Health insurance words to know

Allowed amount

The dollar amount a health plan determines is an appropriate payment for a medical service it covers.

Why it matters: After paying any copay, coinsurance or deductible you may also be responsible for a non-participating  provider’s charges above this amount.

Claim

Information from you, a doctor or a hospital that says health care services were provided.

Why it matters: Doctors and hospitals included in the Blue Cross network submit claims for our 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 after reaching your plan's annual deductible amount. Example: 20%/80%, means you pay 20 percent and the plan pays 80 percent of the allowed amount.

Why it matters: If you have a plan that requires you to pay some coinsurance, your monthly premium can often be lower than a plan with no coinsurance requirement.

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, a higher deductible means that your monthly premium will be lower. To decide on the right deductible for you, think about the maximum amount you could afford to pay for health care expenses in a year.

Formulary

The list of generic and brand-name drugs covered by your health plan.

Why it matters: You’ll usually pay much less for your prescription drugs if they’re on your health plan’s formulary. So before you choose a plan, check its formulary to see if your drugs are covered. 

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

Your "premium" -- the amount you pay for your health plan. Usually shown as a monthly payment.

Why it matters: Generally, the higher the rate, the lower your other out-of-pocket expenses. 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

This includes hospitals, doctors and clinics 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: Network providers, including doctors, clinics and hospitals have agreed to accept the health plan's payment.  Many plans offer larger networks. Using in-network providers costs less than seeing out-of-network ones.  Some plans offer no coverage at all for out-of-network doctors.

Out-of-pocket maximum

Your in-network out-of-pocket maximum is the most you will pay in deductible and coinsurance (and copays, if any) for covered services in a year.

Why it matters: Once you reach your in-network out-of-pocket maximum your plan will pay 100 percent of the allowed amount for covered services received in-network. 

Preventive care

Wellness visits including physicals, some immunizations and cancer screenings, well-child care and prenatal care.

Why it matters: Preventive care helps you keep yourself healthy and lower your health care expenses, because it can cost much less to treat a condition when it’s caught early. Good news: most plans cover preventive care at 100 percent.

Provider

A doctor, clinic or hospital. It also refers to other care facilities or medical professionals, like physician’s assistants, chiropractors and psychologists. 

Why it matters: The term often refers to health care professionals and facilities in general, such as in an online “provider search” tool.

Retail health clinics

Clinics that are often located in major retail stores or pharmacies and offer convenient, 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 copay or none at all. These clinics can help you save time and money when you or your family needs routine care or tests.

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