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Health care lingo, translated.
When you’re reviewing plans, you’re bound to see certain terms over and over. Here’s a cheat
sheet for a few of the most important ones. (If you want the complete glossary, check your
benefit booklet.)
CLAIM IN-NETWORK PROVIDER PRECERTIFICATION
The request for payment that’s sent A doctor, hospital, or other facility A decision made ahead of time by
to your health insurance company that has an agreement with your your health plan that a service,
after you receive covered care. plan to accept your plan allowance treatment, or drug is medically
and cost sharing as full payment. necessary for you. It can be
COINSURANCE They won’t bill you extra for called prior authorization or prior
The percentage you may owe covered services, but you could approval, but it’s not a promise that
for certain covered services after still have to pay your deductible, anything will be fully covered.
reaching your deductible. For coinsurance, or copays.
example, if your plan pays 80%, you PREFERRED PROVIDER
pay 20%. MAXIMUM OUT-OF-POCKET ORGANIZATION (PPO)
The most you’d pay for covered A type of plan that offers more
COPAY care. If you hit this amount, your flexibility in choosing providers,
The set amount you pay for plan pays after that. usually with the added security of
a covered service, for example: coverage for care you might need
$20 for a doctor visit or $30 for NETWORK TYPES when you’re away from home.
a specialist visit. Broad – The network that provides
access to many doctors and facilities PREMIUM
COVERED SERVICES in your area. The monthly amount you or
All the care, drugs, supplies, and your employer pay so you have
equipment that are paid for, at least Tiered – A network that offers health coverage.
in some part, by your health plan access to most doctors and facilities
after you’ve met your deductible. in your area based on a tiered PROVIDER
system — Enhanced and Standard. Whether it’s your primary
DEDUCTIBLE You generally pay less for the doctor, a lab technician, or
The set amount you pay for a Enhanced level of benefits than the a physical therapist, the person
health service before your plan Standard level. or facility where you get care
starts paying. Narrow – Local networks specific is referred to as a health
to certain markets. They tend to be care provider.
EXCLUSIVE PROVIDER close to where you live. You have
ORGANIZATION (EPO) access to the doctors and facilities RETAIL CLINIC
A type of plan where services are in that network. Walk-in centers for less complex
usually only covered if you use health needs, generally open in the
in-network providers, except for OUT-OF-NETWORK PROVIDER evenings and on weekends.
emergencies or urgent care. A doctor or hospital that generally
If you travel, you’ll have coverage charges more than your plan URGENT CARE CENTER
for emergency or urgent care, allowance for the same services. A walk-in center for when you
but usually not for routine care. have a condition that’s serious
PLAN ALLOWANCE enough to need care right away,
The set amount you and your but not serious enough for a trip
plan will pay for a health service. to the emergency room.
In-network providers aren’t allowed
to bill you more than this amount.
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