Health Care Terms and Definitions

The following is a partial list of pertinent health care terms and definitions that a potential subscriber should become familiar with in order to be well informed when considering health care coverage.

Co Pay

Co pay is the out of pocket dollar amount the subscriber must pay in order to receive healthcare services such as a physician visit, pharmacy, or rehabilitation.

Contractual Adjustment

Contractual Adjustment is the dollar amount the healthcare insurance company is not obligated to pay to a provider. The amount is determined by the contractual agreement between the provider and insurance company.

Diagnostic Testing

Diagnostic tests are ancillary tests that are usually ordered by an attending physical or hospital that include x ray, MRI, blood/lab work, mammogram or echocardiogram.


Exclusions are clauses to the health insurance policy that prohibit payment of claims. Example of exclusions is injury due to negligence or the commission of a crime.

Explanation of Benefits

Explanation of Benefits (EOB) is the detail of services that a provider issued a claim to the healthcare insurance company. Type and date of service, charges covered, reduced and paid services are listed on the EOB.

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPPA) was approved in 1996 by congress and offers legal protection to patients such as the assurance of privacy, coverage, transfer and continued health coverage.

Health Maintenance Organization

Health Maintenance Organization (HMO) is an integrated health care system that only allows members to seek care under their management. The subscribers do not have many options when choosing their level of care.

In Network Provider

An in network provider is the option offered by a PPO that are the choice providers of the plan and by choosing an in network provider the subscriber will pay a reduced cost as compared to out of network providers.

Maximum Benefit

Maximum benefit this is the amount a healthcare insurance company will pay over the course of the coverage. Once this maximum benefit is achieved the healthcare company will no longer pay claims.


Medicaid is a government funded program offered to low income individuals regardless of age. This plan is dually funded between the state and federal government.

Out of Network Provider

Out of Network Provider is the health care service offered by a PPO and they are not the choice provider selected. The subscriber may utilize an out of network provider but the cost of treatment will be higher.

Pre Existing Condition

Pre existing condition is a health ailment that is present when a subscriber seeks healthcare coverage. Healthcare insurance companies usually do not cover pre existing conditions to new subscribers.

Preferred Provider Organization

Preferred Provider Organization (PPO) is a health plan that offers the subscriber a choice of services including physicians, hospitals, and diagnostics. Subscribers may choose in network or out of network options.


The underwriter is the person that evaluates the probable risk when determining health care coverage for a new subscriber. The greater the risk posed the higher the premium the subscriber is expected to pay.

Waiting Period

The waiting period is the minimum time allowed before a subscriber to a healthcare plan has coverage which includes time allotted before an employee is covered under an employer plan.

Proficiency with this list of health care terms and definitions will give the potential subscriber the knowledge needed to become better equipped to choose the best individual health insurance rates for their needs. Cheap health insurance quotes are the key to a great insurance policy.

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