Glossary of Health Insurance Terms
Glossary of Health Insurance Terms

Glossary of Health Insurance Terms

Welcome to the comprehensive “Glossary of Health Insurance Terms.” Navigating the world of health insurance can be overwhelming, with its vast array of complex terminology and jargon. Whether you are a policyholder, a healthcare professional, or someone seeking a better understanding of health insurance, this glossary aims to provide you with clear and concise explanations of key terms and concepts.

Health insurance is a vital aspect of modern healthcare systems, providing financial protection and access to necessary medical services. However, the intricacies of health insurance can often be confusing, leaving individuals unsure about their coverage, benefits, and responsibilities.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

In this glossary, we have compiled a wide range of terms used in the realm of health insurance, from basic definitions to more specific concepts. You will find explanations of common terms such as premiums, deductibles, and copayments, as well as more complex topics like network types, formularies, and preauthorization.

You’re no longer on my own if you’re harassed with the aid of terms like “coinsurance” and “copayment,” or if you aren’t certain about the variations among a PPO and HMO plan. Navigating the arena of medical health insurance is a lot less difficult whilst you’re familiar with a number of these complex health insurance phrases. Here are causes for many medical insurance terms that you can come upon as you keep for insurance or navigate your health plan.

Medical Insurance Terms Glossary

A to D

Administrative services simplest (ASO)

An employer-subsidized medical health insurance plan where the enterprise will pay for the employee’s health blessings and is predicated at the coverage organization to manage the plan only. The coverage company may additionally process claims on behalf of the personnel, but the corporation commonly can pay the claims themselves.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Affordable Care Act (ACA)

A health care regulation, also referred to as Obamacare, mounted in 2010, that accelerated cheap medical insurance get right of entry to to people and households in the U.S. The ACA medical health insurance marketplace changed into launched along side the ACA, which permits eligible Americans to buy and buy health insurance. The fitness regulation additionally multiplied Medicaid eligibility, allowed parents to maintain their youngsters on their health insurance until 26, prohibits lifetime monetary caps on insurance, sets annual in-community out-of-pocket maximums and calls for that insurers in the ACA market cowl at the least the ten crucial fitness blessings, and consists of many different provisions.

Allowed quantity

The most amount of cash a medical health insurance plan can pay for qualifying scientific offerings. Alternative terms for allowed amount are “eligible rate” and “fee allowance.”

Balance billing

The difference among what a clinical issuer prices for a remedy or service, and what a medical insurance plan covers. In the case of stability billing, you pay the distinction among what the company costs and what your plan will cowl. For instance, if the provider’s charge is $200 and your fitness plan covers $50, you pay the $one hundred fifty distinction out-of-pocket.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Benefit duration

The duration of time that an insured person can use a specific health benefit blanketed by their plan.

This time period is regularly related to Original Medicare, which refers to a price-for-provider health plan consisting of Part A (Hospital Insurance) and Part B (Medical Insurance). When an Original Medicare recipient gets admitted to a medical institution or professional nursing facility (SNF), the benefit duration starts at the day of admission and ends while the insured hasn’t obtained any inpatient care for 60 consecutive days.

A new advantage length starts whenever the insured person enters an inpatient facility. While there is no limit to the quantity of benefit intervals that Original Medicare gives, the insured person need to pay the inpatient sanatorium deductible on every occasion they enter a brand new advantage duration.

Bronze, Silver, Gold or Platinum medical insurance

Metal stages, Bronze, Silver, Gold and Platinum, are used to distinguish ACA market health insurance plans based totally on out-of-pocket prices and charges.


A fitness care invoice that a company submits to an coverage organization to get paid for a included medical service they supplied to a plan member.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Claim appeal

A request for an coverage company to rethink its selection when an insured character’s claim receives denied. If the man or woman correctly appeals the denied health claim and it receives approved, they acquire coverage for the clinical treatment or service in step with the plan’s phrases.

COBRA coverage

A federal law, which stands for The Consolidated Omnibus Budget Reconciliation Act. COBRA permits an insured to remain enrolled of their organization health insurance plan when they lose or leave their job. Not all fitness plans are COBRA-eligible. When an insured receives COBRA benefits, you’re normally required to pay the plan top class in full without the assist from employers.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.


The percent of the medical invoice value you pay once you’ve met your annual deductible. For instance, if your clinical bill is $500 and your plan has a 20% coinsurance, you will pay $a hundred out-of-pocket, in case you reached your deductible. If you didn’t pay your deductible yet, you will pay the overall $500 out-of-pocket.

Coinsurance restriction (coinsurance most)

The most amount of money an insured individual is required to pay in the shape of coinsurance for blanketed scientific services. Once the coinsurance restrict is met, the coverage organisation covers the insured’s medical payments in complete.

Commercial medical insurance

A sort of medical insurance plan that’s supplied through a non-public medical insurance enterprise, in place of a central authority application, like Medicaid or Medicare. Commercial health insurance can refer to a coverage this is bought thru an agency (institution health insurance), an person ACA market plan or an person plan bought outside the marketplace.

Copayment (copay)

A constant amount of cash an insured person can pay for a covered medical service or treatment after the plan deductible is met. Depending at the plan, copays may be required for physician’s visits, lab checking out and prescription drugs.

Covered individual

Any character who is eligible to receive insurance underneath a medical health insurance plan. On a own family plan, the subscriber and their dependents are taken into consideration blanketed people.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Covered service

A clinical remedy or carrier that an insurance employer has the same opinion to pay for, primarily based on the specs of a medical insurance plan.

Critical contamination coverage

A sort of supplemental health insurance that provides a payout if the insured individual is recognized with a qualifying important contamination, along with a coronary heart attack, stroke or most cancers. Unlike conventional medical insurance, vital infection insurance usually gives a lump sum price, which the insured can use for any reason.


health insurance deductible is a set amount an insured individual pays out-of-pocket in a 12 months before the insurance company covers its part of qualifying medical expenses.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

After you pay your deductible, you could have to pay coinsurance, that’s the percentage of the medical bill value you pay after you’ve met your annual deductible. You may additionally have a copay, that is the fixed amount of cash an insured person can pay for a protected clinical service or treatment after the plan deductible is met.

Dental coverage

An coverage coverage that will pay for sure dental remedies, along with annual cleanings, X-rays, fillings and extractions. Dental coverage guidelines are normally become independent from conventional medical insurance regulations.

Disability insurance

An coverage policy that gives a payout if the insured will become sick or injured and may’t work. Disability insurance is to be had in brief-term and lengthy-term policies, which give advantages for various lengths of time. You can buy incapacity insurance from a personal coverage company or thru your enterprise’s institution plan or via your state authorities.

E to H

Emergency medical situation

A critical condition, consisting of an illness, symptom or injury, that needs instant clinical remedy.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Emergency clinical transportation

Transportation to a health facility or clinical facility, generally through ambulance, while an man or woman is experiencing a scientific emergency.

Emergency room care

Medical remedy received in a health center’s emergency department when an person desires instantaneous remedy for a illness, symptom or harm they’re experiencing.

Emergency services

Inpatient or outpatient hospital therapy this is vital to save you severe harm or dying to an character experiencing a medical emergency.

Excluded services

Medical treatments or offerings that aren’t blanketed by using a medical insurance plan.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Exclusive provider corporation (EPO) plan

A medical health insurance plan that normally calls for contributors to work with a primary care issuer to control and oversee their medical care. Exclusive provider employer (EPO) plans most effective cowl in-network care besides for emergencies.

Explanation of benefits (EOB)

A record that an insured man or woman receives after a medical insurance declare. An EOB consists of the overall price of the scientific provider, a breakdown of what your insurance organisation will pay and what the insured owes. An EOB is not a invoice; rather, it’s a statement that explains how tons turned into blanketed, and what’s leftover.

Flexible spending account (FSA)

flexible spending account (FSA) is a manner to store cash for qualifying out-of-pocket clinical costs, like deductibles, copayments, coinsurance, pharmaceuticals, over the counter medicine and clinical gadgets. You can fund FSAs with tax-unfastened contributions, but you would possibly lose money not used in a calendar yr.

Fully insured plan

A organization health insurance plan wherein the corporation buys medical health insurance from a commercial coverage agency to cover its employees. If an employee enrolled inside the plan has a claim, the insurance agency offers the payout, in place of their corporation.

Group health insurance

A medical insurance plan that’s offered by means of an agency to its employees. Employers normally subsidize group medical health insurance premiums, paying properly greater than 1/2 of prices, so rates are a great deal greater lower priced (or maybe free) for the worker.

Group buying association

An association wherein a couple of employers or people buy health insurance collectively, with the purpose of reducing premiums. Group purchasing preparations (GPAs) can be formed via kingdom law or groups of employers or personnel.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Habilitation services

A category of fitness care services that help people examine and improve the capabilities important for regular living. Examples of habilitation services include physical remedy, occupational therapy and speech-language pathology.

Health coverage

A legally-binding agreement between a health insurance business enterprise and an person, where the insurance employer has the same opinion to pay for particular scientific offerings in change for a top rate.

Health coverage broker

An character or commercial enterprise that helps clients save for health insurance, follow for insurance and purchase a plan. A medical insurance broking can offer professional hints for the ideal medical health insurance plan based on an character’s clinical desires and/or price range.

Health insurance mandate

medical health insurance mandate is a regulation that calls for citizens of a state to carry medical insurance. Only 5 states and the District of Columbia require citizens to have medical health insurance: California, Massachusetts, Rhode Island, New Jersey and Vermont. Unless you qualify for an exemption, citizens of these states (besides Vermont) have to pay a tax penalty.

Congress ended the federal mandate penalty in 2019, which efficiently worn out the ACA’s man or woman mandate.

Health coverage quote

The estimated fee of a health insurance plan. A medical health insurance quote is generated earlier than you buy an insurance plan. Quotes for an ACA market plan are stricken by a variety of personal factors, including age, tobacco use and plan metal tier.

Health preservation business enterprise (HMO)

A health insurance plan that calls for you to paintings with a number one care company to manipulate your care and get specialist referrals. Health protection corporation (HMO) contributors can only acquire care from providers and centers that settlement with the HMO network. If contributors get care out-of-network, they’re answerable for the overall value of the service (except for emergency care).

Health plan

An medical health insurance plan that covers the price of numerous clinical offerings for policyholders.Explore the comprehensive Glossary of Health Insurance Terms to unravel the complexities of coverage, premiums, deductibles, and more.

Health reimbursement account (HRA)

An account that permits people or households to pay for positive fitness care fees. Health reimbursement preparations (HRAs) are owned and managed through a member’s corporation, and simplest the organization can make a contribution to the account. HRA contributions are tax-loose, however the organization has manage over how the HSA budget can be spent and what happens to unused budget. You commonly can’t take an HRA with you when you convert jobs.

Health savings account (HSA)

An account that permits people or families to store money for qualifying scientific expenses. Individuals make fitness savings account (HSA) contributions on a pre-tax foundation and employers can also contribute to the debts. Only human beings with a high-deductible medical insurance plan can contribute to an HSA.

High-deductible health plan (HDHP)

A medical insurance plan with a minimum deductible of $1,500 for an individual or $3,000 for a own family. High-deductible health plans (HDHPs) have lower premiums, however you generally pay extra whilst you need medical care. Any medical insurance plan, like an HMO or PPO, can be a HDHP.

Home fitness care

Medical care which you get hold of in your property, in preference to a health facility or health care facility. Home fitness care is furnished by nurses or other certified fitness care specialists.

Hospice offerings

A form of clinical take care of individuals who are experiencing a complicated contamination and are nearing the end of their lifestyles. Hospice specializes in high-quality of existence and palliative care, as opposed to ailment remedy. Patients can get hold of hospice care in their non-public domestic, in a protracted-time period care facility or in a health facility.


When a affected person is admitted to a hospital for inpatient treatment. Hospitalization typically calls for staying as a minimum one night.

I to L

Indemnity coverage

A supplemental medical health insurance plan that covers a number of the fee of hospital remains. Most health center indemnity coverage plans cover hospitalizations with or without surgery, in addition to extensive care and critical care medical institution remains. This sort of plan will pay out based totally on the wide variety of days you stay within the medical institution.

In-network coinsurance

The percentage of the cost of a clinical invoice you pay when you obtain treatment from a scientific provider that contracts along with your plan’s network. You best pay in-network coinsurance after you’ve met your deductible.

In-network copayment

The amount of money that an insured person will pay for a medical carrier while you visit a company that contracts along with your health plan’s community. In-network copayments are usually much less highly-priced than out-of-community copayments.

In-community provider

A health practitioner, expert or health facility that contracts together with your medical insurance employer. These specialists agree to get paid a reduced price for each service they provide, in exchange for being part of the community. In maximum cases, health plan members pay much less when they go to an in-community provider.

Inpatient offerings

Medical services or remedy that an individual receives when you’re admitted to the clinic and live in a single day.

Long-time period care coverage

A type of supplemental medical health insurance that facilitates you pay for long-time period health care. Many long term care insurance plans can pay for nursing houses, grownup day care and home health aides. To use long term care advantages, maximum policies require adults to need assist with at the least sports of each day dwelling (ADLs) for more than 60 days. It additionally covers adults with cognitive impairment.

M to O


A federal- and kingdom-funded medical health insurance application that offers advantages to low-profits people and households, and those with disabilities. Medicaid eligibility and expenses are based on profits.


Medicare is a federal health insurance application for those who are over age 65 and younger humans with qualifying disabilities. People who’re eligible can pick out between Original Medicare and Medicare Advantage.

Original Medicare includes Part A (sanatorium insurance), Part B (medical coverage) and Part D (prescription coverage). Medicare Advantage, also called Part C, consists of Part A and Part B and frequently has prescription drug blessings incorporated inside the plans. Private health insurance corporations offer Medicare Advantage plans, which frequently offer superior blessings now not discovered in Original Medicare, together with dental and imaginative and prescient, or even assist with nutrients, pest manipulate, transportation for non-clinical wishes and different greater services.

Medical debt

Medical debt is the quantity of money you owe in unpaid scientific bills.

Medically necessary

A shape of healthcare that is required or important to diagnose or deal with an infection or damage, or is in any other case vital to a affected person’s healing. Many medical health insurance groups only pay for clinical offerings which might be deemed medically necessary through a healthcare professional.

Minimum top class plan (MPP)

A medical health insurance plan in which an organization and coverage organisation decide that the employer pays all claims up to a specific quantity, and the insurance company can pay the rest. With an MPP, the insurance employer is generally required to technique claims and administer the plans.

No Surprises Act

A federal law that shields people from paying surprising clinical payments while you by accident or unknowingly get remedy from an out-of-community company. The No Surprises Act bans surprise billing in a few situations, along with receiving emergency offerings at an out-of-community facility and receiving non-emergency offerings at an in-community clinic, however with an out-of-community provider.

Non-favored provider

A non-preferred provider is a scientific expert that doesn’t settlement together with your insurance enterprise. You typically pay greater when you go to a non-desired provider.


Obamacare is every other term for the Affordable Care Act (ACA), a federal law surpassed in 2010 that expanded get right of entry to to low-cost medical insurance within the U.S.

Open enrollment

The time period while eligible people and families can sign up in or alter an ACA marketplace medical insurance plan or different varieties of health insurance plans. Open enrollment takes place yearly beginning within the starting of November and ending in mid-January of the subsequent 12 months in most states for ACA plans. Employers with organization medical health insurance set their own open enrollment periods.

Outpatient services

Medical services or approaches that don’t require an in a single day live in a clinic or medical facility.

Out-of-network coinsurance

The percent of the clinical bill you pay after assembly your deductible whilst you get remedy from a medical doctor or at a hospital that doesn’t agreement along with your insurance organization. Out-of-network coinsurance is commonly extra expensive than in-network coinsurance.

Out-of-network copayment

The amount of money you pay for medical offerings when you get hold of hospital therapy from a company that isn’t a part of your fitness plan’s network. Out-of-network copayments are typically higher than in-community copayments.

Out-of-community provider

A health practitioner, specialist or health facility that doesn’t agreement along with your health insurance enterprise. Depending in your plan, you can need to pay the overall medical bill in case you get remedy out-of-network. Other plans cowl a smaller part of your clinical fees whilst you exit-of-network.

Out-of-pocket cost

The portion of your medical fees that aren’t blanketed by insurance. Examples of out-of-pocket expenses include deductibles and coinsurance.

Out-of-pocket restrict

The out-of-pocket maximum amount of money you pay out-of-pocket for blanketed medical services in a 12 months. After you’ve reached the restriction, your coverage organization can pay one hundred% of your qualifying medical fees. Some of the prices that remember in the direction of the out-of-pocket restrict are deductibles, copayments and coinsurance for in-network care.

Expenses that don’t matter toward the out-of-pocket restriction encompass your charges, the quantity you spend for medical offerings that your plan doesn’t cowl and out-of-community hospital treatment.

The out-of-pocket max inside the ACA market is $9,one hundred for single insurance and $18,2 hundred for circle of relatives insurance.

P to R

Physician offerings

Any provider this is furnished via an authorized Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.).

Physician-health facility company (PHO)

A organization made out of hospitals and physicians that work together to control and coordinate affected person care. The entities in a PHO may also offer blanketed offerings to the subscribers of a medical health insurance plan.

Point-of-provider (POS) plan

point of provider (POS) is a sort of medical health insurance plan that is a hybrid of an HMO and PPO. POS plans permit individuals to acquire care in-community or out-of-network, however members are required to paintings with a primary care company to get referrals for experts. POS plans aren’t almost as not unusual as PPO, HMO and EPO plans.


A health insurance employer may additionally require which you get a preauthorization earlier than getting unique treatments, medicinal drugs, medical devices or other scientific offerings. Insurers use preauthorizations as a manner to potentially lessen useless care.

Preferred provider

Medical vendors that contract together with your insurance business enterprise’s network and provide services at a reduced fee.

Preferred issuer employer (PPO) plan

A kind of medical insurance plan that permits individuals to get medical care in-community or out-of-community. Preferred issuer organisation (PPO) participants aren’t required to get a referral earlier than seeing a expert, so those plans have more flexibility than an HMO or EPO, but that generally comes at a better value.


medical insurance top class is the cost of preserving your medical insurance plan in force. It is the monthly price you pay for the health insurance plan you choose. You may lose coverage if you prevent paying your premium.

Prescription drug insurance

Any health insurance plan that covers the value of prescription medicinal drugs. All health plans purchased through the ACA market cowl prescribed drugs. Original Medicare recipients can get drug insurance through Part D.

Primary care provider (PCP)

A healthcare professional who oversees and manages your fundamental medical care. Some health insurance plans require PCPs to provide referrals to specialists.

Private medical insurance

Private medical health insurance refers to any health plan that’s provided by a medical health insurance employer, instead of a kingdom or federal authorities program.

Provider network

The group of healthcare specialists and hospitals that your medical insurance plan contracts with and presents included services to devise contributors.

Reconstructive surgical treatment

A surgical treatment that’s required to correct parts of the body following an accident, harm, clinical condition or birth defect.

Rehabilitation services

Health care offerings designed that will help you maintain and/or improve the crucial competencies had to characteristic in every day lifestyles. Rehabilitation offerings are often essential after an illness, damage or disability, wherein each day living abilities have been compromised or misplaced.


Reinsurance is a device that financially protects coverage businesses that face highly-priced claims. Rather than pay a whole declare in full, the insurance company can rent a reinsurance employer to pay for a part of the declare once a monetary restriction is met. Reinsurance systems are designed to preserve coverage rates extra cheap and decrease insurers’ hazard.

S to Z

Short-time period medical insurance

A health insurance plan that provides coverage for a confined time period for as much as a yr with the chance to increase for every other two years in most states. Short-term medical health insurance isn’t regulated by the ACA, so the plans aren’t required to cover crucial scientific advantages. Short-term plans may be cheap, however beware of restricted coverage, excessive out-of-pocket prices while you need care. Some states don’t allow short-time period health plans or restriction the length of time.

Skilled nursing care

Medical services furnished through a certified nurse, once in a while beneath the supervision of a medical health practitioner. Skilled nursing care is frequently provided in facilities which includes nursing houses, hospitals and assisted living communities, however additionally can be provided in your private home.

Special enrollment period (SEP)

A time period in which an individual is eligible to join or adjust a medical health insurance plan out of doors of open enrollment. To qualify for a unique enrollment period (SEP), you typically need to enjoy a qualifying existence occasion, which include giving delivery or adopting a infant, switching jobs, getting married or divorced, or transferring to a new country.


A health care professional that specializes in the diagnosis, remedy and prevention of unique scientific conditions, or who works with precise corporations of sufferers.

Supplemental medical insurance

A secondary medical insurance plan that supplements the coverage from your number one coverage. Examples of supplemental medical health insurance encompass dental coverage, vision coverage, disability coverage, most cancers coverage and critical contamination coverage.

Third party administrator (TPA)

A business enterprise that’s hired by an insurance issuer or self-insured organisation to manner subscriber claims, manage billing and cope with other every day administrative tasks. A TPA will also be employed to reduce workload for a employer’s finance or HR branch.

Usual, normal, and affordable (UCR) costs

The cost of a clinical service in a specific area based on what other scientific experts in the vicinity commonly charge for the identical provider.

Urgent care

Treatment for a clinical circumstance, harm, illness or symptom that desires professional attention quickly, but doesn’t require instant treatment in an emergency room or health facility.

Vision insurance

Vision coverage is a kind of insurance that partly can pay for imaginative and prescient care, like eye checks, touch lenses and prescription glasses.

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