For your convenience, scroll down for medical and dental definitions used most frequently.
MEDICAL INSURANCE TERMS
a general overview
Allowable amount - The allowance for covered services rendered or the provider's billed charge which ever is less as agreed by the insurance carrier and provider. This amount is the allowance that the provider and carrier have agreed by contract to be accepted as payment in full for services rendered.
Calendar year - The period beginning at 12:01 a.m. on January 1 and ending at 12:01 am on December 31.
Carrier - A particular insurance company that is contracted with doctors and hospitals such as Blue Shield, Blue Cross etc.
Coinsurance - The portion of the allowable amount that members pay for covered services when receiving benefits. It is the percentage amount that represents the member's share of the cost for covered services. So for a medical service, such as an x-ray, the carrier's in-network allowable amount could be $100, your coinsurance amount is 20%, you would pay $20 and your health plan would pay $80.
Copayment or Copay - A portion of the allowable amount that members pay for covered services when receiving benefits. Can be the fixed dollar amount that represents the member's share of the cost for covered services. If your office visit copayment is $20, you would pay that amount each time you see your doctor. Keep in mind, your plan may not pay for some services until after you meet your deductible.
Covered services - Medical services that are covered by your health plan.
Deductible - This is the amount you must pay each calendar year for most covered services before your plan begins to pay. If your heath plan has a $1000 deductible, you pay for the first $1000 of covered treatment costs. Then the plan pays a coinsurance percentage of all costs except your copayments & coinsurance. With some plans, your plan may pay for the treatment right away before you meet the deductible for covered services such as preventive care.
EOB - Explanation of Benefits, the billing statement sent to the member (you) from the insurance carrier on services received and paid by your plan.
Family Deductible - This applies if you have family coverage and a plan with a family deductible. The individual deductible paid by covered family members count toward the family deductible. Once the family deductible is met, the individual deductibles are also met. Each plan has specific requirements as to how a family deductible is met either by aggregate or individually.
Formulary - A preferred list of covered generic and brand name drugs. You pay less for formulary than for non-formulary drugs.
HMO (Health Maintenance Organization) - a type of health insurance network in a designated area or State. One primary care physician is selected by you to coordinate all health care specific to a zip code area. Must use primary care physician for referrals in most cases. Not transferable out of California. HMO’s access out of California is valid only in case of emergency. Generally monthly premium rates are higher so that your copay costs are lower whenever you access care throughout the year. Unlimited lifetime coverage.
HSA (Health Savings Account) - a high deductible PPO health plan with tax advantages designed to lower monthly premiums and provide investment options. Funds in the savings account are tax-free and available to pay for qualified medical expenses. Setting up a special savings account to fund the high deductible plan is highly recommended. Ask us for more detail.
In or Out of network (PPO plans only) - physicians and hospitals contract with an insurance carrier to be "in-network” for regulating costs for all concerned. Those providers/hospitals who do not contract are considered "out of network" and can charge any fee for services, which are paid by you at a higher rate and by the plan at a lower rate. HMO plans do not have benefits out of network except for emergencies only.
Individual Underwriting - proof of insurability determined by the carrier. The application is your request for a contract with the carrier to issue you a policy. Before a decision is made on accepting this contract, the carrier reviews your health history to determine misrepresentations, fraudulent actions and overall medical risk (height/weight, conditions, medications) of the applicant(s). This process can take 3 - 6 weeks if medical records are requested. Once underwriting is completed, a decision is made to accept (sometimes increasing the premium called a "rate up" due to future risk) or decline. For declined applications, you have the right to appeal the underwriting decision.
Insurer - is the insurance company, also known as the "carrier" (see term above).
IPA - physician listed as an Independent Practice Association in the HMO network.
Non-preferred Provider (PPO plans only) - A provider that is not in the PPO network is also called a non-network provider. Going to a non-network doctor will cost you more because they are independent and not contracted with the insurance company. When members use a non-preferred provider not in the network, you will pay the copayment or coinsurance plus any charges that exceed the allowable amount by the carrier. Charges above the allowable amount do not count toward the out of pocket maximum.
Out of pocket maximum - A dollar limit on the amount a member may have to pay for covered services in a calendar year, usually not including the plan deductible but with some plans it is included, just ask us. Once you reach the maximum, the plan or insurance carrier will pay 100% of the allowable amount for all applicable covered services for the remainder of the calendar year up to a specified maximum. Copayments for certain PPO plan covered services such as office visits, generally do not count toward these maximums and they continue to be the member's responsibility once the maximum is met.
PCP - primary care physician in the HMO network usually affiliated with a medical group.
Personal or primary care physician (HMO plans only) - who serves as an HMO member's designated primary healthcare provider and provides or coordinates all of the member's care especially referrals.
PPO (Preferred Provider Organization) - a type of health insurance network transferable outside of California. Choose your own doctor or specialist without a required referral. Generally lower monthly premium rates with higher out of pocket costs when you need to access care. Limited lifetime coverage from $2 - $6 million dollars depending on plan.
Pre-existing conditions - this means a condition for which a person received medical care, treatment, services, medication, diagnosis, or consultation 6 months before the insured person's effective date of coverage. Pre-existing conditions are not covered until the person has been continuously covered under the policy for 6 months or longer depending on the carrier's policy.
Preferred provider (PPO plans only) - A provider who is part of the PPO network (also called a network provider). PPO plan members don't have Personal Physicians and can see doctors without a referral. PPO members pay less for services when they see preferred providers versus seeing a provider out-of-network who is not contracted with the insurance carrier.
Premium - Monthly payments for insurance, also known as the rate.
Preventive Care - includes annual routine physical exam, well-baby care office visits, gynecological exam office visit (includes pap or other approved screening tests, routine mammography and immunizations when received as part of the annual exam or preventive care visit.
Provider - Interchangeable term for doctor or physician.
DENTAL INSURANCE TERMSAmalgam filling - metal, either silver or gold filling material.
Endodontic services - the branch of dentistry dealing with the treatment of root canals and removal of tooth nerves.
Orthodontic services - treatment including braces, retainer appliances & all related services.
Periodontic services - the dental specialty of treating periodontal disease, example: scaling and root planning.
Prosthodontic services - the branch of dentistry dealing with the construction of artificial appliances for the mouth, especially for the purpose of replacing missing teeth with bridges and dentures.
Resin-based composite filling - natural white color filling material.
Restorative care - amalgam and composite resin fillings and crowns on primary teeth.
If you have a word that is not explained here, please send us an email.
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