Understanding Health Insurance 

Please use the information on this page to better understand some basic information and terminology about health insurance.

Health insurance is coverage that provides payments of benefits as a result of sickness or injury. The health insurance policy is a contract between the insurance provider and an individual or his or her sponsor (employer). The type and amount of health care costs that will be covered by health insurance are specified in writing (policy).

Common Health Insurance Terms

Provider - General:  A party rendering medical care such as a physician or hospital. 

Facilities Provider: Includes hospitals, skilled nursing facilities, assisted living facilities, home health agencies, and ambulatory surgery centers. 

Professional Provider: Includes physicians, pharmacists, nurses, therapists, and allied health professionals. 

Primary Care: Primary care physicians are usually trained in family practice, general practice, general internal medicine, and pediatrics. Physicians serving in primary care roles usually treat common medical conditions or injuries, and often provide preventive health screenings. They are often viewed as serving as a coordinator of a patient’s care, assessing a patient’s condition, and treating if a simple condition, or referring a patient to a specialist physician. 

Specialists: Specialists normally do not provide primary care services, instead focusing their work based on in-depth training in different diseases, body systems or types of healthcare service. 

Third-Party Payer: A health insurance plan paying for the services. 

Out-of-Pocket Payment: Payments by patients that can be required as a part of a health insurance plan are: deductible, copayment, and coinsurance. 

Deductible: The deductible is a pre-determined amount that the patient pays before the insurer begins to pay for service. 

Coinsurance: Coinsurance is a percentage of the insurance payment amount that is paid by the patient, along with the amount paid by the insurer. 

Co-payment: A copayment is a flat amount that the patient pays at each time of service. 

Claim: A bill for services provided. 

Pre-authorization: Permission by the insurer to render services to the patient before actually treating the patient. This includes verification of payment for the service by the insurer. 

Beneficiary: Insurers usually refer to the patient for which services are paid as the beneficiary. 

Covered Benefit: The services for which the insurer will pay are usually referred to as a covered benefit. 

Denial: The insurer may determine that the claim from the provider is not a covered benefit and will not pay the claim to the provider. 

Medicare Part A: Medicare Part A is funded primarily by Medicare taxes paid by current workers to fund the costs of current beneficiaries. Patients are usually eligible for Medicare Part A if they are a US citizen over age 65, disabled or have End Stage Renal Disease and have paid Medicare wage taxes for at least forty (40) calendar quarters – known as categorical eligibility. Medicare Part A covers inpatient hospital services, certain organ transplants, ESRD treatment, inpatient skilled nursing facility care, home health care and hospice care. 

Medicare Part B: Medicare Part B is a voluntary program where a patient that meets the age or medical condition requirements for Medicare Part A (but not the requirement to pay taxes for 40 calendar quarters) may participate in this insurance benefit. It is possible for a patient to be covered by Medicare Part B but not Medicare Part A. 

Medicare Part D: The Medicare Part D program covers outpatient prescription medicines for persons otherwise eligible for Medicare benefits. 

Medicare Advantage: Medicare Advantage plans market to Medicare beneficiaries by offering benefits above those provided through traditional Medicare Part A or Medicare Part B programs in exchange for the patient being willing to obtain services from a select panel of providers and to be subject to utilization management programs that may limit the patient's access to certain high cost services. 

Medicaid: Medicaid is an insurance program for the poor and medically needy that is operated as a joint program between the federal government (CMS) and the individual states. 

Provider Networks: Provider networks are groups of selected providers contracted with insurers as “preferred” or “in-network” by the insurer. Under this relationship, the insurer will pay a higher proportion of the patient’s costs of care in exchange for the patient going to the “in-network” provider. 

Individual Mandate: The Individual Mandate was a change to require individuals without employer-provided insurance to purchase health insurance through health insurance exchanges in each state or face tax penalties. 

Insurance Exchange: Insurance Exchanges are state-run health insurance markets designed to make health insurance affordable and broadly available.