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Glossary of health insurance terms

Allowed amount

The amount that FCHP has negotiated with the provider to charge for a medical service. On your Health Benefits Statement, you'll see the allowed amount next to a service that you received.

Claim

A statement that includes the health care services you’ve received and what the services cost. A claim is provided by a doctor, hospital or other health care facility and is then sent to FCHP for payment.

Coinsurance

The percentage you need to pay on covered medical expenses. For example, if your plan has an 80%/20% coinsurance rate for a covered benefit, FCHP will pay 80% of the cost, while you will pay the remaining 20%.

Copayment

The specified dollar amount you’re responsible to pay at the time you receive a covered service. For example, if your plan has a $10 copayment for doctor office visits, you'll pay $10 when you visit the doctor.

Covered services

Health care services or supplies that are covered by the plan. Covered services include visits to your doctor, prescription medications and surgeries. Each plan is different, so be sure to reference your Member Handbook/Evidence of Coverage to confirm your covered services.

Deductible

A deductible is a another way to share the cost of your health care. A deductible is a dollar amount that must be paid by you before FCHP starts to pay for certain covered services. For example, if your plan has a $1,000 deductible, you'll pay the first $1,000 for certain services that apply to the deductible, and then FCHP will begin to pay for those services.

Typically, preventive visits (like a routine check up) or services (regular tests) to the doctor are not subject to the deductible. Diagnostic services are subject to the deductible.

If you have a plan with a deductible and you visit the doctor, your doctor will send a claim to FCHP. FCHP will inform your doctor that you have a deductible, and your doctor will send you a bill for payment.

Each health plan is different, so make sure to review your plan materials to understand which covered services apply to the deductible.

Diagnostic service

A service that is intended to diagnose, check the status of, or treat a disease or condition. For example, blood tests, X-rays, and imaging services like MRIs or CT scans, may be diagnostic services.

Explanation of Benefits (EOB)

See Health Benefits Statement.

Formulary

The drug formulary lists prescription medications covered by your plan. It includes both brand-name drugs and generic drugs.

Health Benefits Statement

A document for members who have a plan with a deductible. A Health Benefits Statement shows how your medical claims have been paid and your deductible amount to date. Health Benefits Statements are sent monthly when claims are received. Therefore, you may not receive one each month.

HIPAA

Health Insurance Portability and Accountability Act. This is a federal law that outlines the requirements that FCHP must fulfill in order to provide you with health insurance coverage. HIPAA also outlines strict guidelines to ensure the privacy and confidentiality of your personal health information, requiring that your personal health information be used for purposes of treatment, payment and health plan operations—and not for purposes unrelated to health care.

HMO

A Health Maintainence Organization, or HMO, is a health plan that covers your hospital, medical and preventive care. In an HMO, you can only see the providers that the HMO has agreed to work with—except in an emergency, when you can see any provider. This group of providers is called the provider network.

If you see a doctor who is not part of your HMO’s provider network, your services will not be covered.

Out-of-pocket maximum

A dollar amount determined by FCHP that places a limit on the amount of expenses you pay for specific services during a particular time period, typically a year. May only apply to certain services.

PPO

A Preferred Provider Organization, or PPO, works like an HMO in that it covers many of the same services. The difference is that with a PPO you not only have access to network providers, but you can also see doctors outside of the network—for higher out-of-pocket costs.

PPOs give you more choice in where you get care, but generally comes at a higher price.

Preauthorization

A guarantee from FCHP that the services you need are medically necessary and approved for coverage.

Premium

A prepaid payment made to FCHP by you and/or your employer for your health insurance coverage.

Preventive service

Any test, immunization or service geared to help screen for diseases and improve early detection when symptoms or a diagnosis are not present. For example, routine physical exams (also called wellness visits), routine eye exams every 12 months, immunizations and health screenings are preventive services.

See your Schedule of Benefits for more examples of preventive services.

Primary care provider (PCP)

A network provider who specializes in internal medicine, family practice or pediatrics, with whom you choose to work to manage your medical care.

Provider

A doctor or other medical professional, hospital or other facility, that provides health care services to you.

Provider network

A group of health care providers like doctors, hospitals and other health care facilities that are contracted with FCHP to provide covered services to you.

Referral

A recommendation from your primary care provider that gives you the ability to see another provider for specialty services.

Subscriber

The person whose name the health insurance policy is in.

Tiering (drug tiers)

The drugs that FCHP covers are categorized into tiers—revealing at a glance the drugs with the lowest out-of-pocket costs.

Tier 1 - lower copayments - contains generic drugs, which have the same active ingredients and effects as brand-name drugs.
Tier 2 - moderate copayments - contains cost-effective, preferred brand-name drugs.
Tier 3 - highest copayments - contains all other brandname drugs, including newer drugs and very expensive drugs.

Tiering (of providers)

In tiered provider networks, we categorize hospitals or physicians into tiers (typically two or three) using cost or some combination of cost and quality metrics.

Members in plans with tiered providers pay higher cost-sharing amounts to use the higher cost or less efficient providers in the network. They will pay lower cost-sharing amounts with the lower cost or more efficient providers.

For example:

Tier 1 doctors and hospitals - you pay a lower amount when you see one of these providers.
Tier 2 doctors and hospitals - you pay a higher amount when you see one of these providers.

Wellness visits

A routine visit to your primary care provider. See Preventive service.