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Health Insurance Terminology

You cannot be sure that you’ve gotten the best health insurance coverage unless you understand health insurance terminology. Here are some of the most commonly used terms in the health insurance industry.

COBRA: The Act that allows for continuation of group coverage for a limited time after you leave the group.

Co-insurance: The amount you must pay for treatment after copayments and deductibles.

Copayment: The fixed amount that you must pay out-of-pocket for physician visits, medical procedures and prescription medications.

Deductible: The out-of-pocket amount you must pay before your policy benefits start kicking in.

Exclusions: Any medical conditions or illnesses whose expenses are not covered by your insurance policy.

HIPAA: A health insurance Act that sets privacy standards in an electronic world and guarantees portability of coverage and new policy issue after COBRA benefits run out, as long as there has not been a significant break in coverage (varies by state but usually at least 63 days).

HMO: A type of insurance policy that allows only treatment within a set network of physicians and facilities.

Lifetime limit: The maximum amount your insurer will pay out in benefits.

PPO: The type of insurance policy that has a network of physicians but still allows you to visit physicians and facilities outside the network for a reduced benefit.

Pre-certification: Some insurance companies require that you get preapproval from them before you have surgery or other medical procedures. This is called a pre-certification.

Pre-existing conditions: Any illness, injury or chronic disease you suffered from before you took out your insurance policy is considered a pre-existing condition.

Premiums: The fee that you pay to your insurance company monthly, annually or quarterly is your premium.

Underwriting: The process of reviewing and evaluating the risk you pose to the insurance company based on your medical history.

Waiting period: The amount of time you must wait before your pre-existing conditions are covered by your policy.

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