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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.)
PREMIUM MAXIMUM OUT-OF-POCKET PRECERTIFICATION
The monthly amount you or The most you’d pay for covered A decision made ahead of time
your employer pay so you have care. If you hit this amount, your by your health plan that a service,
health coverage. plan pays after that. treatment, or drug is medically
necessary for you. It can be
DEDUCTIBLE CLAIM called prior authorization or prior
The set amount you pay for a The request for payment that’s sent approval, but it’s not a promise that
health service before your plan to your health insurance company anything will be fully covered.
starts paying. after you receive covered care.
PREFERRED PROVIDER
COPAY COVERED SERVICES ORGANIZATION (PPO)
The set amount you pay for All the care, drugs, supplies, and A type of plan that offers more
a covered service, for example: equipment that are paid for, at least flexibility in choosing doctors and
$20 for a doctor visit or $30 for in some part, by your health plan hospitals, usually with the added
a specialist visit. after you’ve met your deductible. security of coverage for care you
might need when you’re away
from home.
COINSURANCE EXCLUSIVE PROVIDER
The percentage you owe, after ORGANIZATION (EPO)
your deductible. For example, if A type of plan where services are PROVIDER
your plan pays 80%, you pay 20%. usually only covered if you use in- Whether it’s your primary
network doctors or hospitals, except doctor, a lab technician, or
a physical therapist, the person
PLAN ALLOWANCE for emergencies or urgent care. If or facility where you get care
The set amount you and your you travel, you’ll have coverage is referred to as a health
plan will pay for a health service. for emergency or urgent care, but care provider.
In-network providers aren’t allowed usually not for routine care.
to bill you more than this amount.
OUT-OF-NETWORK PROVIDER RETAIL CLINIC
IN-NETWORK PROVIDER A doctor or hospital that can Walk-in centers for less complex
health needs, generally open in the
A doctor or hospital that has an charge more than your plan evenings and on weekends.
agreement with your plan to allowance for their services.
accept your plan allowance and If they do, you’ll most likely be
cost-sharing as full payment. on the hook for additional costs. URGENT CARE CENTER
They won’t bill you extra for A walk-in center for when you
covered services, but you could have a condition that’s serious
still have to pay your deductible, enough to need care right away,
coinsurance or copays. but not serious enough for a trip
to the emergency room.
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