Glossary of California Health Insurance Terms

Co-Insurance

The amount you must pay for medical care in a point-of service plan (POS) or preferred provider organization (PPO) after you have reached your deductible. It is often a percentage of bills charged.

Co-Payment

A charge you pay for medical services. Your health care plan covers the remaining medical charges. As an example, you may pay $10.00 for an office visit or a prescription.

Deductible

The amount of money you must pay each year for coverage to your medical care expenses, before your insurance policy begins to pay.

Exclusions

Specific conditions or circumstances in which the policy will not offer benefits.

Fee-For-Service

Payment agreements for health care in which the provider is paid for each service, rather than a pre-negotiated amount for the patient.

HMO (Health Maintenance Organization)

Prepaid health plans for which a premium is due each month. The HMO covers your cost of care to see a doctor within their working network at pre-negotiated rates. You are required to choose a primary care physician who takes care of you and makes referrals to any specialists you may need. If you, as an HMO member, do not use the doctors, hospitals and clinics that do not participate in your planýs network, you may be required to pay the cost of those medical services.

IPA (Independent Practice Association)

An independent group of physicians who unite with an HMO to offer services for the HMO members.

Lifetime Maximum

The maximum percentage of benefits available to a member during their lifetime, in which, all benefits served are subject to this limit unless stated as unlimited.

MSA (Medical Savings Account)

A tax-advantaged personal savings account used along with a high deductible health policy. You may deposit money into this account on a pre-tax basis to set aside money for medical care and expenses that qualify, including annual deductibles and co-payments.

Out-Of-Pocket Maximum

The highest amount of money you will pay in a year for deductibles and coinsurance plus regular premiums.

Point-Of-Service (POS) Plan

A certain managed care plan combing features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You may choose whether to go to a network provider and pay a flat dollar amount or to an out-of-network provider and pay a deductible and/or coinsurance charge

Pre-Existing Condition

A health problem that existed or was treated before your insurance became in effect. Most health insurances have a pre-existing condition plan that describes under what conditions they will cover medical expenses that relate to a pre-existing condition.

PPO (Preferred Provider Organization)

A network of health care providers that offers medical services to health plan members at a discounted cost. PPO members usually make their own decisions about their health care instead of going through a primary care physician like an HMO member. The costs to use physicians within the PPO network are less than using a non-network provider.

Premium

The amount you must pay in exchange for health insurance coverage.

Primary Care Physician

Under a health maintenance organization (HMO) or point-of-service (POS) plan, a primary care physician is often the first contact for health care. It is usually a family physician, internist, or pediatrician. A primary care physician makes referrals to specialists if necessary.

Provider

Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) which is certified, that provides medical care.

Well Baby

Health services, which include immunizations provided by the members participating medical group, up to a certain age as specified by the carrier. This benefit is usually provided in HMO plans and/or POS plans. The level of benefit will vary for PPO plans if specified as a benefit.