Glossary

  • Deductible
    A. The amount for which the insured is liable on each loss, injury, etc., before an insurance company will make payment
    B. The amount of medical expenses in dollars that the patient needs to obtain (and has to pay) before the insurance starts to pay for any further medical expenses. The cycle usually starts January 1 and is valid for 1 year. Then it gets reset, and the patient must meet the deductible again.
  • Co-insurance
    A. A type of insurance in which the insured pays a share of the payment made against a claim.
    B. A percentage of healthcare costs that the patient is responsible for. 10% coinsurance implies that the insurance will cover 90% of the costs (after deductible/copayments made), and the patient is responsible for 10%. This can get expensive fairly quickly.
  • In-network services
    A. Provided by personnel/facilities contracted with health insurance companies to provide services to plan members
    B. Providers and facilities that are “in network” have agreed contractually with the insurance companies to accept specific amounts of payments for services provided to the patient. This guarantees to the patients that they will not be charged for any amount above their copayment/deductible/coinsurance.
  • Out-of network services
    A. Provided by personnel/facilities that do not have any contractual obligations with the health care insurance company
    B. The physician/facilities can charge higher rates that the insurance is willing to pay, and the patient is responsible for the difference. Many insurance companies/plans do not have “out of network” privileges, in which cases the patients are responsible for 100% of the healthcare costs provided by such providers/facilities. Please be very careful when getting out of network services, and make sure you discuss the eventual costs to you with the providers/facilities/and your insurance company for any healthcare services received in such fashion.
  • HMO (Health Maintenance Organization)
    A health plan usually requiring a selection of a specific primary care provider who serves as the gatekeeper for your overall health, and most of the time requires referrals by the PCP for specialty services. Most of the time, referral can only be made to in-network providers.
  • PPO (Preferred Provider Organization)
    Health plan that covers healthcare services without a need for a primary care provider selection or referrals. Most plans have in-network and out-of-network coverage, but usually more out of pocket cost to the patient if out-of-network providers/facilities are utilized.
  • PCP (Primary Care Provider)
    A. A healthcare provider who sees people with common medical problems.
    B. A healthcare provider (doctor/nurse practitioner/physician assistant) who focuses on internal medicine/family practice. They usually assume the responsibility of overseeing the overall care of a patient and treat common illnesses such as diabetes and high blood pressure. They refer patients to specialists and medical facilities for more specialized care. -Insurance wise, certain providers can be labeled as “PCP” for insurance purposes. If requested by the insurance company, you might have to choose a specific PCP, whose name will go on the front of your insurance card. That provider will then be in charge of your healthcare medically and administratively, based on the plan specifics and requirements (most importantly whether your plan is an HMO, EPO, or PPO). For HMOs, any referrals usually go through the PCP. For other types of plans, it is suggested that your PCP is medically involved in your care, but you usually do not need referrals to see other healthcare providers.
  • Out of pocket maximum
    A. The most you will have to pay for covered medical expenses in a plan year through deductible and coinsurance before your insurance begins to pay 100% of covered medical expenses
    B. The maximum amount of money the patient will be responsible for before the insurance covers all of the costs of healthcare. This recycles every year (usually from January 1), and is usually different for single and/or family plans. After this amount is met, the insurance covers all in-network healthcare costs. Out of network benefits vary by plans when the patients reach this level, but usually do not provide coverage for 100% of the costs.
  • Referral
    A. The act of directing a patient to a medical specialists for services
    B. A document that shows the intent of a provider to have the patient visit another provider/facility for healthcare services. Although most of the time it is a simple written communication between providers indicating the need for specialty services, sometimes it turns into a big administrative job.
    a. HMOs usually require referrals. Sometimes it is a simple prescription by the PCP, which happens very quickly. Many times, a computerized referral from the PCP for any services is required. This can take upto a few days to do (as it requires computer access, fully functioning login accounts by PCP, and the presence of PCP in the office (as opposed to on vacation)). Although rare, some insurances take up to 2-3 weeks to approve referrals. If you add all of the possible delays that could occur (time to get an appointment with PCP to get referral, logistics of getting referral, insurance approval of referral) few weeks can pass prior to you being able to see a specialist.
    b. PPOs usually do not require referrals.
    Please make sure you clearly check the referral policy of your insurance plan, and the average time it takes to obtain the referral under the plan.
  • Premium
    A. An amount to be paid for an insurance policy
    B. Your monthly cost of the insurance. This fee generally does not go towards your deductibles/out of pocket maximums.
  • EPO (Exclusive Provider Organization)
    Health plan that covers healthcare services from providers and facilities inside the plan’s network. A selection of a primary care provider, and referrals, are usually not required.