Glossary of Terms

Insurance has its own vocabulary, so let us help you by providing definitions of common terms that can help you make an informed buying decision. If you have any questions feel free to contact us through our toll free number 1-800-472-7199.

This glossary has many commonly used terms but is not a complete list. Some of the terms may not have exactly the same meaning when used in your policy or plan. Please refer to your specific plan document provided for detailed information on benefits covered by the Plan and the terms and conditions of coverage.

Allowed Amount: Maximum amount on which payment is based for covered health care services. If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing)
Appeal: A request for your health insurer to review a decision or a grievance again.
Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for the covered services.
Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductible you owe. For example, if the health insurance’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of the 20% would be $20. The health insurance pays the rest of the amount.
Copayment: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible: The amount you owe for health care service your health insurance covers before your health insurance begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Effective Date: The date that your insurance coverage goes into effect.
Emergency Medical Condition: An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Room Care: Care you receive in an emergency room.
Excluded Services: Any service that is not covered under the health plan. All plans have a list of exclusions that may include things such as experimental, non-referred, cosmetic, etc.
Grievance: A complaint that you communicate to your health insurer.
Health Insurance: A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Insurer: A company that is in business to provide health insurance coverage plan options for enrolled members.
Total Employees: The number of employees including part time, seasonal and all other employees on your payroll.