Claim: A request by an individual ( or his or her health care provider) to an individual’s insurance company for payment of services obtained from a healthcare professional.
Deductible: The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.
Exclusions: Specific conditions or circumstances for which the policy will not provide benefits.
Health Maintenance Organization, HMO: You pay a monthly premium and the specific plan HMO covers your physician visit(s), hospital stay(s), emergency and other medical treatments. You must use the physicians and hospitals designated by the HMO. For further visits with specialists or test, you will need to go to a primary care physician and get a referral.
Managed Care: Ways to manage costs, use, and quality of the health care system. All HMO’s and PPO’s, and many fee-for-service plans have managed care.
Out-of-Pocket Expenses: The money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
Preferred Provider Organization, PPO: You pay a monthly premium and can choose a physician from primary to a specialist without getting a referral first. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered.
Pre-existing Condition: A health problem that existed before you purchased your insurance policy.
Premium: The amount you or your employer pays in exchange for insurance coverage.
Primary Care Doctor: This is often a family physician. A primary care doctor diagnoses and treats minor health problems, and refers you to specialists if another level of treatment is needed.
Provider: Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.