Glossary of Common Healthcare Terminology
The percentage of the healthcare costs for which you have to pay. The coinsurance amount is your responsibility even if your deductible has been met. Each plan has a different coinsurance. For example, Medicare patients are responsible for 20% of the fee schedule amount for physician office services once they meet their deductible.
The payment rate that your insurer has agreed to pay a specific provider for a specific service. Often times a patient's out-of-pocket responsibility (e.g., coinsurance amount) is determined relative to this contracted rate.
A flat fee that is paid at every outpatient visit with an in-network provider.
An annual out-of-pocket amount to be paid before insurance covers services.
Exclusive Provider Organization (EPO)
A managed care network that has a group of providers listed as “in-network.” Referrals are not needed to see a clinician that is in-network. However, referrals are required if you go outside of the network.
Health Maintenance Organization (HMO)
An insurance plan that requires authorizations from a primary care provider every time a patient is referred to a specialist.
A group of providers, hospitals, and other healthcare organizations that have a contract with an insurance plan. If there is no contract between the insurance and a particular doctor or group, they are considered “out of network” and the insurance may not cover and/or the patient will have a higher out-of-pocket cost.
A group of doctors, hospitals, outpatient centers, and pharmacies that have a contract with an insurance company.
When an insurance company will not pay for a service because it has determined that medical necessity criteria have not been satisfied.
A group of doctors, hospitals, outpatient centers, and/or pharmacies who do NOT have a contract with an insurance company. A patient may have a higher out-of-pocket cost if they obtain a service with an out-of-network provider.
The amount that is owed by the patient after insurance pays its portion to the provider.
When authorization/approval from an insurance company is required before performing a procedure. The services that require precertification vary based on the insurance plan.
Preferred Provider Organization (PPO)
An insurance plan that has a contract with a given set of doctors, hospitals, pharmacies, etc. Patients do not need an authorization if they choose to go out-of-network, however they may have a higher out-of-pocket cost.