Glossary

Trying to decipher the technical jargon of your health plan and provider? You’re in luck! Browse this helpful list of terms below that will provide some clarity!

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Claim

When you see the doctor, get lab tests, or go to the hospital, a claim is submitted by the doctor, hospital, or other provider to the health plan for reimbursement.

Coinsurance

This is the percentage of your share of the costs of your health care. Your health plan pays the remaining amount. For example, if your coinsurance is 20% and you have a procedure that costs $100, you will be responsible for paying $20 and your insurance company will pay the other $80.  Depending on your plan, coinsurance payments may only begin after you reach your deductible – the amount that you are required to pay before your insurance pays.

Copayment (Copay)

A fee due to the provider at the time of service, usually between $5 and $100 depending on the type of plan and care received.  Copays need to be paid whether or not you have reached your deductible – the amount that you are required to pay before your insurance pays.

Deductible

The amount you may be required to pay before your health plan pays for services. If you have a deductible, you pay your medical costs up to a certain dollar limit.  After you have reached that limit, your health plan pays your medical costs. Usually, after you reach your deductible you still need to pay copays or coinsurance.  The deductible typically resets at the beginning of each plan year.

EOB (Explanation of Benefits)

This document summarizes the claims submitted to the insurance company by your provider (doctors, hospitals, and other health care providers).  It breaks down which costs were paid by the health plan and which costs are the subscriber’s.

FSA (Flexible Spending Account)

A flexible spending account (FSA) is an account where you can set aside pretax money to pay medical expenses and other health-related items.  Flexible spending accounts are usually offered alongside your insurance benefits.

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Health Plan

This term can refer to your health insurance company (for example, Tufts Health Plan), or it can refer to the type of coverage you have (for example, HMO Advantage Plan).  Generally, health insurance companies offer many plan types.  If you obtain coverage where you work, your employer selects the plan(s) offered for the employees.

HMO (Health Maintenance Organization)

An HMO is a type of health plan that arranges for services and provides coverage through your doctors, hospitals, specialists, and other providers on an approved list. Usually with an HMO you will need a referral from your primary care provider for specialty care.

HRA (Health Reimbursement Arrangement)

An HRA is a bank account that your employer can put money into – tax free – for you to pay for eligible health care expenses (such as doctor visits, lab tests, hospitalizations, prescription medications, and even medical equipment). An HRA is similar to a Health Savings Account (HSA), except the money does not roll over from year to year and the funds are not reported to the IRS.

HSA (Health Savings Account)

An HSA is a bank account that you put money in–tax free–to pay for eligible health care expenses (such as doctor visits, lab tests, hospitalizations, prescription medications, and even medical equipment). An HSA rolls over from year to year and you can take it with you if you change jobs. You only spend it when you receive care.

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Network

A group of doctors, hospitals, and other providers that participate in a specific type of health plan (for example, HMO or PPO).  Networks can be different based on the type of health plan in which you are enrolled.

Open Enrollment

The period when you can join or change your health plan.

PCP (Primary Care Provider)

A doctor, nurse practitioner, or other qualified health care professional responsible for managing your health care services.

PHI (Protected Health Information)

Any identifiable information that can be associated with a specific person. This includes not only names and addresses, but also specific health information.

POS (Point-of-Service)

A POS health plan allows you to choose between two options.  In the first level of coverage, you may obtain care from any primary care provider (PCP) found on your health plan’s list of approved providers. In this case, your PCP will coordinate the care you receive from other providers and you will be covered at a higher level.  Your other option is to receive care that is not coordinated through your PCP. With this second option, referrals are not needed but you usually have a deductible and pay coinsurance.

PPO (Preferred Provider Organization)

A PPO health plan allows you to use health care providers even if they are not on your health plan’s approved list. If you choose a provider that is not on the health plan’s approved list, you may pay a higher copayment or coinsurance. In a PPO plan, you do not need referrals from your primary care provider to see a specialist.

Premium

The monthly amount you pay for your health plan coverage. If you get your coverage at work, your employer may pay a portion of the premium.

Provider

A licensed health care professional, group. or facility that provides health care services. This can include doctors, hospitals, physical therapists, labs, medical equipment suppliers, etc.

Qualifying Event

A change in a subscriber’s or dependent’s circumstances that lets them change their health plan. Usually you can only change your plan during open enrollment. Examples can include marriage, the birth of child, etc.

Referral

A letter or preapproval sent to the health insurance company by your PCP (primary care provider), allowing you to see a specialist or other health care practitioner for services.

Service Area

The area where your health plan provides health care services. Usually, you must live in the health plan’s service area in order to be covered.

Subscriber and Dependent

The person who enrolls in a health plan is called the subscriber.  Everyone else covered under the subscriber’s plan is called a dependent.

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