Cambridge, Massachusetts Health Insurance

Glossary of Terms

Coinsurance

amount you have to pay for medical care in a fee-for-service plan after you have reached the deductible. The coinsurance rate is usually written as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.

Coordination of Benefits

A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim.

Copayment

Another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.

Covered Expenses

Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy.

Customary fee

Most insurance plans will pay only what they call a reasonable and customary fee for a particular service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference.

Deductible

The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.

Exclusions

Specific conditions or circumstances for which the policy will not provide benefits.

Fee-for-Service

The insurer only pays for part of your doctor and hospital bills. This is the traditional kind of health care policy. Insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals.

HDHP

High-Deductible Health Plan. With this type of plan, you pay a smaller premium, but have to pay a larger amount out of your own pocket when you use medical services.

HMO

(Health Maintenance Organization): Prepaid health plans. You pay a monthly premium and the HMO covers your doctors’ visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO.

Institutionalized

People under formally authorized, supervised care or custody in institutions (for example, correctional facilities, nursing homes, and mental hospitals). Generally, restricted to the institution, under the care or supervision of trained staff, and classified as "patients" or "inmates."

Kaiser

Figure refers to employer-based health insurance. Individual plans may be more expensive. ("Employer Health Benefits 2007 Annual Survey" (#7672), The Henry J. Kaiser Family Foundation & HRET, September 2007)

Managed Care

Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.

Maximum Out-of-Pocket

The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Noncancelable Policy

A policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.

PPO

(Preferred Provider Organization): A combination of traditional fee-for-service and an HMO. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered. You can use other doctors, but at a higher cost.

Preexisting Condition

A health problem that existed before the date your insurance became effective.

Premium

The amount you or your employer pays in exchange for insurance coverage.

Primary Care Doctor

Usually your first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed.

Property crime

Property crime includes burglary, larceny-theft, motor vehicle theft, and arson. The objective of the theft crimes is the unlawful taking of money or property, and does not include use or threat of force against the victims.

Provider

Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.

Race

Race is a self-identification data item in which respondents choose the race or races with which they most closely identify. [US Census]

Single Coverage

Health insurance that covers medical expenses for one person.

Third-Party Payer

Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the Federal Government.

Violent crime

Violent crime includes four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. Violent crimes involve force or threat of force.

References

• US Census Bureau - http://www.census.gov
• Kaiser Family Foundation - http://www.kff.org