Glossary of Terms

Annual Deductible — The amount you pay for covered expenses first, before an insurance plan begins to pay benefits. Some plans require deductibles for all services, some for just certain types of services; others require no deductible at all.

Co-Pay/Co-Insurance — The flat amount or percentage you pay for a covered service after you satisfy the annual deductible, if applicable.

Covered Expenses — Charges for services that are medically necessary and eligible for payment under the plan contract.

Emergency — A sudden, unexpected or serious acute illness, injury or condition which could permanently endanger your health if medical treatment is not received immediately.

HMO (Health Maintenance Organization) — An organization that provides a wide range of comprehensive health care services through a designated group, network of doctors, hospital or lab. To receive benefits, you must see the doctor you select as your Primary Care Physician (PCP) first for care or a referral, except in the case of an emergency. Your choice of doctors is restricted to those in the network.

IPA (Independent Physicians Association) — Primary Care Physicians who practice in his/her own office, but are part of a larger network of physicians.

Individual Insurance — Health care coverage for individuals or single family units.

Limited Fee Schedule — A list of maximum amounts the insurance carrier will pay for certain services provided by non-network providers. You are responsible for paying your co-insurance and any amount over the limited fee schedule.

Network/In-Network — The term used for services received from doctors, hospitals and other providers contracted with the carrier to provide care at the negotiated fee and to handle the paperwork.

Out-of-Network/Non-Network — The term used for services received from doctors, hospitals or other providers that are not part of the network. You pay substantially more for Out-of-Network services.

Out-of-Pocket Maximum — The most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the rest of the year. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count.

PCP (Primary Care Physician) — The doctor who serves as your health care manager and coordinates virtually all of the health care services you receive. Your PCP provides you with routine medical care and refers you to a specialist if necessary.

PMG (Participating Medical Group) — A group of doctors, both primary care physicians and specialists, who are practicing in one location to provide health care services. Most medical services, including special exams, x-ray and laboratory tests are available in one convenient location.

PPO (Preferred Provider Organization) — Health care providers who are under contract to provide care at discounted or fixed fees. Unlike HMOs, health plans with a PPO allow you to choose any doctor at any time. However, if you select a non-PPO provider you will pay more out of pocket for services than you would if you selected a PPO "network" provider.

Pre-existing Condition/Pre-existing Waiting Period — An illness, disease or physical condition for which medical advise, diagnosis, care or treatment was recommended or received from a licensed health practitioner during the six months prior to the effective date of a person’s new medical coverage or plan.

Qualifying Prior Coverage — Any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage or coverage under a publicly sponsored program such as Medicare or Medicaid. It does not include accident only, credit, disability income, Medicare supplement, long term care insurance, dental, vision, workers' compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.

Specialist — A physician whose practice is limited to a particular branch of medicine or surgery.