Glossary of Health Insurance Terms

Annual maximum benefit amount
The total dollar amount the plan must pay for all healthcare services provided to an insured member in a year as set by a MCO (Managed Care Organization).

At-risk
The insurance risk associated with healthcare a provider organization might give to a prospective member.

Behavioral healthcare
Mental health and substance abuse treatment.

Capped fee
A fee or charge deemed acceptable by a MCO for a service or procedure, which the doctor agrees to accept as payment in full. Also known as: fee allowance, fee maximum, or fee schedule.

Claim
An itemized statement of costs from hospital care, doctor visit or other healthcare or specialty care provisions that are submitted to the insurer by the member or care provider.

Claim form
An application for reimbursement or benefits to be paid by a health plan.

Claimant
The person or group submitting a claim.

Co-insurance
A method of cost-sharing in which the insurer and insured each pay a percent of the total after the deductible is met according to a specific formula.

Co-payment
Specific dollar amount expected from the insured at the time services are rendered.

Deductible
A specific amount an insured member must pay in total before the insurer will pay for any treatment or healthcare.

Fee-For-Service (FFS)
A healthcare system in which the insurer will either pay a percentage of healthcare costs to the provider directly or reimburse the insured member after the expense has been incurred.

Health Maintenance Organization (HMO)
A healthcare system in which an insured member prepays for services within a specified network.

Large group
A group of people whose health coverage is provided by a company or group sponsor. The group usually consists of 250 or more individuals.

Lifetime maximum benefit amount
The highest dollar amount a plan must pay for all healthcare costs to an insured member set by a MCO.

Managed care
A healthcare system that seeks to manage the cost, quality and accessibility of healthcare through both the financing and delivery of that healthcare.

Managed Care Organization (MCO)
Also known as a Managed Care Plan, any group or entity that utilizes specific techniques to manage the cost, quality, and accessibility of healthcare.

MCO
See managed care organization.

Network
A group of medical care providers, such as physicians and hospitals, who are under contract with a specific care plan to deliver medical services to its members.

Open access
The ability given by an insurance provider for an insured member to self-refer to a specialist, either in-network or out-of-network, at full or reduced benefit.

Out-of-pocket maximums
The maximum dollar amount an insured member must pay out-of-pocket as set by a MCO during a specific time period.

PPO
See preferred provider organization.

Preferred provider organization (PPO)
A healthcare system in which an insured member may enjoy discounted costs by using in-network physicians or the insured member is free to choose a doctor out-of-network at a higher cost.

Premium
A prepaid amount made to insurance plan by insured members for medical benefits.

Prepaid care
Healthcare provided to a HMO insured member in exchange for a fixed monthly premium paid in advance of the medical care.

Primary care
General medical care, such as; preventative care, treatment of routine injuries, and illnesses provided directly to an insured member without referral from another doctor.

Primary care provider (PCP)
A doctor or medical professional who is an insured members first contact with their health insurance system. Also known as primary care physician, personal care physician, or personal care provider.

Self-insured plan
A healthcare system in which the insured member is solely responsible for paying plan expenses, including claims.

Small group
Usually a group consisting of 2 to 99 people whose insurance is provided by a company or group sponsor.

Specialist
A physician or medical healthcare person who is specially trained in a specific field.