The amount of money you must pay out of pocket before your insurance starts to cover the costs of your care.
Deductible
The monthly fee you pay to keep your health insurance policy active.
Premium
A fixed fee you pay for each doctor's visit or prescription.
Copay
A percentage of the cost of your care that you pay after you have met your deductible.
Coinsurance
The maximum amount of money you will have to pay out of pocket for your care in a calendar year/plan year.
Out-of-pocket maximum
A doctor or hospital that has contracted with your insurance company to provide care at a discounted rate.
In-network provider
A doctor or hospital that has not contracted with your insurance company and may charge you more for care.
Out-of-network provider
A recommendation from your doctor to see another doctor or specialist.
Referral
The process of determining which of your insurance plans will pay for your care when you have multiple insurance policies.
Coordination of Benefits
The determination that a medical treatment or service is necessary to diagnose or treat a medical condition.
Medical Necessity
A process that insurance companies use to determine whether a patient is eligible to receive certain procedures, medications, or tests, except in an emergency.
Pre-authorization
A type of health insurance plan that requires you to choose a primary care doctor who coordinates your care and refers you to specialists within the HMO network.
Health Maintenance Organization (HMO)
A type of health insurance plan that allows you to choose any doctor or hospital, but you may pay more for out-of-network care.
Preferred Provider Organization (PPO)
A type of health insurance plan that combines features of HMO and PPO plans.
Point-of-Service (POS)
A cap on the total lifetime benefits you may get from your insurance company.
Lifetime Maximum
A type of funding arrangement that are subject to state insurance regulations, whereas self-insured health plans are not – they’re regulated at the federal level instead, under ERISA.
Fully-insured
