Agent or Broker –  An insurance sales person, licensed by the state.

COBRA -  A federal law that allows you to keep your health insurance for 18 months if you lose your group health insurance from an employer with more than 20 employees.

Co-Insurance – The money that is your part of the payment of services after a deductible has been met.  The coinsurance is often a percentage of what is due to the provider after service.  There is also usually a cap on how much coinsurance that you must pay for the year.

Co-Payment – A set amount of money, usually 30 to 40 dollars that you pay the provider for each office visit or per prescription.  This amount is separate from you co-insurance.

Deductible – The set amount of money you must pay for health care before your insurance starts paying.  Often, this does not apply to copayments.

Dependents – Your spouse or domestic partner and the unmarried children (whether natural , adopted or step).

Exclusions – Medical expenses that are not covered under the plan.

Fully Insured Plans -  An insurance product where the insurance company absorbs all the risks of the plan and not the employer. These plans must abide by state mandated benefits. These plans are regulated by the Office of Insurance and Fire Safety.

HMO – Health Maintenance Organization – Similar to PPO’s in the use of a select group of providers.  There is no out of network benefit except in selected emergencies.

In-Network – Using the group of providers that have contracted together.

Managed Care – A health care system that has procedures in place to control your health utilization and their costs of services.

Members – The insured individuals on a health insurance plan.

Network – A group of providers that are contracted together to deliver health care for an insurance group for a reduced fees to the members.

Out-of-Network – This refers to providers that have not contracted for a particular insurance group.  Use of out of network providers is more costly for the members.

Out of Pocket – A predetermined amount of money that a member must pay before benefits for that plan year are paid at 100%.  Co-pays usually do not count toward this amount. 

PPO – Preferred Provider Organization refers to a plan that uses a provider network for its members use.  If you stay in the network, your costs are lower.  These plans usually allow in and out-of-network providers.

Pre-Existing Conditions – A medical condition that a person has for which he/she has received coverage for in the past.  This can also refer to a condition not treated but that any prudent person would have sought treatment for.

Providers – In the insurance industry this refers to the entity that is delivering your care.  It can be doctors, hospitals, ambulance, etc.

R & C – This is the average fee charged by types of providers for your geographical area.  The term means reasonable and customary.

Risk – The degree of chance that you will utilize your insurance.  Often heard is the person is of high risk and this makes him/her uninsurable.

Self Funded Plans – The employer assumes the risks for the insurance for the employees.  The overwhelming majority of plans are self funded.  These plans have more control over what is offered and do not have to abide by state mandates.  These plans are regulated by the Georgia Department of Labor.

Short Term Medical –This is an individual health insurance policy for temporary coverage for a person, usually for no more than six months. 

State Mandated Benefits – Laws from states that require health insurance companies to cover certain things.  Examples of this are well-baby visits, mammograms, etc.  These only apply to fully insured plans and not self funded plans.

Waiting Period – The amount of time specified that you are not covered or not covered for a specific period of time.

Disclaimer