Health Insurance Terms and Definitions

Deductible

(For any services subject to a deductible) The amount of money you pay out of your pocket before the insurance company pays anything.

Coinsurance

When you and the insurance company share costs (usually expressed as 80/20, 70/30, 50/50 etc.) until you have reached your Maximum Out of Pocket

Maximum Out Of Pocket

(or as we like to call it, the MOOP)
The maximum amount that you will pay out of your pocket (excluding premiums) in a year before the insurance company covers your care without anything further out of your pocket.

Co-pay

A flat dollar amount which you pay for certain services under your plan

Formulary

(aka Prescription Drug List)
This is the list of prescription drugs that will be covered under your plan. Formularies are often broken out by “tiers”. These will determine what your out of pocket costs are for a covered prescription.

Pre-Authorization/Pre-Certification

These are required before your doctor can perform or provide certain medical services. This is typically handled between the doctor’s office and the insurance company (we recommend that you ALWAYS ask to make sure this has been done!)

Gated/Non-Gated

Refers to the need to obtain a referral from your primary care physician before seeing a specialist. With a “Gated” plan, you need a referral, with a “Non-Gated” plan, you don’t.

Preventive Services

(aka Routine HealthCare) Includes screenings, checkups and patient counseling to prevent illnesses, disease or other health problems. Covered on most health plans at no cost to you. For a list of covered services visit www.healthcare.gov/coverage/preventive-care-benefits/

Health Savings Account (HSA)

A tax-advantaged way to put aside money for your healthcare. In order to open an H.S.A., you must have a Qualified High Deductible Health plan.