Health insurance words to know
Allowed amount
The dollar amount that a health plan determines is an appropriate charge for a medical service it covers.
Why it matters: Depending on your plan and whether you visit an in- or out-of-network provider, you may be responsible for a provider’s charges above this amount.
Claim
Information from a health care provider or member that says health care services were provided.
Why it matters: Blue Cross network providers submit claims for members, so you don’t have to. When you visit out-of-network providers, you may need to submit a paper claim to your health plan.
Coinsurance
The percentage of covered health care costs that you pay (or your health plan pays) after reaching your deductible. Example: 80%/20%, where the plan pays 80% and you pay 20%.
Why it matters: Generally, your monthly rate can be lower for a plan in which you pay some coinsurance.
Deductible
The amount you pay for health care services each year before the health plan begins to pay for covered medical services.
Why it matters: Generally, the higher your plan’s deductible is, the lower your monthly rate will be. When considering deductibles, think about how much you could pay for health care if you need it.
Formulary
The list of generic and brand-name drugs covered by your health plan.
Why it matters: Generally, you’ll pay much less for your prescription drugs if they’re on your health plan’s formulary. You can usually check a plan’s formulary to see if your drugs are covered before you choose the plan.
Health savings account (HSA)
Money you set aside in a tax-advantaged savings account to help you pay for health care services; like a savings or checking account from a bank.
Why it matters: Choosing a health plan that works with a health savings account is a way you can save money for health care expenses and even save to use for health care expenses after you’re retired.
Rate
The amount you pay for your health plan. Also known as “premium.”
Why it matters: Generally, your rate is related to your health plan’s coverage and your age – the higher the rate, the more complete the coverage. It’s generally shown as a monthly amount. Pay attention to coverage specifics as you compare plans. It’s possible that a very low rate may mean you’re not getting the coverage you may need.
Network
The hospitals, doctors and other medical professionals who sign a contract with a health plan to provide care for its members. Also referred to as participating or in-network providers.
Why it matters: You can check a health plan’s network to see if your desired doctors, clinics and hospitals are included. Many plans offer large provider networks. Seeing providers that are in the network will cost you less than seeing those that are not; in some instances, you may not have any coverage for out-of-network providers.
Out-of-pocket maximum
The most you will pay in deductible and coinsurance (and copays, if any) for covered services in a year.
Why it matters: You can think of this as your “worst-case scenario” for the year. This is the most you’ll have to pay out of your pocket for covered services if you or your family has high health care expenses.
Preventive care
Wellness visits including physicals, some immunizations and cancer screenings, well-child care and prenatal care.
Why it matters: Preventive care is an important way to keep yourself healthy and lower your health care costs, since it can cost much less to treat a condition when it’s caught early. Most plans cover preventive care at 100 percent.
Provider
A doctor, clinic or hospital. It can also mean other care facilities or professionals, such as physician’s assistants, chiropractors, psychologists and many others.
Why it matters: You’ll often see this term used to refer to health care professionals and facilities in general, for example, in an online “provider search” tool.
Retail health clinics
Clinics often located in major retail stores and pharmacies that offer convenient and affordable treatment for many common illnesses.
Why it matters: Some health plans include coverage for visits to these clinics. Sometimes you may have a small, or even no, copay. These clinics can help you save time and money when you or your family needs routine care or tests.
