Insurance 101 / Terms
We know insurance terms can be confusing, but it’s important to know how YOUR specific plan works. Below you will find some common insurance terms and definitions to better help you understand your policy/ Always call your insurance to verify coverage if you are unsure of how your plan works.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
A fixed amount (for example, $15) you pay for a health care service.
The amount you owe before your health insurance begins to pay; for example, if your deductible is $1000 your plan won’t pay anything until you’ve met your $1000 deductible. The deductible may not apply to all services.
Maximum amount on which payment is based for covered health care services; for example, if an office bills $180 for an appointment but the insurance allowed amount is only $150, you are responsible for any balance based off of the allowed amount rather than the full $180.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.
A type of insurance plan which involved the selection of a Primary Care Physician (PCP) and IPA/PPG (also known as a medical group). This type of plan requires authorization for certain specialists and diagnostics.
A type of insurance plan which generally offers more flexibility than HMO plans; however, premiums and out-of-pocket expenses tend to be higher. A PPO policy does not usually require the selection of a PCP or IPA/PPG, but may depending on your plan.
this stands for, Primary Care Physician. When enrolled in a HMO plan, you can only see your selected PCP for primary care services.
Also known as IPA/PPG. These groups are responsible for payment of claims and authorizing referrals. When enrolled in a HMO policy, you are required to select a medical group. Each group has its own network of physicians and facilities