Life and Health Insurance Foundation for Education
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Key Terms

Agent

Advisors who work with you to assess your insurance needs and help plan for long-term financial security and stability.

Balance billing

A bill for the difference between what your insurer will pay and what the physician charges for a service.

Coinsurance

The amount you are required to pay for medical care in a fee-for-service plan and certain managed care plans after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.

Coordination of benefits

A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans are usually limited to no more than 100 percent of the claim.

Copayment

A way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $10 for every visit to the doctor). The insurance company pays the rest.

Covered expenses

Most insurance plans, whether they are fee-for-service or managed care plans, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy.

Deductible

The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.

Exclusions

Specific conditions or circumstances for which the policy will not provide benefits.

Managed care

The way a health care system manages costs, use, and quality. All HMOs and PPOs, and even many fee-for-service plans, apply managed care techniques.

Maximum out-of-pocket

The maximum amount money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Noncancellable policy

A policy that guarantees that you will receive insurance as long as you pay the premium. This is also known as a guaranteed renewable policy.

Preexisting condition

A health problem that existed before the date your insurance coverage became effective.

Premium

The amount you or your employer pay, in addition to copayments, coinsurance and deductibles, in exchange for insurance coverage.

Primary care physician

A primary care physician monitors your health, diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. This is often a family physician or internist, but some women prefer to use their gynecologist.

Provider

Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.

Third-party payer

Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the Federal Government.