Co-payment: Most people have this system within their policy. Essentially, it’s another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.
Covered Expenses: Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for the total services. Some may not even pay for prescription drugs. Others may not pay for any mental health care coverage or other type of specific coverage. Covered services are those medical procedures the insurer agrees to pay for, bottom line. 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 kicking in.
Exclusions: This includes specific conditions or circumstances where the policy will not provide benefits.
Health Maintenance Organization, HMO: You pay a monthly premium and the specific plan HMO covers your physician visit(s), hospital stay(s), emergency and other medical treatments. You must use the physicians and hospitals designated by the HMO. The insurance provider will give you a list of physicians to choose from. For further visits with specialists or tests you will need to go to a primary care physician and get a referral.
Managed Care: A vast system and process that manages costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have a type of managed care.
Out-of-Pocket Expenses: This is the money you will need to pay each year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
Preferred Provider Organization, PPO: You pay a monthly premium and can choose any physician without getting a prior referral. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered.
Pre-existing Condition: Any health problem that may have existed before you purchased and took ownership of your insurance policy.
Premium: The amount you or your employer pays in exchange for insurance coverage, usually expressed in an annual amount.
Primary Care Doctor: This is often a family physician, but sometimes not. Basically, a primary care doctor diagnoses and treats minor health problems, and refers you to specialists if an additional level of treatment is needed and required.
Provider: Any doctor, nurse, dentist, hospital or clinic that provides medical care.
