Commonly Used Terms
- Co-Pay – fixed payment for a covered service that is to be paid when an individual receives service. It is defined by an insurance policy and paid by an insured person each time a medical service is accessed.
- Deductible – set amount you have to pay every year toward your medical bills before your insurance company starts paying. It varies by plan, and some plans do not have a deductible.
- Co-Insurance – cost share responsibility between a patient and their insurance policy. This cost share is often accessed once a plan deductible has been met.
- Out of Pocket maximum – maximum that you’ll have to pay during a policy period (usually one year) for healthcare services. Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100% of the allowed amount for covered services.
- Catastrophic Cap – maximum out-of-pocket expenses incurred per fiscal/enrollment year. The out-of-pocket expenses are defined as enrollment fees, co-payments, deductible, co-insurance, cost shares, etc.
- Coordination of Benefits – allows plans to determine their respective payment responsibilities (i.e. which plan is primary, secondary, etc.).
- Allowed amount – the maximum amount an insurance plan will pay for a covered healthcare service. It may also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
- Non-covered – service(s) that are not a defined benefit with your insurance plan.
- Inclusive – reimbursement of health care providers on the basis of expected costs. It is also known as “episode-based payment,” “episode-of-care payment,” “case rate,” “evidence-based case rate,” “global bundled payment,” “package pricing,” or “packaged pricing.”
- In Network – providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount.
- Out of Network – providers or health care facilities that are considered nonparticipants in an insurance plan.
- Not Medically Necessary – insurance plan did not feel service was needed to prevent, diagnose, or treat the illness, injury, condition, disease or its symptoms.
- Services Not Authorized – provider failed to obtain authorization for coverage of service or a service was not deemed medically necessary. Insurance will not pay.
- No Referral Obtained – special pre-approval needed was not obtained before seeing a primary care physician or specialist. Insurance will not pay.