Coinsurance: The amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent. Coordination of Benefits: A system to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim. Co-payment: Another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest. Covered Expenses: Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy. Deductible: The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying. Exclusions: Specific conditions or circumstances for which the policy will not provide benefits. HMO (Health Maintenance Organization): Prepaid health plans. You pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO. Incurred Expense:  Expenses not yet paid Indemnity Plan: A set dollar amount paid by an insurance policy for an insured loss. Limited Policy. A policy that covers only specified accidents or sicknesses Major Medical Expense Insurance: A form of health insurance that provides benefits for most medical expenses up to a high maximum benefit. Such contracts may contain internal limits and are usually subject to deductibles and co-insurance. Maximum Out-of-Pocket: The amount of money an insured will pay in a benefit period in addition to regular premium payments. Noncovered expenses are the employee's responsibility in addition to out-of-pocket amounts. Managed Care: Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care. Maximum Out-of-Pocket: The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Noncancellable Policy: A policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy. Point-of-Service (POS) Plan. Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.   PPO (Preferred Provider Organization): A combination of traditional fee-for-service and an HMO. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered. You can use other doctors, but at a higher cost. Preexisting Condition: A health problem that existed before the date your insurance became effective. Premium: The amount you or your employer pays in exchange for insurance coverage. Primary Care Doctor: Usually your first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. Provider: Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care. Reasonable and/or Customary Charges:  Amounts charged by health care providers that are consistent with charges from similar providers for identical or similar services in a given locale.   Third-Party Administrator (TPA). An outside person or firm, not a party to a contract, that maintains all records regarding the persons covered under the insurance plan.   Third-Party Payer: Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, Third Party Administrator or the federal government. Underwriting:  The process of selecting risks and classifying them according to their degrees of insurability so that the appropriate rates may be assigned. The process also includes rejection of those risks that do not qualify.   Checkup on Health Insurance Choices. AHCPR Publication No. 93-0018, December 1992. Agency for Health Care Policy and Research, Rockville, MD. Works by the U. S. Government are not eligible for U. S. copyright protection.