GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS
Our glossary includes many commonly used terms, but it is not a complete list. We’ve provided terms and definitions that are most relevant to your plan and are intended to be educational. Some terms might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document. Please contact us if you have any questions about health coverage or medical terms.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference (see Balance Billing).
Balance billing is when a provider bills the patient for the remainder of the provider’s charge after the patient’s health insurance has paid the allowed amount.
A health insurance broker is an agent who is licensed and regulated to sell insurance. They can help you compare plans and figure out which plan is best for you. Typically they receive a commission for their assistance.
A "co-payment" or "co-pay" is a specific charge that your health insurance plan may require you to pay for a specific medical service or supply. For example, your health insurance plan may require a $20 co-payment for an office visit or $15 for a brand-name prescription drug, after which the insurance company often pays the remainder of the charges.
A "deductible" is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all WINhealth Partners Freedom Plans require a deductible. Be sure to note whether the plan you are considering includes a deductible.
A formulary is a list of drugs covered by the specific healthcare plan.
A Health Savings Account (HSA) is similar to a personal savings account, except the money you save in it is used to pay for health expenses. One advantage of having an HSA is that the contributions are not taxed, up to certain annual limits. The funds in the HSA may also be invested at your discretion. Unused funds remain in the account and accrue interest year-to-year, tax-free. In order to be eligible for an HSA you must have a qualified high-deductible health insurance plan.
An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. WINhealth does not require authorization for most services if provided by an in-network provider, but does require authorization to see out-of-network providers.
An out-of-network provider is one not contracted with the health insurance plan. WINhealth does not require authorization for most services if provided by an in-network provider, but does require authorization to see out-of-network providers.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
A payment made on a regular basis to maintain your health insurance coverage. Typically, the monthly premium on a high deductible plan is less expensive than the monthly premium for a lower-deductible health insurance plan.