Glossary of Terms

Coinsurance

This is the amount that you are obligated to pay before insurance pays and after you’ve satisfied any co-payment or deductible. Coinsurance is typically expressed as a percentage of the charge for a medical service. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance. Because there is no upper limit on coinsurance, you could end up paying a significant amount if your medical expenses are high.

Co-payment

A fee you pay every time you use a given service, like a doctor’s visit, prescription refill, or hospital stay. Plans sometimes refer to this payment component as an “office visit.”

Deductible

The dollar amount (usually per calendar year) you need to pay for medical expenses before the insurance kicks in. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most PPO plans do.

Exclusive Provider Organization (EPO)

As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care.

Exclusions

Not all services are covered. You are generally expected to pay the full cost of non-covered services out of your own pocket

Health Maintenance Organization (HMO)

Requires a visit to your PCP prior to visiting a specialist. Less expensive, but less flexible. You must use in-network physicians.

Primary Care Physician (PCP)

The family doctor you often need to contact before you can see a specialist. Often referred to as a "gatekeeper."

Point of Service Plan (POS)

Falls between an HMO and a PPO. The variety of plans is infinite, but they are usually moderately priced and flexible; you must visit your PCP for in-network, but you can go in or out of network (for an added cost).

Preferred Provider Organization (PPO)

Often the most flexible managed care insurance plan, but also the most expensive. You can go to any doctor you choose or got to in-network doctors for less money. No visit to your PCP is required before visiting a specialist. PPO plans often require co-payments or coinsurance, and almost always have an annual deductible.