Insurance terms

This is the amount a healthcare provider charges a patient for the difference between what their insurance covers and the cost of the services rendered.

This is a plan that is used as a reference point for determining the level of coverage and costs for health insurance offered in a particular area.

Beneficiaries receive advantages or payments from an insurance policy, as in the case of a person covered by a health insurance plan. Beneficiaries can have any health insurance, including Medicare, Medicaid, or private coverage.

Some plans limit coverage for health treatments or services by capping the number of visits or dollar amount they'll shell out for them in a year. For example, an insured person may encounter a hard cutoff after 20 chiropractor sessions or 30 physical therapy appointments annually. Other caps could restrict how much the plan covers for high-cost infertility treatments. While benefit caps aim to prevent overutilization, knowing which critical services have limits can help buyers choose the best insurance policy.

Unlike the calendar year, which starts fresh on January 1, a benefit year is based on the date when a plan began. This 12-month cycle serves as the basis for all the elements of a policy, from deductibles, out-of-pocket maximums, and covered drugs to in-network providers and more. It's essentially how insurance companies keep track of a person’s accumulating costs and enrollment specifics over time. Switching plans mid-year? Understanding the benefit year provided insight into upcoming changes to expect.

A book of business, in the context of insurance, is a database or “book” that lists all of the insurance policies the insurance company has written or completed.

These are medications with exclusive patent-protected names, like Vyvanse for treating ADHD or Keytruda for different types of cancer. Despite high price tags, they advertise directly to patients because no generic equivalents exist yet to compete with them. Being the only one on the shelves gives brand-name drugs the leverage to charge more and maximize profits during the patent protection period. This contributes to rising insurance premiums. If you prefer brand names over generics, be prepared to pay hefty coinsurance costs or copays.

Brokers are like the matchmakers of insurance. They help buyers find and enroll in the right insurance plan to suit their needs.

This is one of the tiers of health insurance plans under the ACA and usually offers lower monthly premiums but higher out-of-pocket costs for healthcare services.

Bundled plans combine different types of insurance coverage, like health, dental, and vision, into one convenient plan.