HIA key terms

The amount a policyholder pays, usually monthly or annually, to keep an insurance policy in force. It is set before coverage begins and does not change based on how much care is later used.

The amount of covered medical expenses a member must pay out of pocket each period before the insurer begins paying its share. Deductibles reset on a schedule set by the plan.

A percentage split of covered costs shared between the insurer and the member after the deductible is met, such as the plan paying 80 percent and the member paying 20 percent.

A fixed dollar amount a member pays at the time of a covered service, such as a set fee for an office visit or a prescription. It is not a percentage of the charge.

The most a member will pay in a plan period for covered in-network services through deductibles, coinsurance, and copayments. After it is reached, the plan generally pays covered costs in full.

A specific service or expense the policy promises to help pay for, such as hospital care, lab work, or prescription drugs. Benefits are described in the policy and may carry limits or conditions.

A service, condition, or circumstance the policy specifically does not cover. Exclusions narrow the promise to pay and are listed in the contract so members can see what is left to them.

A health problem a person had signs of or was treated for before coverage started. Whether and how a plan may limit coverage for such conditions depends on the applicable rules.

A cap on what an insurer will pay, such as a dollar maximum per service, a visit limit per year, or a lifetime ceiling. Limits define the outer edge of a benefit.

A total dollar cap on what a plan will pay for a member's covered care over the entire life of the policy. Once reached, no further benefits are payable under that cap.

A set number of days after a premium due date during which the policy stays in force even though payment is late. Claims during that window may still be paid if the premium arrives in time.

The ending of coverage because a required premium was not paid within the allowed period. A lapsed policy provides no benefits for services after the termination date.

Restoring a lapsed policy to active status, usually by paying overdue premiums and meeting any conditions the insurer sets. The insurer may limit coverage for conditions arising during the gap.

A span of time after coverage starts during which certain benefits are not yet payable. It delays payment for specified services rather than denying them permanently.

The number of days a person must wait after a covered event, such as disability or a hospital stay, before benefit payments begin. It functions like a time-based deductible.

Rules that decide which of two or more health plans pays first when a person is covered by more than one. The primary plan pays its share, and the secondary plan considers what was already paid.

The insurer's process of checking whether care is medically necessary and appropriate before, during, or after it is delivered. It may involve prior authorization, concurrent review, or retrospective review.

Approval the insurer requires before certain services, drugs, or procedures will be covered. Getting approval first helps the member avoid a denied claim afterward.

A managed care plan that generally covers care only from its own network of providers and often requires a primary care physician to coordinate referrals. Care outside the network is usually not covered except in emergencies.

A plan that contracts with a network of providers at negotiated rates but still pays some benefits for out-of-network care, typically with higher member cost sharing. Members may see specialists without a referral.

The group of doctors, hospitals, and other providers that have contracted with an insurer to deliver care at agreed rates. Using network providers usually costs the member less.

When an out-of-network provider charges the member the difference between its full fee and what the insurer paid. Network providers generally agree not to do this for covered services.

A traditional plan that pays a set share of covered charges and lets members choose any provider. It generally imposes fewer network rules but often carries higher member costs.

A federal health insurance program mainly for people age 65 and older and for certain younger people with qualifying disabilities. It is divided into parts covering hospital care, medical services, and prescription drugs.

A joint federal-state program that provides health coverage to people with limited income and resources, including some children, pregnant people, older adults, and people with disabilities. Eligibility rules vary by state.

The Children's Health Insurance Program, a federal-state partnership that covers children in families whose income is too high for Medicaid but too low to afford private coverage. Benefits and eligibility vary by state.

A private plan approved by Medicare to deliver Part A and Part B benefits, often with extra services such as vision or dental. Enrollees receive care through the plan instead of original Medicare.

The process an insurer uses to evaluate an applicant's health history, age, and other risk factors to decide whether to offer coverage and on what terms. It aims to match premium to expected risk.

Grouping applicants or members into categories with similar expected costs so that premiums reflect the risk each group presents. It relies on factors the insurer is permitted to consider.

Setting a group's premium partly on that group's own past claims and cost history. Groups with higher past use of care tend to pay more than groups with lower use.

Setting premiums for a group or area without regard to individual members' health history, so everyone in the pool pays a similar rate. It spreads risk broadly across the covered population.

A request for payment submitted to the insurer for services a member received. It includes information about the care, the providers, and the charges so the plan can decide what to pay.

A statement the insurer sends after processing a claim showing the services billed, the allowed amount, what the plan paid, and what the member owes. It is not itself a bill.

The maximum amount an insurer will recognize as payable for a covered service under its contract or fee schedule. Member cost sharing is generally calculated from this figure rather than the provider's full charge.

A formal request by a member or provider to reconsider a denied or reduced claim or a coverage decision. The insurer must review the request and respond within set timeframes.

A complaint about the plan or the care experience that is not primarily about a coverage denial, such as a service or communication problem. Plans must have a process to receive and resolve them.

A legitimate financial or personal stake in the person being insured, such as a spouse's or dependent's wellbeing. It helps prevent insurance from being used as a wager on someone else's life or health.

The person or entity named to receive policy benefits, such as a death benefit. Naming one clearly helps ensure proceeds go where the policyholder intended.

Giving false or misleading information on an insurance application or claim. It can affect whether coverage is issued, whether a claim is paid, or whether the policy can be rescinded.