Quick answer
Insurance terms describe different parts of the same process: keeping coverage, getting care, sharing costs, and understanding the claim.
Costs
Money terms| Term | Meaning |
|---|
| TermPremium | MeaningThe amount paid to keep coverage in force, whether or not you use care. |
| TermAllowed amount | MeaningThe amount recognized by the plan for a covered service; often a negotiated rate in network. |
| TermDeductible | MeaningYour required payment for services subject to the deductible before the plan begins sharing those costs. |
| TermCopay | MeaningA fixed amount for a covered service. Other services during the same visit may be billed separately. |
| TermCoinsurance | MeaningYour percentage share of the allowed amount under plan rules. |
| TermOut-of-pocket limit | MeaningA limit on specified covered cost sharing; it does not include every expense, such as premiums or noncovered care. |
Follow a cost-sharing example →
Access and coverage
Care terms| Term | Meaning |
|---|
| TermNetwork | MeaningProviders participating in the plan’s contracted network. |
| TermPPO, HMO, EPO | MeaningPlan/network designs with differing access and referral rules. Check the actual plan rather than relying only on its initials. |
| TermReferral | MeaningA direction or authorization to obtain care from another provider, when required. |
| TermPrior authorization | MeaningA plan review required before certain services. Approval is not an unconditional payment guarantee. |
| TermFormulary | MeaningThe plan’s prescription-drug list, with tiers and coverage rules. |
| TermStep therapy | MeaningA requirement to try specified treatment before another is covered, subject to applicable exceptions. |
Documents and accounts
Find the right document| Term | Meaning |
|---|
| TermEOB | MeaningExplanation of Benefits: how a claim was processed; not a bill. |
| TermSBC | MeaningSummary of Benefits and Coverage: a standardized plan summary useful for comparison. |
| TermSPD | MeaningSummary Plan Description: describes an ERISA plan’s operation and participant rights; consult governing documents and applicable law when a dispute arises. |
| TermHSA | MeaningAn individually owned Health Savings Account. Keeping the account and being eligible to contribute are different questions. |
| TermHealth FSA | MeaningAn employer-sponsored health spending arrangement with contribution and expense deadlines. |
| TermHRA | MeaningAn employer-funded Health Reimbursement Arrangement governed by its plan terms. |
Enrollment and other benefits
Workplace terms| Term | Meaning |
|---|
| TermOpen enrollment | MeaningA scheduled period for benefit elections under the plan’s rules. |
| TermSpecial enrollment | MeaningA right to enroll outside that period after certain qualifying events and within applicable deadlines. |
| TermWaiting period | MeaningTime an otherwise eligible person waits for coverage; applicable group health waiting periods generally cannot exceed 90 days. |
| TermCOBRA | MeaningTemporary continuation of certain employer coverage for qualified beneficiaries after qualifying events, subject to eligibility and deadlines. |
| TermDisability coverage | MeaningBenefits replacing part of covered income when policy conditions are met. |
| TermVoluntary benefits | MeaningOptional coverage often paid by employees; check premiums and what the product supplements. |
| TermEAP | MeaningEmployee Assistance Program: services and limits vary by the employer’s arrangement. |
