Health Insurance Glossary of Commonly Used Terms
We know understanding insurance benefits and coverage can be confusing and even overwhelming. Here are some common insurance terms and definitions to help get you started.
C
Carve out
An insurance plan may carve out specific services or providers by not including them in your coverage. Instead, your plan may include them in another plan or network. For example, mental health services may be managed by a different plan or network.
Claim
You or your provider can submit a claim to your insurance company to ask that they pay for a doctor’s visit or treatment you had.
Co-insurance
Co-insurance is a percentage of the cost that you will have to pay before or at the time you receive care. Your co-insurance will begin to apply after you have paid your deductible.
For example, if your co-insurance is 20%, after you have paid your deductible, you will pay 20% of the cost and your insurance will pay 80%.
Co-payment (or copay)
A fixed dollar amount paid before or at the time you receive care. For example, you may have a $20 copay to see a primary care doctor or a $30 copay to see a specialist.
D
Deductible
The amount you must pay before the insurance company begins paying your medical bills. Some plans may have both an individual and family deductible and out-of-pocket max. There are also plans with a separate deductible for pharmacy.
For example, if you have a $1,000 deductible, you will pay the first $1,000 of covered services. After you pay your deductible, you will only have to pay co-payments and co-insurance for covered services.
Dependent
Anyone, such as a spouse or child, who is covered by your plan.
Deposit/Pre-Service Payment
You may be asked to pay a deposit toward your expected cost of service. Your provider might ask that you pay a deposit before or at the time you receive care.
F
Formulary
A list of prescription drugs that your insurance will cover, and you will receive from a pharmacy.
G
Group number
An ID number that can be found on your insurance card. For example, people who receive insurance through the same employer might have the same group number.
I
In-network or in network
Healthcare professionals, hospitals or pharmacies who are covered by your health insurance plan. They offer services at a discounted rate. You will generally pay the least for in-network providers.
Insurance card
Your ID card that shows proof of your health insurance coverage. You may be asked to share your insurance card before receiving care.
M
Marketplace
A platform that helps people compare health insurance plans and costs, created as a part of the Affordable Care Act. Georgia residents can enroll in health coverage through the state Marketplace, Georgia Access.
N
Narrow network
A narrow network plan places limits on the providers your insurance covers. For example, the plan may only include a specific hospital or physician group.
O
Out-of-network
Healthcare professionals, hospitals or pharmacies that are not listed as a preferred provider by your plan. Your insurance will pay the least for out-of-network providers.
Out-of-pocket (OOP) costs
OOP costs include what your health insurance charges you and expenses that are not covered by your insurance. These include co-payments, co-insurance, deductibles, and the cost for non-covered services.
Out-of-pocket maximum
The OOP maximum is the most that you have to pay for covered services in a year. After you have paid your OOP, your plan will pay 100% of the costs of covered benefits. The OOP maximum does not include monthly premiums or non-covered services.
P
Payor
The insurance company that pays for your cost of health services.
Policy number/Member ID
The ID number assigned to you. You can find this number on your insurance ID card. It allows providers and your insurance company to review the details of your plan.
Pre-certification/Prior authorization
The process that helps determine if your care is medically necessary and should be covered by your insurance company. Your plan may require prior authorization before receiving certain services. You do not need prior authorization before emergency services.
Premium
The set amount that you will pay—usually each month—for your health insurance coverage.
Primary Care Provider (PCP)
A provider who practices general healthcare and monitors your overall health. They are usually your first stop for receiving care.
Provider
Any person or organization who provides healthcare. Providers include entities such as doctors, hospitals and urgent care clinics.
R
Referral
Your primary care provider (PCP) may send you to another doctor or specialist for care. For example, if your PCP thinks you need to see an eye doctor, they can give you a referral, so your health insurance can help pay for it.
S
Subscriber (member or enrollee)
A subscriber is the main person enrolled in the health insurance plan. If you have a family plan, the subscriber is the person in charge of the insurance. Other family members, like a husband, wife, or kids, are called dependents.
T
Third-party payer
A payer other than you that pays for your healthcare expenses, such as the government or your employer.
Tiers
A tiered network further categorizes in-network providers or services, which may affect how much you pay. For example, a provider in Tier 1 of a plan may cost less than a provider in Tier 2.
