Insurance Terms

The following terms and explanations may help you navigate through billing, your insurance statements, and expected costs of care. This will apply mostly to Commercial Insurance Plans.

• Premium: monthly fee patient pays to her insurance carrier
• Deductible: the amount a patient must pay before insurance will cover any costs
• Co-Payment: flat dollar amount due by the patient at an office visit (frequently $25, $40, $60)
• Co-Insurance: percentage of the fees allowed by the insurance company that will be owed by the patient
• Out of Pocket Maximum: maximum amount of cost to patient per year
• Plan Maximum: the maximum amount of cost per year that insurance will pay for
• Preventative Care: care to prevent medical conditions, such as a Well-Woman Exam, Pap test, Birth Control

• Global Charges: some services, such as pregnancy care, are billed encompassing multiple visits; for example, one global fee is billed for all pregnancy visits, the delivery, and the post partum check up.
• Plan Year: 12 month period before deductibles and rules change; this may be January 1 to December 31, or may start any day of the year
• Individual vs Family Amounts: there may be a deductible or out of pocket max just for the patient, or bigger amounts for the whole family
• Explanation of Benefits: statement sent to you and doctor/hospital/lab from your insurance company, explaining
  • what was billed
  • charges that were allowed
  • charges that were paid/covered
  • amounts owed by patient
  • an Explanation of Benefit is not a bill