Health Insurance: Terms You Should Know

Healthcare Terms: Explained

What is a premium?

A health insurance premium is the amount that policyholders pay monthly out of pocket for health insurance coverage.

What is a deductible?

A deductible is the amount you pay for out-of-pocket costs for your covered health care before your plan begins to pay.

What is coinsurance?

Coinsurance is the amount a patient pays for a covered service after their deductible has been met. 

What is a copay and how does it work?

A copay is a fixed flat fee that is paid by a patient to their provider before receiving a healthcare service. 

What is an Explanation of Benefits (EOB) and how do they work?

An Explanation of Benefits (EOB) is the insurance company’s written explanation regarding a claim. An EOB shows what the insurance company paid, what the member owes, and other helpful information, such as how to seek support. An EOB is not a bill.

What’s the difference between in-network and out-of-network?

In-network means a provider contracted with your health plan, and your health plan provides a higher level of benefit coverage than it provides for out-of-network services. Out-of-network means a provider has not contracted with your health plan, and your health plan provides a lower level of benefit coverage.

What is the difference between walk-in clinics, urgent care (including virtual), and the emergency room (ER)?

Walk-in clinics are typically conveniently located in retail facilities and offer medical care for minor illnesses and injuries, such as cold and flu-like symptoms or minor skin conditions. Some walk-in clinics also offer some immunizations and testing.

Urgent care centers cater to medical conditions that are not considered emergencies but still would lead a person to believe timely care is necessary to avoid serious deterioration of the condition or a person’s health. They’re similar to walk-in clinics, but with additional capabilities! Virtual urgent care means you’ll have access to an interactive virtual office visit with an on-demand urgent care doctor.

Emergency care means healthcare services provided in a hospital emergency facility (for example, an emergency room), freestanding emergency medical care facility, or comparable emergency facility to evaluate and treat emergency medical conditions.

What is considered Medically Necessary?

Medically Necessary/Medical Necessity means the health care services needed to diagnose or treat an illness, injury, condition, disease, or its symptoms that meet medically acceptable screening criteria used by your health plan.

What is prior authorization?

Sometimes, before receiving a service or prescription, a provider will want to ensure that it’s covered by your insurance. Prior authorization means that your health plan will review the services or prescriptions requested from a provider for medical necessity and appropriateness before you receive them. 

What is an Adverse Determination?

Adverse determination occurs when it is determined that treatment or service is deemed not medically necessary or appropriate or is experimental or investigational.

What is a medical claim? When, how, and why should I submit one?

A medical claim is a request for payment that your healthcare provider sends to your health plan. 

What is a Qualifying Life Event?

A Qualifying Life Event is a change in your circumstances  — for example, you got married or welcomed a new child — that would make you eligible for special enrollment outside of the year’s open enrollment period.  

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