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Medical Insurance Terms

Key Terms
What You Need To Know

Copay – Fixed amount for covered service paid by patient before receiving service

Deductible – Amount patient pays for medical care before health insurance plan begins to pay

Coinsurance – Percentage of costs patient pays for a service that insurance covers after the deductible has been paid; for example, patient pays 20% and insurance pays 80%

Out of pocket maximum – The most a patient has to pay for covered services in a plan year. This is the total of amount for deductibles, copayments, and coinsurance.

Copay assistance – Program patients may qualify for assist with financial need

Foundation funding – Various programs for patients in treatment that provide direct financial assistance for copays, deductibles, and coinsurance

Prior Authorization (or Preauthorization) – Decision by insurance that a service, treatment plan, prescription drug or durable medical equipment is medically necessary. Prior authorization does not guarantee the plan will cover the cost.

Coordination of Benefits – Process of determining which of two (or more) insurance policies will have primary responsibility of paying a claim. This only applies if you have more than insurance.

EOB (explanation of benefits) vs Statement/Bill – An explanation of benefits is a statement sent by insurance to the patient explaining what medical treatments/services were paid on their behalf. A statement/bill is a form from the provider showing what is owed after insurance has paid for treatments/services.