A
Agent - An appointed representative of the insurance company licensed to sell insurance.
B
Benefit - The amount an insurance company pays to a policyholder for a claim.
Brand-Name Prescription Drug - Drugs developed, manufactured, and marketed with a brand name by the drug company.
Broker - An agent that searches for quotes and plan options.
C
Carrier - The company that provides insurance plans.
Claim - A request filed to an insurance company for payment of a covered service received.
Creditable Coverage - Health insurance coverage while on a guaranteed-renewable individual or group health insurance plan, used in determining eligibility for coverage for pre-existing conditions (see Pre-Existing Condition Credit). Creditable coverage extends for 63 days after health coverage is lost.
COBRA (Consolidated Omnibus Budget Reconciliation Act) - Legislation allowing employees to keep their group health coverage for up to 18 months after they leave employment.
Coinsurance - The percentage of a claim to be paid by the insurance company after the deductible has been satisfied.
Copayment - The cost share of a certain medical expense such as a doctor’s office visit or prescription drug to be paid by the insured.
D
Deductible - The amount an insured must pay out-of-pocket before coinsurance begins.
Dependents - A person for which the insured is financially responsible. This commonly includes their spouse and unmarried children.
E
Effective Date - The date when insurance coverage begins.
Exclusions - Medical services not covered by the insurance plan.
F
Formulary - The list of all covered prescription drugs.
G
Generic Drug - Brand-name equivalent drugs made after the patent expires of the company who developed the original Brand-Name drug. In general, generic drugs are less expensive than brand-name drugs. They pass certification and inspection and are FDA approved to be just as safe and effective as the Brand-Name equivalent.
Group Insurance - Health insurance coverage offered for full time W-2 employees of a business.
Guaranteed Issue - Guaranteed issue medical insurance plans accept insurance applicants to be regardless of health conditions, or health history.
Guaranteed-Renewable - Long-term health insurance plans where the plan cannot be cancelled due to health conditions or claims history as long as the premium is paid.
H
Health Insurance Quote - The estimated premium of a health insurance plan.
HIPAA (Health Insurance Portability and Accountability Act) - Legislation that allows guaranteed issue of health insurance regardless of pre-existing health conditions when certain qualifications are met.
I
Individual Health Insurance - A health plan purchased on an individual basis rather than through an employer or group for oneself or one’s family.
In-Network Care Providers - Any health care professional that is contracted with the insurance plan to accept specific rates of payment for services rendered to members of the plan.
Inpatient Care - Care in which patients must stay overnight in a hospital or other medical facility.
Insurability - The eligibility of a person to be insured by the plan. Common factors include health conditions, medications, health history, citizen status, and Medicare eligibility.
L
Limitations - A specific limit on the benefits paid for a specific claim.
M
Major Medical Insurance - Insurance that provides coverage for severe medical expenses.
Maximum Covered Expense - The maximum amount of money for benefits and claims that an insurance company will pay in a certain period of time, such as an annual limit, a limit per coverage period, or a limit per incident.
Maximum Lifetime Benefit - The maximum amount of money for benefits and claims an insurance company will pay in the insured’s lifetime.
Medicare - A government-sponsored program which provides health care for Americans over the age of 65, or those with end-stage renal disease or other qualifying disabilities under the age of 65.
N
Network - A group of doctors, physicians, hospitals, clinics, and specialists that are contracted with the insurance plan to accept specific rates of payment for services rendered to members of the plan.
O
Out-Of-Pocket Maximum (Limit) - The maximum amount of out-of-pocket cost the insured is responsible for during the coverage period for covered expenses. After the out-of-pocket max is met, the plan will cover 100% of covered expenses afterwards until the maximum covered expense or maximum limit is reached.
Outpatient Care - Medical care that does not require a patient to stay overnight in a hospital or other medical facility, such as outpatient surgery, doctor’s office visits, X-rays, lab work, and most health screenings.
P
Pre- Certification - Notifying the plan by telephone before scheduled hospitalization or within 48 hours of hospitalization. This is not a guarantee of coverage.
Pre-Existing Conditions - Any health condition for which the insured has received treatment or which began showing symptoms or developing before coverage under the health plan begins can be considered a pre-existing condition.
Pre-Existing Condition Credit - Up to 12 months of credit given towards the coverage of pre-existing conditions while on a guaranteed-renewable health insurance plan.
Preferred Provider Organizations (PPO) - A network of doctors, hospitals, or other medical professionals contracted with the insurance plan to accept specific rates of payment for services rendered to members of the plan. If the insured chooses to go out of network, benefits are typically reduced.
Premium - The price of coverage for the insurance plan. Non-payment of premiums will result in termination of the plan.
Preventive Care - Basic doctor’s check-ups, physicals, well-baby care, health screenings, and immunizations received to screen for early detection and prevention of serious illness.
Provider - Any doctor, physician, hospital, clinic, specialist, or any health care professional that provides health services.
Q
Quote - An estimate of premium for a specific health insurance plan.
R
Rider - An additional benefit (usually optional for an additional fee), OR a specific exclusion to an insurance plan.
Risk - The possibility of a person to become ill or injured, also the chance of financial loss for either a person or the insurance company.
S
Short-Term Medical Insurance - A temporary medical insurance plan which lasts for a specific amount of time, generally ranging from one month to one year, and generally at lower cost than guaranteed-renewable health insurance plans.
T
Travel Insurance - Health plans that provide coverage for people while during a trip to another country or for foreign travelers while traveling in America.
U
Underwriter - An employee of the insurance company that determines the premiums and insurability of applicants.
Underwriting - The process by which an underwriter determines the premiums and insurability of applicants.
Usual, Customary, and Reasonable Fees - The common amount that is usually covered or charged for medical services and supplies.
W
Waiting Period - Also called an elimination period, this is the amount of time the insured must wait before certain services or benefits will be covered by the plan.
