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Copayment

A type of cost sharing where insured persons pay a specific flat amount per incident of service or a percent of the amount allowed as reimbursement for a covered service. Also referred to as "co-insurance".

Deductible

An amount the insured person must pay before insurance payments for covered services begin. For example, an insurance plan might require the insured to pay the first $250 of covered expenses during a calendar year. There may be other, separate deductibles that apply to certain types of services.

Exclusions

Conditions, situations, and services not covered by the health care plan.

Health Care Provider

A doctor, hospital, laboratory, nurse, or anyone who delivers medical or health-related care.

HMO (Health Maintenance Organization)

A type of health care plan that provides a full range of health care services to its members. Members of an HMO must typically receive all of their medical care form health care providers in the HMO network, coordinated by a primary care physician.

Indemnity (Traditional Medical Insurance)

A type of insurance plan under which you pay 100% of all medical bills up to an annual deductible. The insurance company then pays a percentage of all covered charges.

In-Network

A group of doctors, hospital and other health care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.

Lifetime Maximum

The maximum dollar amount paid for all covered sickness and injuries for each insured person.

Managed Care

A health care program designed to make sure you receive the highest quality of medical care for the lowest cost, in the most appropriate health care setting.

Out-Of-Network

Health care services received outside the HMO, POS or PPO network.

Out-Of-Pocket Expense

Any medical care costs not covered by insurance, which must be paid by the insured.

POS (Point of Service Plan)

With a POS Plan, benefits are determined at the point the member decides to use either In-Network or Out-Of-Network services, giving members greater freedom of choice. When a member remains In-Network or uses a participating provider, benefits are provided as an HMO (low out-of-pocket expenses and no deductible or claim forms. Members choosing Out-Of-Network benefits will have reduced benefits and higher out-of-pocket expenses.

PPO (Preferred Provider Organization)

A delivery system where providers are under contract to an insurance company or health plan to provide care at a discount or negotiated rate. There is freedom of choice among In-Network providers, including specialists. When In-Network providers are used, out-of-pocket expenses are lower and no claim forms are required.

Pre-existing Conditions

A condition for which medical advice, diagnosis, care or treatment, including use of prescription drugs, was recommended or received from a licensed health practitioner during a specified period of time immediately preceding the effective date of coverage.

Primary Care Physician

The doctor in your HMO or POS network who serves as your health care manager and coordinates virtually all of the health care services you receive. Your primary care physician provides you with routine medical care and will refer you to a specialist if necessary.

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