Terms related to the insurance structure itself and who is involved.
Carrier
A carrier is another name for an insurance company.
Copay (or Copayment)
The amount that you must pay up-front to receive a healthcare service or medication. A copay is usually a set amount of money and is determined by your insurance plan. The copayment is usually different depending on the type of service or medication you receive. For example, the copay to see your primary care doctor is usually lower than the copay to visit an urgent care center, and the copay for a generic medication is usually lower than the copay for a name-brand medication.
Coinsurance
The amount that you must pay to receive a healthcare service or medication. A coinsurance amount is usually a percentage of the total cost of the service or medication and is determined by your insurance plan. For example, your coinsurance for a surgery might be 20% of the total surgery cost.
Deductible
The amount that you must pay out of pocket before your health insurance plan begins paying for certain services. If you’ve paid the full deductible amount out of pocket, you have “met your deductible.” Some services are “subject to deductible,” meaning that you must meet your deductible before a plan will begin to pay for those services. Some services are “not subject to deductible,” meaning that your plan will begin to pay for those services even if you have not met your deductible. If you have a maximum out-of-pocket amount that is higher than your deductible, you may still pay some costs until you meet your maximum out-of-pocket amount.
Health insurance
In a nutshell, insurance is a contract that requires the company that insures you to pay some or all of your healthcare costs in exchange for your monthly payments.
Health plan
Your health plan is the specific insurance plan you choose, and will have specific doctors and providers in the network who can take your insurance.
Out-of-pocket maximum (or maximum out-of-pocket amount)
Your out-of-pocket maximum is the most you will spend in a calendar year for your and your dependents’ medical care. This is above and beyond your deductible for the year. Once you hit your out-of-pocket maximum, insurance covers all of your medical care costs for the remainder of that plan year.
PPO (Preferred Provider Organization)
A type of health plan where you pay less for going to providers in the plan’s network. In this situation, you can still go to doctors, hospitals, and providers outside of the network without a referral, but there will be an additional cost.
Premium
The amount that you pay to continue to have coverage through your health insurance plan. If you receive your health insurance through an employer, this amount is usually taken directly out of your paycheck. If you stop paying your premium, your health insurance plan will drop your coverage, and you will be uninsured.
Provider
A doctor, nurse practitioner, pharmacist, therapist, or other type of healthcare worker who provides healthcare services to you.