
Participating Provider Any doctor, hospital, pharmacy, clinic or other healthcare provider who has agreed to provide health care services at contracted rates for the plan’s members.
Primary Care Physician The particular doctor you select to be your main doctor to monitor your overall health.
Prescription Drug A prescription drug is a pharmaceutical drug that legally requires a medical prescription to be dispensed. In contrast, over-the-counter drugs can be obtained without a prescription.
Specialist A doctor who has completed advanced education in a specific area of medicine. Some examples would include immunologist, orthopedist, or a radiologist.
Urgent Care A walk-in facility that is set up to assist with an illness or injury that does not appear to be life-threatening, but also can’t wait until the next day for the primary care doctor.