New to insurance? Open any term below. Examples explain the idea; your plan’s actual rules still apply.
Deductible
The amount you pay for care that counts toward this rule before the plan starts its after-deductible payments. It adds up across visits; it is not a fee you pay again at every visit. Some benefits do not require it.
For example Sarah has a $500 deductible. If she pays $200 for qualifying care, she has $300 left to meet. A plan with no deductible skips that first-spending requirement; its other limits still apply.
In-network / network price
Doctors, hospitals and other care providers that have agreed to the plan’s network prices. An in-network bill can be lower than the original charge. Check the exact plan and the exact doctor or facility; the size of any discount varies.
For example Sarah’s doctor normally bills $400. For this invented example, that doctor has agreed to $200 through her plan’s network. Any plan payment or her share is then worked out under that plan’s rules.
Provider / facility
A provider is the person or place giving you care, such as a doctor, lab or hospital. A facility is the place itself. Their network participation can differ.
For example Sarah checks both her surgeon and the hospital. One taking her plan does not by itself establish that the other takes it.
Fixed benefit / plan pays
A specified amount the insurance plan pays when care meets the benefit’s rules. “Fixed” means the amount comes from the plan’s schedule, rather than increasing to match the size of your bill.
For example Sarah’s eligible in-network doctor bill is $200. If her plan’s doctor benefit is $80, the plan pays $80 and she has $120 left to pay. These bill amounts are only an example.
Covered care / covered stay
Care that meets this plan’s conditions for a payment. “Covered” does not automatically mean free or fully paid. The type of care, exclusions, approvals and remaining limits matter.
For example Sarah’s hospital stay meets the plan’s rules. The listed hospital benefit can apply, but she can still owe part of the hospital bill.
Office visit
An appointment with a doctor or other clinician, usually at their practice. On these pages, doctor, specialist and urgent-care benefits share the stated visit allowance. Hospital care and tests have different rules.
For example Sarah sees her regular doctor twice and a specialist once. Those are three visits used from the shared allowance, not three separate allowances.
Specialist
A doctor who focuses on one kind of problem or part of the body, such as the heart or skin.
For example Sarah sees a heart doctor after her regular doctor suggests it. She checks the specialist benefit and whether the doctor participates in her exact plan’s network.
Urgent care
A clinic for an illness or injury that needs prompt attention but is not a life-threatening emergency. Its benefit is different from an emergency-room benefit.
For example Ben gets a minor cut treated at an urgent-care clinic. The urgent-care rule applies, not the hospital ER amount. For a medical emergency, seek emergency help.
Visit limits / service limits
The most visits, days, treatments or dollars a benefit allows in its stated time window. A shared limit is one total across the named kinds of care. After it is used, that benefit stops paying under that allowance.
For example If Sarah has 10 shared visits and uses 6 doctor visits and 4 specialist visits, she has used all 10. She does not still have 10 urgent-care visits left.
Year one
The starting level of benefits shown for the plan. Later increases have their own timing and rules; they do not all rise after the first visit or on your birthday.
For example Sarah compares the year-one amounts when first choosing her plan. Before counting on an increase, she checks the qualifying date and whether it applies to injury, illness or both.
Calendar year
January 1 through December 31. A benefit counted per calendar year uses that window, subject to the plan’s other rules.
For example Sarah uses one eligible benefit in November. She checks the plan’s rules for a new calendar-year allowance starting in January.
Individual / family coverage
Individual coverage is for one person. Family coverage includes eligible family members. A family amount and a per-person amount are different; confirm how each member’s spending counts.
For example Sarah compares the amount for herself with the family amount if she also covers Ben. She does not assume every family member must separately pay the full family amount.
Hospital admission / inpatient
Being formally admitted to a hospital for a stay. An ER visit or being kept under observation does not automatically count as an inpatient admission.
For example Sarah spends time in the ER, then a doctor formally admits her for a hospital stay. The ER and inpatient benefits can have different rules and charges.
Outpatient
Care without a formal inpatient hospital admission. It can happen at a hospital, a clinic or a surgery center.
For example Sarah has a procedure at a surgery center and goes home the same day. She checks the outpatient procedure and facility rules.
Percentage payments (%)
A percentage says how much of an eligible charge the plan pays or how much you pay. Check whose share it describes and whether a deductible or maximum also applies.
For example Sarah has an eligible $100 dental charge after her deductible. If the policy pays 60%, it pays $60 and Sarah pays $40, while the benefit is available.
Pre-existing condition
A health issue you had before coverage began, as defined by the policy. It can affect what the plan pays; rules differ by product and state.
For example Ben already has a treated condition. He answers the application fully and checks the specific rule before expecting the plan to help with that condition.
Exclusion / not covered
Something the policy does not pay for, or pays for only under a stated exception.
For example Sarah checks whether a planned treatment is excluded. A benefit amount elsewhere on the page does not override an exclusion.
Comprehensive health insurance
Broader health coverage for many kinds of care. HPG pays specified benefits and has exclusions and limits; it is not a replacement for comprehensive health insurance.
For example Sarah knows HPG can contribute toward a qualifying hospital bill. She does not assume it will pay all the costs of a serious illness.
MRI / PET / CT / X-ray
Tests that create pictures of the inside of your body. MRI uses magnetic resonance; CT uses computed tomography; PET uses positron emission tomography. These are different tests, with their own payment and use limits.
For example Sarah’s doctor orders a CT scan. She checks the scan benefit, network location, any approval and remaining test allowance before estimating her cost.
Labs / diagnostic tests
Tests, such as blood tests, that help check your health or find the cause of symptoms. A test to investigate a problem is not automatically a free routine screening.
For example Ben has a blood test to investigate symptoms. He checks the lab benefit instead of assuming it is included in the price of his doctor visit.
Preventive care / screening
Routine checks aimed at finding problems early or helping prevent illness. The plan decides which services, ages and schedules qualify.
For example Sarah books a routine screening. She confirms the exact test is on the eligible list; extra testing for symptoms can use a different benefit.
Telehealth / virtual visit
A medical visit by phone or video. The named service and type of care matter; it does not mean every online appointment is included.
For example Sarah uses the virtual service named by her plan for an eligible visit. Booking a different online doctor does not automatically get the same benefit.
Generic / brand medicine
A generic medicine uses the same active ingredient as its brand-name equivalent. Plans can pay differently by drug and type. A formulary is the plan’s covered-drug list.
For example Ben checks his exact medicine, strength and form on the applicable drug list. A benefit for some generic medicines does not establish that his prescription is included.
Intensive care / ICU
A hospital unit for people who need very close monitoring and specialized treatment. An intensive-care benefit has its own eligibility and day limits.
For example Sarah receives eligible intensive care during a hospital stay. She checks whether the plan pays an extra ICU benefit and for how many days.
Lifetime maximum
A limit over the period defined by the policy, rather than a new allowance each year. Check whether it applies to one condition, category or the whole policy.
For example If Ben uses a policy’s full lifetime benefit for a category, he does not assume the same category receives a fresh allowance next January.
Critical illness / qualifying diagnosis
For a critical-illness policy, only the diagnoses and severity definitions listed in that policy trigger its payment. A serious condition is not automatically a qualifying diagnosis.
For example Sarah checks the exact CriticalGuard definition and waiting period. She does not assume every cancer diagnosis pays the full amount. This is separate from her health-plan benefits.
