Commonly Used Health Insurance Terms

Posted October 17 2013



Health Insurance Terms

MHG Insurance strives to provide our clients with the best service and the most viable information regarding insurance policies and services currently available on the market. We want our clients to be able to make informed decisions about their healthcare, as well as become familiar with what their own insurance needs are. This can be a challenging task, however, as the insurance industry has practically established its very own language which includes a myriad of terms and confusing industry related jargon.

Below are commonly used health insurance terms, clearly defined to make it easier for you to apply this information when you review your current policy, or when you are considering making changes to your existing plan. As always, MHG is available at any time to discuss any questions you may have regarding your existing plan, or to examine these terms in more depth:

  • Deductible: A deductible is a fixed dollar amount during the benefit period, usually a year, which an insured person pays before the insurer begins to make payments for covered medical services. Plans may have individual and family deductibles. Some plans may have separate deductibles for specific services, such as a deductible for each hospitalization admission.

  • Coinsurance: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible (if any) has been paid. Once the deductible and/or coinsurance have been paid, the insurer is responsible for the rest of the reimbursement for covered benefits.

  • Copay: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is then responsible for the rest of the reimbursement.

  • Out of Pocket Maximum: This is the maximum dollar amount a group member (the insured) is required to pay out of pocket during a benefit year.  Until the maximum is met, the plan and group member share in the cost of covered expenses.

  • In/Out of Network or Participating Provider: Your health plan contracts with a wide range of participating doctors, specialists, hospitals, pharmacies, and labs. These providers have agreed to accept your plan’s contracted rate as payment in full for services. The contracted rate includes both your insurer’s and your share (deductible, copay, coinsurance) of the cost. For those with out of network benefits, services from a provider who is outside of this network are not based on agreed upon or set contracted rates with your insurer, and therefore the services may be subject to higher charges. This may result in you paying more out of pocket for the difference owed between what the provider is charging and what your plan will cover.

  • HMO: HMO stands for Health Maintenance Organization. It is defined as a health care system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for health care delivery in a particular geographic area to HMO members, usually in return for a fixed, prepaid fee. Financial risk may be shared with the providers participating in the HMO. There are different types of HMOs, including a Group Model HMO which contracts with a single multi-specialty medical group that provides coverage to the HMO’s membership. There is a Staff Model HMO where patients can receive services only through a limited number of providers, in which physicians are employees of the HMO, usually operating within the HMO’s own facilities. There is also a Network Model HMO that contracts with multiple physician groups to provide services to HMO members. Finally, an Individual Practice Association HMO is a type of health care provider organization composed of a group of independent practicing physicians who maintain their own offices and band together for the purpose of contracting their services to HMO’s.

  • POS: A POS plan is an HMO/PPO hybrid; sometimes referred to as an open-ended HMO when offered by an HMO. POS plans resemble HMOs for in-network services. Services received outside of the network are usually reimbursed based on a fee schedule, or what is considered to be reasonable and customary charges.

  • PPO: A PPO plan is an indemnity plan where coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. The enrollees may go outside of the network for services, but would incur larger costs in the form of deductibles, higher coinsurance rates, or non-discounted charges from the providers.

  • COBRA: COBRA stands for the landmark Consolidated Budget Reconciliation Act of 1986. This law provides the continuation of group health coverage that would otherwise be terminated for a former employee, retirees, spouse’s former spouses and dependent children. The coverage is available when coverage is lost due to certain specific events, such as voluntary or involuntary termination of employment, reduction of the number of hours worked by the employee, covered employees becoming entitled to Medicare, or divorce or death of a covered employee. However, in most cases, the insured person must continue to pay his or her portion of the insurance premium as well as the portion that was previously being paid by the employer in order to maintain coverage.

MHG Insurance wants you to understand health insurance terminology that can often be confusing and overwhelming. We welcome your feedback and any questions you may have. You may contact MHG at 954-828-1819, or by visiting us at mhginsurance.com. Here’s to your good health!