Balance Billing: When a provider, who isn’t in your plan’s network, charges more than your plan pays and bills you for the difference in addition to cost-sharing.

Benefits: The health care services a health plan covers. The plan’s documents define the benefits that it does and doesn’t cover.

Claim: A request for your health plan to pay for health care services. You or your health care provider submits to the claim.

Coinsurance: The percentage of the cost of a covered health care service you pay (20%, for example) after you’ve met your deductible.

Let’s say your plan’s allowed amount for an office visit is $100, and your coinsurance is 20%. 

Coordination of Benefits: A way to figure out which plan pays first when two or more health plans are responsible to pay the same claim.

Co-payments: A fixed amount ($20, for example) you pay for a covered health care service after you’ve met your deductible.

Let’s say your health plan’s allowed amount for a doctor’s office visit is $100. Your co-payment for a doctor’s visit is $20. • If you’ve met your deductible: You pay $20, usually at the time of the visit. • If you haven’t met your deductible: You pay $100, the full allowed amount for the visit.

Co-payments (sometimes called “co-pays”) can vary within the same plan for different services, like drugs, lab tests, and visits to specialists.

Cost-Sharing: The share of costs for covered services that you pay yourself. This term generally includes deductibles, coinsurance, and co-payments. It doesn’t include premiums, balance billing amounts for providers not in the network, or the cost of health care services the plan doesn’t cover.

Deductible: The amount you pay for covered health care services before your health plan starts to pay. If you have a $2,000 deductible, for example, you pay the first $2,000 of covered services in a plan year. After you’ve paid $2,000 of your own money for covered services, you usually pay only a co-payment or coinsurance for covered services for the rest of the plan year. Your plan pays the rest.

Exclusions: Health care services your health plan doesn’t cover. If you receive these services, you pay all of the costs.

Network: The facilities, providers, and suppliers your health plan has a contract with to provide health care services.

Open Enrollment Period: A time (once a year) when anyone can enroll in or change their health plan.

Out-of-Pocket Costs: Expenses for health care your health plan doesn’t pay. Out-of-pocket costs include deductibles, coinsurance, and co-payments for covered services plus all costs for services your health plan doesn’t cover.

Out-of-Pocket Maximum/Limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and coinsurance, your health plan pays all of the costs of covered services.

The out-of-pocket limit doesn’t include your monthly premium. It also doesn’t include anything you pay for services your plan doesn’t cover.

Primary Care: Health services that include a range of prevention and wellness as well as treatments for common illnesses.

Primary Care Providers (PCP): Health care professionals (including doctors, nurses, nurse practitioners, and physician assistants) who manage your care. A PCP often maintains long-term relationships with you. He/She advises and treats you for a range of health-related issues. A PCP also may coordinate your care with specialists.

Prior Authorization: Approval from a health plan to get a service or fill a prescription. If your plan requires prior authorization and you don’t get it, the plan may not pay any of the costs.

Qualifying Event: A life change (for example, a marriage or a job change) that lets you enroll in or change your health plan before the next open enrollment period.

Referral: An order from your Primary Care Provider to see a specialist or get certain medical services. Many Health Maintenance Organizations (HMOs) require you to have a referral before they pay for health care from anyone other than your Primary Care Provider.

Self-Funded Health Plan: A type of plan where the employer itself collects premiums from enrollees and pays medical claims. Used by many large employers, the employers can contract with a third-party administrator to manage enrollment, process claims, and manage provider networks. Or, the employer can manage the plan itself.

Special Enrollment Period: A time when you can enroll in or change your health plan because of a qualifying event.

Third-Party Administrator: A company that reviews and pays claims for an employer’s self-funded health plan. May share a brand name with a health insurer.

Urgent Care: Care for an illness, injury, or condition so serious that a reasonable person would seek care right away, but not so serious as to require emergency department care.