Health Insurance Terms 101

Posted January 22 2015

health insurance termsWith the Open Enrollment deadline looming, many people are starting to purchase health insurance plans. Health insurance may be a topic that many aren’t very familiar with, such as the lingo, rules, and meanings. So we thought it would be a great idea to put together a list of terms that we find ourselves explaining more often than not. Hopefully this list will give you a better understanding of healthcare in general, and be able to assist you when purchasing your future plans from the healthcare marketplace.  


  • Coinsurance- The percentage of medical costs that you pay after you have met your deductible
  • Copayment (or Copay)- A fixed dollar amount that you pay directly to your doctor or physician, hospital, or other medical provider (doctor visit or CT scan) at the time of service.
  • Cost-Sharing- Determines how much you will pay and how much your insurance company will. Various parts include deductible, copay, and coinsurance.
  • Deductible- The amount that you will have to pay out of pocket each year before your insurance begins to pay their part. Some benefits are not subject to the deductible.
  • Emergency Services- Emergency room or an admission to the hospital via the ER. An emergency situation is always treated as in network.
  • Formulary- A list of prescription drugs that are covered under your plan.
  • Health Maintenance Organization (HMO)- Plan that requires the use of providers in a certain network for your plan to pay for the service. If the provider is not in the network, the insurance won’t pay.
  • In-Network- Providers that are members of the approved network for your plan.
  • Medicaid- Social healthcare program for individuals and families with low income and limited resources.
  • Medicare- Social healthcare program for people aged 65 and older who have worked and paid into the system or people who have received Social Security Disability payments for 24 months.
  • Open Access- Plan that allows the insured to see another service provider without the need of obtaining a referral.
  • Out-of-Network- Providers that are NOT members of the approved network for your plan.
  • Out of Pocket Maximum- The most you pay during a policy period before your health insurance plan starts to pay 100% for covered benefits.
  • Pre-existing Health Condition- An illness, injury, or condition, you had before joining a health insurance plan. All ACA compliant plans cover pre-existing conditions without a waiting period.
  • Preferred Provider Organization (PPO)- A plan that allows you to go to any provider that you choose, however insurance pays less for providers that are not in your network.
  • Premium- The monthly payment you pay in order to have coverage from a plan.
  • Premium Tax Credit- Subsidy. Amount of federal aid based on a government formula.
  • Point of Service (POS)- Insurance plan where you decide if you will use HMO benefits or PPO benefits at the point of service, when you first visit a health care provider.
  • Preventative Care- Procedures such as mammograms conducted to prevent disease.
  • Provider- A person or company that provides health care service to you such as a doctor, hospital, urgent care, minute clinic, lab, pharmacy, etc.
  • Provider Network- A group of providers approved to provide health to a particular health insurance plan or plans.
  • Referral- The transfer of patient care from a primary doctor to a specialist.
If you have any more questions about health insurance terms that may have not been on this, please feel free to ask us or comment below! If you are in the need or interested in purchasing health insurance, please contact us at 954 828 1819 or visit We have the insurance specialists to assist you in finding the best health insurance for you, your loved ones, or group. For more health insurance help, read our previous blog Should I Buy My Insurance On or Off Exchange? Don’t forget, the Open Enrollment deadline is February 15th, 2015!