Insurance Terms and Definitions
Here is a list of common health insurance terms and definitions. You're not alone when it comes to understanding some of the jargon on your health insurance plan. Feel free to call or text us with any other questions you may have.
Benchmark plans may be a lower cost alternative to traditional Individual & Family (Affordable Care Act) plans. They only cover Essential Health Benefits as defined by your state. They will still cover services like preventative care, doctor visits and lab test, but do not cover certain services like sleep studies, CPAP and BPAP machines, canes, crutches, wheelchairs and glucometers. If you need those services covered, please let your local agent know so they can find the right coverage for you.
This is the health insurance company that your health plan contract is with. They are the company that you pay your premiums to, if applicable, and the company that covers a portion or all of your eligible medical expenses.
This is the company that you pay your health insurance monthly premiums to. They are also the company that will pay all or a portion of your medical services like doctor visits, ER visits, labs and surgeries.
Children's Dental Check Up
Some medial health insurance plans will cover a dental check up, including exam and x-rays for children under the age of 19. Ask your local agent or see full benefits of coverages for details. This check up does not normally include cleanings or coverage of extra services like filling a cavity, crowns, or root canals. For full dental coverage, ask your agent about dental insurance.
Children's Eye Exam
Some plans will cover children's basic eye exams if they are under the age of 18 as preventative care. Please ask your local agent or see full plan coverage details to learn more.
When coinsurance applies, you must pay a percentage of the charges from a provider or facility for covered services. This percentage is called a coinsurance. Your health insurance plan will pay the rest of your medical bill.
Coordination of Benefits (COB)
When a member is enrolled in more than one plan COB is used to determine which plan processes claims first.
A copay is a fixed amount you must pay the doctor, pharmacy, or facility for services. Most plans have lower copays for primary care providers and higher copays for secondary care providers.
This is the shared cost of your medical services. Your health insurance plan will pay a portion of your care and you are responsible for the rest.
A deductible is an amount you must pay to doctors and facilities before your plan begins to pay for eligible charges. (But remember, you’re still only paying our allowed amount for covered services from participating providers!) Some categories of benefits may have a separate deductible.
Pharmacy or Rx Deductible: This is a separate deductible that only applies to your prescription coverage. You must pay this amount before your plan begins to pay for prescriptions.
Some services like doctor visits and urgent care visits may be covered with a payment of a copay before deductible is met.
This is an emergency room visit. Your health insurance plan must cover you for an emergency room visit at any hospital in the nation and cover your medical expenses as in network. Hospitals and doctors may be allowed to bill you for excess charges if you go to an out of network facility.
Explanation of Benefits (EOB)
Each time your health plan receives and processes a claim, they create an explanation of benefits, or EOB, that explains how much they paid for your medical services, how much you are responsible to pay, and more. You can receive this statement by mail, view it online on your mobile app or receive it via email depending on which health plan you have.
Generic Prescription Copay
This is the amount that you will pay for preferred generic prescriptions. For a list of covered prescriptions, or to see if your prescriptions will fall under this category, please ask your local agent or see the formulary list of your plan.
Maximum Out of Pocket or MOOP
An out-of-pocket maximum is the total amount you may pay for services covered by your plan each year. Amounts you pay toward your deductible, coinsurance, and copays apply to your out-of-pocket maximum. Some plans have separate medical and pharmacy deductibles, individual deductibles may vary from family deductibles, and some services may not apply to or may exceed the out-of-pocket maximum.
Mental Health Visit Cost Sharing
This is the amount that you will pay for an in-office or telehealth outpatient visit with a mental health therapist, behavior health therapist, or family counselor.
This is the calendar year that your plan is active. For health insurance plans on the Marketplace it is January 1 through December 31. For some group, work and private health insurance plans, the plan year may differ. Please check with your agent or HR or plan director to know when your plan year is.
Some services require prior approval from SelectHealth. This approval is called preauthorization. In-network (participating) providers will typically get it for you, but if you are seeing an out-of-network (nonparticipating) provider, you need to get it yourself. If a service requires preauthorization and it isn’t obtained, your benefits may be reduced or denied.
A premium is the monthly bill you pay for insurance coverage (to be a member of SelectHealth). It does not apply toward the cost-sharing amounts on your plan such as deductibles or out-of-pocket maximums. An employer may pay a portion of your premium.
Primary Care Doctor (PCP)
A primary care doctor or Primary Care Physician (PCP) is a doctor who sees you for common medical problems, performs routine exams, and helps prevent or treat illness. Seeing the same doctor for most visits will help you establish a relationship that can improve your care. The providers—and their physician’s assistants and nurse practitioners—who are generally considered PCPs are:
Internal medicine doctors
Obstetricians and Gynecologists (OB/GYNs)
This list of physicians may vary depending on your health insurance company.
A specialist doctor is a doctor who sees you for a specific condition or concern. Some health plans may require you to get a referral from your primary care physician in order to see a specialist. Check with your local agent to see if you need a referral before you schedule your appointment.
A subscriber is the primary account holder on your plan.
Summary of Benefits SOB or Summary of Benefits and Coverages SBC
This is a general list of the most common services and your financial responsibility for those services.
Urgent Care Visits
This is an office visit for medical services with an immediate need. Services must be rendered at an in-network facility unless your plan allows for out of network services.
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Sometimes, you may get a medical bill that you weren't expecting. Our local agents can review those charges and help you dispute them if needed. We can also help you submit claims if you have any extra supplemental insurance that covers accidents, sickness or hospitalizations.
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