Health Insurance Resources

An authorization is an approval granted by your insurance provider to pay for any treatment or care that is covered by your insurance policy. If you receive care that is not authorized, you will bear the full financial costs.  In  an HMO, authorization is permission to receive the treatment or care that you get from the HMO before the care is given.

Co-insurance is the portion of your medical care you are responsible for paying, after your insurance company pays its portion, and after your deductible has been paid. Your co-insurance responsibility is usually defined as a specific percentage of the costs for your care.  For example, once your deductible has been paid, if you have 80/20 coverage, you pay 20% of the cost and your insurance company pays the other 80%.

A co-payment is a flat fee that you pay for a specific health care service, such as an office visit or a prescription, that is in addition to what you pay in a monthly fee or premium for you health insurance. Co-payments are a common feature of managed care health plans. Your co-payment can vary from service to service within your plan.

A complaint is when you contact your health insurance provider to express dissatisfaction with the healthcare you received or the financial coverage authorized.

Your deductible is the amount you must pay for your medical care before your insurance starts paying the costs. Most deductibles are calculated annually.

A denial of claim is the refusal of your insurance provider to honor your or your healthcare provider's request to pay for healthcare services you received.

A DHMO is managed dental healthcare plan. You pay a monthly fee to receive care from the network of care providers within the DHMO.

A DPPO is a managed dental healthcare plan. A DPPO  consists of a network of dental care providers that agree to accept payment for your dental care according to the fee structure determined by the insurance plan provider. You can go outside the network for your care, but you will pay all the costs or a higher percentage of the costs than for in-network care.

An exclusion is provision in your health insurance policy that eliminates coverage for certain treatments.

Fee-for-service is a type of health care delivery system where you pay your care provider a fee for each service, treatment, or prescription you receive. After you pay the fee, you or your care provider submit paperwork to your insurance provider, so you can be reimbursed for the portion of the costs you paid for that your insurance covers.

Fee-for-services plans are also called indemnity plans. They are benefit payment system in which your insurer reimburses you or pays your care provider directly for each covered medical expense, after the expense has been incurred.

Group health insurance is an insurance plan that provides healthcare coverage to you if are a member of a qualifying group. Examples are employees covered under a group plan offered by the employers , union members covered under a  group plan offered by the union, or members of trade associations covered under plans offered through the association. Members of the group are not subject to individual underwriting.  If you have a pre-existing condition that makes qualifying for individual insurance problematic, you will not be turned down for a group insurance, if you are a member of a qualified group.

An HMO is a managed healthcare plan. You pay a monthly premium for medical services provided by a network of hospitals, doctors and other health care providers that contract with the HMO. Many services require a co-payment. A distinguishing feature of HMOs is that you must first see your primary care physician (PCP), before you can see any specialist. All referrals go through the PCP.

An Indemnity plan, also called a fee-for-services plan, is a type of medical insurance plan that reimburses you or your care provider, after the expenses are incurred.

A representative working on behalf of one or more insurance companies who has been authorized to sell and service insurance contracts.

A claim is a request that you or your care provider make to your insurance company for the insurance company to pay all or part of the costs of the medical services you obtained.

A contract obligating the insurer to pay for particular losses and provide specific services in the event that certain events take place (such as a car accident, an illness, or a home fire).

The agreed upon amount that a policy holder pays the insurance company for the insurance policy coverage. Depending on the type of insurance, the premium may be payable annually, semi-annually, monthly or even twice a month.

An insurance quote is the estimated amount for the insurance premium for coverage specified in an insurance policy.

Managed care integrates the financing and the delivery of healthcare in one system. Managed care attempts to control the cost, access to,  and quality of the healthcare system it manages.

Managed care plans usually provide comprehensive health services offered through a network of healthcare providers. They either restrict care to providers within the network or offer financial incentives for patients to use the network providers. Examples of managed care plans are HMOs, PPOs, and POS plans.

A network is a group of  health care providers contracted to provide services to managed care plan's and insurance company's customers for less than their standard fees.

Out-of-network care is when you seek healthcare from any care provider that is not part of your managed care plan's network of providers. Some managed care plans exclude coverage for out-of-network care, while others may cover a portion of the costs.

A POS is a hybrid of HMO and PPO insurance plans. You have a primary care physician, like an HMO. You can seek coverage outside of your network, like in a PPO.

A pre-existing condition is a medical condition that is excluded from coverage by your insurance company because the condition was believed to exist prior to the time that you obtained your insurance coverage.

A PPO is a type of managed healthcare plan with a network of care providers. In a PPO, you do not have a  primary care physician. You are not restricted to seeking care within the network, however, your costs are likely to be higher when using a care provider who is not part of the network.

A PCP is a doctor who is your first contact within a managed care plan's healthcare system.  The requirement to select a PCP is a feature of some managed care plans.  For you to see a medical specialist, it is often necessary for you be referred to the specialist by your PCP.

A provider is a healthcare professional that provides services to patients.

A referral is a recommendation by a physician or healthcare provider for you to be evaluated or treated by a different physician or care provider. In an HMO, almost every referral must come from your primary care physician.

A specialist is a physician or healthcare provider who is certified to treat a specific body system,  such as a neurologist (nervous), gynecologist (woman's reproductive system), or hematologist (blood). Specialists can also be physicians or care providers whose expertise is certified in a certain area of care, such as an oncologist (cancer), radiologist (x-rays and using radiation for treatment) or a surgeon.