Health Insurance Terms

Helps Americans pay some or all of the cost of medical services in exchange for a monthly payment or premium.

The fees you pay each month for your health insurance coverage.

The amount of money you need to spend before your health insurance provider starts to share the costs.

The flat fee you pay when you visit your doctor or pick up a prescription from the pharmacy.

The percentage of the costs you pay for your medical service, and your health insurance provider pays the rest.

The amount of health care costs that are covered by insurance but are paid by the patient out of their own pocket.

The share of health care premiums that a health insurance provider spends on claims and activities to improve patient quality of care. If a health insurance provider has an MLR of 80%, that means 80 cents out of every dollar of premiums went to pay for claims and quality of care efforts, and 20 cents on other expenses, such as operating the customer service center, operations to fight fraud and abuse, and federal and state taxes and fees.

A federal law that sets minimum patient protection standards for most commercial retirement and health plans.

A statement that a patient receives after they receive care. The EOB describes claims billed by the provider, discounts the health insurance provider negotiated on the patient’s behalf, total costs paid by the health insurance provider, and total costs that the patient is responsible for. It also shows how much of the patient’s deductible and out-of-pocket costs have been met for the benefit year.

A predetermined amount that an individual must pay before their health insurance provider will pay 100% of their covered medical treatments and services.

The health care providers who are part of a health insurance provider’s network and who have negotiated discounts with the health insurance provider.

The health care providers who do not participate in an individual’s health insurance provider’s network.