Appeal: An action that a patient takes if they disagree with a coverage decision that their health insurance made.

Benefits Investigation: A process to determine a patient’s health insurance coverage.

Claim: A medical bill that is provided to the patient or health insurance.

Coinsurance: A percent of cost that represents a patient's portion for a healthcare service after their insurance has paid its share.

Co-pay/Co-payment: An initial fixed amount that represents a patient’s portion of an approved healthcare service after their insurance has paid its share.

Cost Sharing: A patient pays a portion of their healthcare costs that is dictated by the plan they have.

Deductible: An amount a patient pays (see Out-of-Pocket) to their health insurance before a claim is paid or a medical service is performed.

Health Insurance Marketplace (also known as a Health Insurance Exchange): A place where individuals can find information about available health insurance options in order to enroll and purchase. Marketplaces can be federally facilitated or state-run.

Health Maintenance Organization (HMO): A health plan that offers health services within a network of doctors/healthcare professionals who are contracted by the HMO. The patient will pay for the services that are given to them at a certain cost. A primary care physician is required if the patient has an HMO. (See Primary Care Physician)

High Deductible Health Plan (HDHP): A health plan that requires a patient to pay a large amount of out-of-pocket costs (ie, deductible) before they receive a service or before their health plan starts.

Medicaid: Federal and state-funded health insurance for low-income individuals.

Medical Plan: Covers doctor visits, tests, treatment, etc.

Medicare Part D: Federal prescription insurance that covers individuals who are:

  1. 65 years of age or older
  2. Under the age of 65 who have certain disabilities
  3. Diagnosed with end-stage renal disease, regardless of age

Military Health Insurance: Government health insurance (e.g., VA, DOD, TRICARE) that provides health plans to military servicemen or veterans.

Network Provider: A doctor or healthcare professional who is contracted by a health insurance company to provide health services to patients.

Out-Of-Pocket (OOP): Expenses that are not covered by health insurance, which include deductibles, coinsurance, co-pays and other service-related costs.

Preferred Provider Organization (PPO): A health plan that offers patients a preferred network of doctors, hospitals and access to other healthcare professionals in which their plan will pay a certain amount for the service they receive. A patient can see a doctor or visit a hospital outside of their network but they will pay a portion or the whole cost of the service.

Premium: An amount that a patient pays for health insurance coverage.

Prescription Plan: Coverage for prescription medications.

Primary Care Physician (PCP): A patient’s main healthcare provider.

Prior Authorization: An approval process through which a healthcare provider must obtain approval from a patient’s health insurance in order for a service or product to be covered.

Referral: Authorization from a primary care physician for a patient to see a specialist for treatment or diagnosis.

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