Health terms and definitions to help you better understand health care insurance.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.
A statement from a patient or health care provider presented to an insurance company for payment for services performed.
This is the share of the cost you pay for health care received after you meet your deductible. If your plan has a 20% coinsurance, your insurance may pay 80% of the cost and you might pay 20%. But once you meet your out-of-pocket maximum, your insurance pays 100% of qualifying costs.
A flat dollar amount you pay for some covered services. Copay amounts can vary by plan, health care service, and the type of doctor you see.
The amount you must pay for covered medical care before your health insurance starts to share the cost. Deductibles vary by health plan. Not everything you pay for, including your premiums and copays, count toward your deductible. You will have to continue to pay for certain things, such as copays or coinsurance even after you meet your deductible. To learn more and see easy-to-follow examples of how a deductible works, click here.
EOB (Explanation of Benefits)
A report or statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefits and charges covered or not covered by the plan. For more information, visit our EOB page.
Evidence of Coverage (EOC)
The Evidence of Coverage (EOC) is an in-depth explanation of your plan benefits. It tells you how to use your plan, its benefits, what the plan covers, and includes how much you pay.
Individual (embedded) deductible
For a family medical plan (2 or more members), there are two deductible amounts; individual and family. The individual deductible is embedded in the family deductible, so no one family member can contribute more than the individual amount toward the family deductible. Once a member meets the individual deductible, that member would begin paying only copays and/or coinsurance (for their services only) even though the family deductible may not have been met yet.
The most you pay in a year before your health insurance pays 100% of qualifying costs. These limits put a cap on health care costs if you ever have a major illness or injury. This limit generally does not include things like your premium or non-covered services. If your plan has an individual (embedded) out-of-pocket maximum, each family member is capped at the individual out-of-pocket maximum, meaning no one family member can exceed that amount in payments during the plan year.
When one health care professional recommends the patient see another health care professional for further diagnosis and/or treatment. The second health care professional may often be a specialist in a certain area. Your plan may or may not require a referral.