Sometimes it seems like health coverage comes with its own language! Use this mini-glossary to learn more about your choices.
Benefits (also called covered services): The healthcare services that are covered by your health plan, such as office visits, X-rays, preventive care, laboratory tests, etc.
Coinsurance: Your share of the costs of a covered healthcare service. It is calculated as a percentage. Let’s say the coinsurance is 20% and the medical bill is $100. You would pay $20 and the health plan would pay the rest.
Copayment (also called copay): Your share of the costs of a covered healthcare service, set at a fixed amount. For a doctor visit that might cost $150, you might pay $15 and the health plan pays the rest. Copayments vary by plan.
Cost-sharing: The amount of money you pay out of your own pocket for services covered by your health plan. Deductibles, coinsurance and copayments are examples of cost-sharing.
Deductible: The amount you owe for some covered services before your health plan begins to pay. For example, if your deductible is $1,000, you must pay for the healthcare services you use up to this amount. The deductible may not apply to all services.
Dependents: Spouse, domestic partner or children of the primary member.
Excluded services: Healthcare services that your health coverage doesn’t pay for or cover.
Member: The person who receives benefits under the plan.
Network: The doctors, hospitals and other healthcare providers that your health plan has contracted with to provide healthcare services.
Out-of-pocket maximum: The most you pay during a policy period (usually a calendar year). After you pay the out-of-pocket maximum, your health plan will begin to pay 100% of the allowed amount for covered services. This limit never includes your premium or charges for services your health plan doesn't cover.
Premium: The amount you pay every month to maintain your coverage.
Preventive care: Routine healthcare that includes screenings, checkups and patient counseling to prevent illnesses, disease or other health problems.
Primary care physician (PCP): A doctor who gives or coordinates healthcare services for a patient. A PCP can be a medical doctor (M.D.) or Doctor of Osteopathic Medicine.
Subscriber: The name of the primary member.