In case you’re completely blanking on the terms you just read, here’s a little cheat sheet as a reminder for all that jargon. If you know these terms, maybe you won’t get frustrated when health insurance policies mention them to you:

• Health Care Provider: Anyone or any place giving you health care. This can include hospitals, doctors, and specialists like Orthopedists (bone doctors).
• Insured patient: A patient (you) that is covered under a health plan.
• Premium: The amount of money you pay (or someone else pays for you) each month (or year) to purchase and stay on a health plan.
• Contracted Rate: An agreement between a health care provider and the health insurance company on how much a service will cost.
• In-Network Provider: A health care provider that has a contract with a health plan. If you use the services of an in-network provider, you will get the discounts that the health care provider and health insurance company agreed on.
• Out-of-Network Provider: A health care provider that does NOT have a contract with a health plan. You will pay the full cost for treatment to the out-of-network provider UNLESS the health plan provides some benefits when using an out-of-network provider.
• Out-of-Pocket: The amount of money you will pay for treatment that the health plan does not pay. The premium is not considered as out-of-pocket.
• Co-payment: The amount that you MUST pay out-of-pocket to visit or use a service from a health care provider. For example, you might pay a $45 co-payment for a doctor’s visit or to obtain a prescription. A co-payment must be paid each time you use a service. The co-payment is not included as part of the deductible unless the health plan says otherwise.
• Deductible: The amount that you must pay out-of-pocket for treatment before the health plan “kicks in.” For example, you might have to pay a $500 deductible per year before any of your health care is covered by the health plan. It may take several doctor’s visits or medicine refills before you reach the deductible and the insurance company starts to pay for care. Sometimes a health plan does not include a deductible.
• Coinsurance: If the co-payment has been paid and you have also paid the deductible for the year, then the co-insurance is a percentage of the total cost that you must also pay when the health plan starts paying for treatment. For example, you might have to pay 20% of the cost of a surgery along with a copayment, while the insurance company pays the other 80%. Some plans don’t include a coinsurance.
• Out-of-pocket maximum: If you have paid out-of-pocket to a certain amount (which may include co-payment, deductibles, and co-insurance), the health plan will pay for the rest of treatment. Out-of-pocket maximums can apply to a specific category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
• Coverage limits: The opposite of an out-of-pocket maximum. Some health insurance policies only pay for health care up to a certain dollar amount. You may be expected to pay any charges in excess of the health plan’s maximum payment for a specific service. Some health plans have yearly or even lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the coverage maximum and you must pay all remaining costs.
• Exclusions: Services not covered by the health plan. You are generally expected to pay the full cost of non-covered services out-of-pocket.
• Medical Necessity: Services that are approved by the health plan based on documented evidence that the service provides necessary benefit to a patient. For example, there is debate now over whether marijuana is a medical necessity.
• Prior Authorization: When the health insurance company must authorize (approve) a medical service before it occurs. Many smaller, routine services do not require authorization. If the health plan authorizes a service, then it must pay what the health plan agrees to pay for the service.
• Explanation of Benefits: A document sent by a health plan to you after a medical service explaining what the health plan paid for the medical service, how they arrived at the payment amount, and any amount you have to pay.