| A | B |
|---|
| A system of health Insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered | Fee for Service |
| A health insurance program for low-income individuals who can’t otherwise afford Medicare or a commercial health plan | Medicaid |
| A list of drugs included in the drug coverage portion of your insurance plan | Formulary |
| The refusal of an insurance company to make payment for a service rendered | Denial of a claim |
| This phrase refers to a physician, hospital or office that is non-participating with an insurance plan | Out of network |
| Monthly payment you make in return for insurance | Premium |
| A provision within a health plan that eliminates coverage for a certain reasons or conditions for which the plan will not cove | Benefit exclusion |
| A percentage of the medical/pharmacy charges the patient is responsible for | coinsurance |
| Letter explaining what your insurance company covered/ didn’t cover for a service | Explanation of benefit |
| A federal health insurance program created to provide health coverage for Americans aged 65 and older as well as individuals with end stage renal disease or patients needing kidney transplants and/or treatmen | Medicare |
| Plans created to specifically cover the remaining 20% and sometimges the deductible leftover from Medicare | Medicare Supplement |
| Guidelines created by individual health plans that state what services may be covered or denied based on medical necessity or denied for reasons like service is considered investigational/experimental or cosmetic | Medical Policy |
| A period of time during which your insurance company will not pay for pre-existing conditions | Waiting Period |
| A set dollar amount that a patient must meet to increase coverage to 100% | Out of pocket |
| Phrase that refers to a physician, hospital, facility, or office that is participating with a patients plan | In Network |
| Another term for health care professional | Prescriber |
| An Amount an individual must meet before Medicaid will cover them | Spend down |
| Maximum amount a health plan will pay in benefits for an insured person during their lifetime | Lifetime Max |
| The amount an individual must pay in health care expenses before plan will cover anything | Deductible |
| Date after which the policy is no longer in effec | Termination date |
