Understand insurance terms and definitions in plain English. Navigate the complex world of insurance with confidence.
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits.
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
A request for your health insurer or plan to review a decision or a grievance again.
The person who receives the benefits or proceeds from an insurance policy, retirement plan, annuity, trust, or will.
A health insurance plan category that pays 60% of average overall costs of providing essential health benefits to members.
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service.
Also called the 'donut hole.' A temporary limit on what Medicare Part D will cover for prescription drugs.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.
A set of health care service categories that must be covered by certain plans, including ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health services, prescription drugs, rehabilitative services, laboratory services, preventive care, and pediatric services.
A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
A health insurance plan category that pays 80% of average overall costs of providing essential health benefits to members.
Additional time allowed to make a premium payment after the due date during which coverage remains in force.
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.
A medical savings account available to taxpayers who are enrolled in a high-deductible health plan.
Providers or health care facilities which are part of a health plan's network of providers with which it has negotiated a discount.
The requirement that most Americans have health insurance or pay a penalty.
The maximum dollar amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.
Insurance sold by private companies that can help pay some of the health care costs that Original Medicare doesn't cover.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
The yearly period when people can enroll in a health insurance plan.
Providers or health care facilities which are not part of a health plan's network of providers.
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers.
The amount that must be paid for a health insurance or plan.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage.
An add-on to a basic insurance policy that provides additional benefits at additional cost.
A health insurance plan category that pays 70% of average overall costs of providing essential health benefits to members.
A time outside the yearly Open Enrollment Period when you can sign up for health insurance.
The process by which insurance companies evaluate the risks of insuring your home, car, life, or health and determine premiums.
Our insurance experts can explain any terms and help you understand your coverage options in plain English.