Insurance Terms

Below are some common terms used in discussion of insurance. When deciding on what insurance to purchase, you may want to refer to this glossary of insurance terms.

Accident: An unexpected event that causes injury.
Allowable Charges: The charges agreed to by the Preferred Provider Organization (PPO) for specified covered medical treatment, services and supplies.
Benefits: The money the insurance company pays the health care provider for medical services provided to you if you become ill or injured.
Claim: A request by you for the insurance company to pay medical expenses that are covered under the insurance policy. If the provider of a medical service is in network, they will file the claim for you.
Coinsurance: A provision of the insurance by which the covered person and the insurance carrier share in a specified ratio the eligible hospital or medical expenses resulting from a sickness or accident, (e.g. 80%:20%; the insurance carrier paying 80%, the insured person paying 20%). Coinsurance typically comes after the deductible, but not always.
Coverage: The conditions for which the insurance company will pay.
Copayment: A specified dollar amount a Covered Person must pay for specified services, typically for office visits, urgent care, and ER visits.
Covered Person: A Covered student and his or her dependent(s) insured under the Policy.
Deductible: The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a "$250 deductible," the insurance company pays as agreed after you pay the first $250.
Provider: A licensed practitioner providing medical expertise and services within the scope of his or her license and practice.
Effective Date: The date insurance coverage begins.
Eligible Expenses: An expense defined in a health plan as being covered and not listed in the exclusions section.
Essential Health Benefits: A set of health care service categories that must be covered by certain plans, starting in 2014. The complete list of categories can be viewed at HealthCare.gov - Essential Health Benefits.
Exclusions: Specified conditions or circumstances for which a policy does not provide benefits.
Expiration Date/ Termination Date:: The date that insurance coverage ends.
Explanation of Benefits (EOB):: The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.
Identification Card:: A card given to you that identifies you as a member of a particular health insurance plan. The card must be presented when seeking treatment, as it contains identifying information specific to you and your plan in order to process claims.

Insurance: A system under which individuals, businesses and other organizations, in exchange for a premium, are promised payments for losses resulting from certain dangers as specified in a contract.
Insurance Policy: The legal document issued by the company to the policyholder, which outlines the terms and conditions of the insurance; also called a "contract."
Insured: A person or organization covered by an insurance policy.
In-Network: Defines providers or health care facilities that are contracted with a particular network and have negotiated discounts with the participants of that network.
Major Medical: A plan that provides basic medical coverage, typically with a high deductible.
Medical Necessity/Medically Necessary: Services, supplies, or treatment for particular diagnoses that are within the standard of care in the medical community and/or as defined by CDC.
Open Enrollment:: Time period when students are eligible to enroll or change coverage for any reason.
Out-of-Pocket Costs:: The total you pay out of your pocket for a policy year. These costs include the deductible, co-insurance and amounts considered by the insurance company to be above the "Usual and Customary charges.”
Out-of-Network: Defines providers or health care facilities that are not contracted with a particular network and do not have negotiated rates or discounts with that particular network.
Pharmacy:: A business where drugs approved by a doctor are legally sold.
Pre-existing Condition:: A medical condition that was diagnosed and/or required treatment during a fixed period of time, usually 3 or 6 months, before you purchased your insurance policy.
Preferred Provider Organization (PPO): A type of managed care health insurance plan that utilizes a network of physicians and facilities contracted by the insurance carrier to provide services for a negotiated price bound by contract. Utilizing PPO providers helps to keep the out of pocket costs lower to you overall and claims costs lower to the insurance plan.
Policy Term:: The length of time a health policy provides benefits to a covered person.
Premium:: The price you pay for your insurance policy.
Usual and Customary Charge/Reasonable and Customary: The routine charge for a medical service by similar professional medical providers in the same geographical area. You may be required to pay an amount above the Usual and Customary charge for an out-of-network provider, if that provider charges more than other providers for the same service.