Reference and Insurance Terms
Coinsurance: A specific percentage you must pay for
a service. For example 20% coinsurance means you
pay 20% and the insurance company pays 80%
Copay: A fixed dollar cost associated with a specific
medical service. Usually you do not have to meet the
deductible in order to utilize this benefit
Creditable Coverage: Your previous insurance
coverage. Proof of this coverage can be used to avoid
pre-existing condition limitations.
Deductible: A dollar amount you must pay out of your
own pocket in order to receive the best cost sharing
from your plan.
Evidence of Coverage: Is a comprehensive listing of
most of the benefits and limitations of your specific
Formulary: A list of prescription drugs and costs
category associated with them (Brand Name,
Generic, or non-formulary or not covered).
HMO: A Health Maintenance Organization is a type of
health insurance where you use a specific primary
care physician who handles all your care, or refers
you to a specialist in the same network.
HSA: A Health Savings Account is a special tax
shelter associated with certain insurance plans. This
feature can often lower your income taxes, by letting
you contribute money from your paycheck pre-tax.
Inpatient services: Any medical care requiring you to
stay overnite at a hospital.
MRMIP: Managed Risk Medical Insurance Board is
the state of California's high risk pool. It provides
health insurance to people with pre-existing
Out of pocket Maximum: The most money you will
have to pay for all covered services for a calendar
year. All other covered costs will be 100% paid for by
the insurance company.
Outpatient services: Usually a surgery or procedure
where you go home the same day.
PCIP: The Pre-existing Insurance Plan is a Federal
program, that provdes health insurance to people
with pre-existing conditions.
POS: A Point of Service Plan is usually a hybrid of a
HMO and PPO plan. Each plan is unique, so read
your evidence of coverage for details.
PPO: A Preferred Provider Organization is a type of
health insurance where you are free to choose any
primary care physician or specialist. You can go
outside the network, but costs can very significantly, if
you do so.
Primary Care Physician: Usually your family doctor
who handles most of your basic care. In an HMO, you
must get a referral from him or her to see a specialist.
Specialist: Any doctor who is NOT a family practice
Summary of Benefits: Is a brief description of the
most commonly utilized benefits of a health