Insurance Terms Defined

Deductible 

Is the amount paid out of pocket by the policy holder before an insurance provider will pay any expenses. In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments.

Out-of-Pocket Expense 

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

Co-Insurance

The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible. Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. If you’ve paid your deductible: You pay 20% of $100, or $20.

Co-Pay

 A co-pay, short for co-payment, is a fixed amount that a healthcare beneficiary pays for covered medical services.

Limitations

 A limitation is the highest amount your insurer will pay for a claim that your insurance policy covers. Think of it this way: It’s like filling up a fishbowl. If you file a covered claim, your insurance policy will pay up to a certain amount. You’re responsible for any expenses that exceed the limit.

Excluded Services

Health care services that your health insurance or plan doesn’t pay for or cover.

Medically Necessary

Health care serviceHealth care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Rehabilitation Services

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.