INSURANCE GLOSSARY

Many of these definitions are adapted from HealthCare.gov

A

ACO – Accountable Care Organizations (ACOs) are doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

 

ACOs tie payments to quality metrics and the cost of care. The ACO is accountable to patients and third-party payers for the quality, appropriateness and efficiency of its services. You can count on SJRA to provide the highest level of quality care.

C

Co-Payment – A supplemental cost-sharing arrangement in which the HMO enrollee pays, to the provider, a specified amount for a specific service at time of service.

 

Cobra – A federal law which permits many people who lose eligibility under a group health plan to continue that coverage without lapse.

 

Coinsurance – The percentage of costs of medical care that a patient pays himself. Coinsurance rates generally hover in the 10 percent to 30 percent range.

 

Coordination of Benefits – A method of determining who pays first when two or more health insurance plans are responsible for paying for the same medical claim.

 

Cost Share – The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

D

Deductible – A set dollar amount that a person must pay before insurance coverage for medical expenses can begin.

E

Effective Date – The date on which the Health Plan Agreement goes into effect.

 

EMR – An acronym for Electronic Medical Records. You can find your South Jersey Radiology test results by logging into our secure Patient Portal on our website.

F

Flexible Spending Account (FSA) – An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin, and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. Your employer’s plan sets a limit on the amount you can put into an FSA each year.

H

Health Reimbursement Account (HRA) – An employer-funded group health plan from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account.

 

Health Savings Account (HSA) – A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses if you have a “high deductible” health insurance plan.

 

Health Maintenance Organization (HMO) – An HMO is a managed-care plan in which you select a primary care physician (PCP) from within a network of participating health providers.

O

Out-of-Pocket Expense – Money that comes out of your pocket to pay medical costs. This includes the money you pay towards your deductible, your copayments, and your coinsurance. Your health care plan sets a maximum limit on the amount of out-of-pocket costs you pay within a plan year.

P

Payer – In health care, payer generally refers to entities other than the patient that finance or reimburse the cost of health services. In most cases, this term refers to insurance carriers, other third-party payers, or health plan sponsors (employers or unions).

 

Preferred Provider Organization (PPO) – A type of insurance plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less by choosing doctors, labs, and hospitals within the network.

 

Provider – A term used by managed care organizations, referring to anyone rendering medical care, including physicians, nurse practitioners, physician assistants, and others.

R

Referral Authorization – A written approval of a request for a member to receive medical services or supplies outside of the participating medical group.

 

Referring Physician – A physician who sends a patient to another healthcare provider for examinations, surgery, or to have specific procedures performed on the patient, usually because the referring physician is not prepared or qualified to provide the needed service.

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