Centers for Medicare & Medicaid Services (CMS)
CMS is the federal agency that runs Medicare, Medicaid and the Children’s Health Insurance Programs as well as the
federally facilitated Marketplace.
Coinsurance is your share of costs and generally applies after you’ve met your deductible. As an example, once you’ve
met your deductible, your plan might pay 80 percent for covered services and you might pay 20 percent in coinsurance.
Copayment or Copay
Copay is a fixed amount you pay for a covered service, like a doctor’s visit. You usually pay it at the time you go
to the doctor.
A deductible is the amount you pay for medical costs before your health insurance begins to make benefit payments.
For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for
allowable charges, not the billed charges.
Healthcare services that could, without immediate rendering, result in placing the patient’s health in serious jeopardy.
A formulary, (often called a “drug list”), is a list of preferred prescription drugs that have been designated as safe
and cost-effective and are covered by your health insurance plan.
Inpatient Hospital Services
Services received when a patient is admitted to a hospital or non-hospital facility as a registered bed patient for
whom a room-and-board charge is made.
Maximum Out-of-Pocket Responsibility
Maximum out-of-pocket responsibility is the most you have to pay out of your own pocket for expenses (including deductibles,
coinsurance and copayments) under your insurance plan during the year. After you’ve reached that amount, your plan
pays for the rest of your covered services that year.
Outpatient Hospital Services
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital
or other inpatient facility. Examples include outpatient surgery, lab tests and X-rays.
The premium is the fixed amount you pay each month for your health insurance coverage. Essentially, it’s your monthly
Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other
Primary Care Physician (PCP)
The physician you choose to be your primary source for basic medical care. Your PCP coordinates all your medical care,
including hospital admissions and referrals to specialists.
A healthcare professional whose practice is limited to a certain branch of medicine, including specific procedures,
age categories of patients, body systems or certain types of diseases.
Underwriting is the practice of using an applicant’s medical or health insurance information to evaluate eligibility