Glossary of Terms

Benefit
A financial payment made by your health plan for covered services or drugs.

Copayment or Copay
A fixed dollar amount you must pay with your own money for medical services, such as office visits or prescription drugs.

Cost Sharing
The health care costs that are your responsibility to pay, including deductibles, copays, coinsurance and other costs not covered by your health plan.

Coverage
The costs your health plan pays for your medical services or prescription drugs.

Deductible
The amount you must pay each year – with your own money – before your health plan begins paying benefits. This does not include copays.

Health Insurance
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

In-network
When a doctor, hospital or other provider accepts your health insurance plan.

In-network Co-insurance
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

In-network Copayment
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Maximum Allowable Charge (MAC)
The maximum dollar amount your health plan will pay a doctor, hospital or other health care provider for a covered medical service.

Network 
A group of doctors, hospitals and other health care providers contracted to provide services to health plan members at a rate that is less than their usual fees.

Non-preferred Provider A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-network
When a doctor, hospital or other provider does not accept your health insurance plan.

Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Out-of-network Copayment
A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments. 

Out-of-network Doctor
A doctor with whom your health plan does not have a contract. If your plan allows you to receive covered services from a doctor or other provider outside your network, you may pay a higher share of the costs.

Out-of-pocket Costs
The amount you must pay out of your own pocket for your medical or prescription drug expenses. These costs include things like deductibles, coinsurance or copays.

Out-of-pocket Maximum
The most you will pay with your own money – or out of your own pocket – in a year.

Physician Services
Health care services that a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Plan 
A benefit that your employer, union or other group sponsor provides to you to pay for your health care services.

Preferred Provider
A health care provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can obtain care from all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan; but the discount may not be as great, and you may have to pay more.

Preferred Provider Organization (PPO)
A network of doctors, caregivers and medical facilities that agree to provide health care services to our members at a lower cost; members get the most from their PPO plan when network providers are used.

Premium 
The monthly payment made for an insurance policy.

Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Practitioner
A health care provider specializing in family practice, internal medicine, general practice, pediatrics, obstetrics or gynecology, or a physician assistant or nurse practitioner.

Provider 
Any doctor, health care practitioner (nurse, physician assistant, etc.), hospital, facility or pharmacy that provides you with medical services or prescription drugs.

Specialist 
A physician specialist focused on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.