Health Insurance and Medical Terms

Deductible: A specified amount you pay before your insurance will start paying towards your medical expense. For example, if you have a $2,000 deductible, you will pay $2,000 out of your pocket before your health insurance begins to cover their share for certain medical services.

Co-Insurance: Your share of the costs of a covered health care service, calculated as a fixed percentage.

Co-Payment: A fixed dollar amount that you pay, for office visits and prescription medicine. This amount will vary by the type of health care service and/or type of medication prescribed.

Annual Maximum: A limit on the benefits your insurance company will pay per policy year. After an annual maximum is reached, you must pay all associated health care costs for the rest of the year. The Affordable Care Act has eliminated maximum dollar amounts on health insurance plans in most cases.

Out-of-Pocket Maximum:
The maximum amount of coinsurance, deductible, and co-pays you will pay out of your pocket. After the out-of-pocket maximum is met, your plan will begin to pay 100% of covered costs for the duration of the policy year.

Preventive Care: Services provided for a reason other than to diagnose or treat an illness or injury. Examples of preventive care include immunizations and routine screenings.

Emergency Medical Condition: An illness, injury, symptom, or condition so serious that immediate medical attention is necessary or your health is jeopardized.

Emergency Medical Transportation: Ambulance services for an emergency medical condition.

Emergency Services / Emergency Room Care: Available at all times for the evaluation of an emergency medical condition and treatment to keep the condition from getting worse. If you receive medical services in an emergency room, you will receive multiple bills.

Preferred Provider/ In-Network Provider: A healthcare professional who has a contract with your health insurance company. Seeking a preferred provider will mean less out of pocket cost to you.

Specialist: A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. Example: Dermatologist, Cardiologist.

Pre-Certification/Prior Authorization: A decision by your health insurance plan that a specific health care service or a prescription medication is medically necessary.

Prescription Drugs: Drugs and medications that, by law, require a prescription.

Brand-Name Drugs: A medication that has been patented with the Brand Name and is produced by the original manufacturer under that Brand Name. These usually cost more than their generic equivalent.

Prescription Formulary: A list of prescription drugs (brand and generic) covered by your insurance plan. The prescription formulary indicates your cost share (co-pay) for medications.