Health Insurance Vocabulary

Question 1

Name the term that meets the following definition: groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated, high-quality care.

Answer 1

Accountable Care Organization (ACO)

Question 2

Name the term that meets the following definition: the person that receives any of the benefits of the insurance coverage.

Answer 2

Beneficiary

Question 3

Name the term that meets the following definition: the payment of a fee to a healthcare provider providing services to a number of people, such that the amount paid is determined by the number of total patients.

Answer 3

Capitulation

Question 4

Name the term that meets the following definition: the amount a beneficiary must pay for medical care after they have met their deductible.

For instance, the insurance company may pay for 80% of an approved amount, and the patient’s __________ will be for 20%.

Answer 4

Coinsurance

Question 5

Name the term that meets the following definition: the flat fee that a beneficiary must pay each time they receive medical care.

For example, a patient may pay a $10 ______ for every doctor visit, while the insurance plan covers the rest of the cost.

Answer 5

Copayment

Question 6

Name the term that meets the following definition: the maximum amount that a health insurance plan may pay for certain healthcare services. Some health insurance policies may also have a maximum annual or lifetime coverage amount. After any of these limits are reached, then the policyholder may have to pay for all remaining costs.

Answer 6

Coverage limits

Question 7

Name the term that meets the following definition: the amount the beneficiary must pay each year before their health insurance coverage plan begins paying.

Answer 7

Deductible

Question 8

Name the term that meets the following definition: services that are not covered by the specific insurance plan. These must be clearly defined in the plan literature.

Answer 8

Exclusions / limitations

Question 9

Name the term that meets the following definition: a payment system where healthcare services are unbundled and paid for separately.

Answer 9

Fee-for-service

Question 10

Name the term that meets the following definition: an insurance provider’s list of covered drugs.

Answer 10

Formulary

Question 11

Name the term that meets the following definition: a form of managed care in which all care is received from participating providers within the network. A referral from a primary care provider needs to be obtained prior to seeing specialists.

Answer 11

Health maintenance organization (HMO)

Question 12

Name the term that meets the following definition: an account established by an employer to pay an employee’s medical expenses. Only the employer can contribute to a ___.

Answer 12

Health reimbursement account (HRA); HRA

Question 13

Name the term that meets the following definition: an account established by an employer or an individual to save money toward medical expenses on a tax-free basis.

Answer 13

Health savings account (HSA)

Question 14

Name the term that meets the following definition: a plan that provides comprehensive coverage for high-cost medical events but features a high deductible coupled with a limit on annual out-of-pocket expense.

Answer 14

High-deductible health plan (HDHP)

Question 15

Name the term that meets the following definition: insurance coverage purchased independently (as opposed to as part of a group), usually directly from an insurance company.

Answer 15

Individual health insurance

Question 16

Name the term that meets the following definition: a federal program administered by individual States to provide healthcare for certain poor and low-income individuals and families.

Answer 16

Medicaid

Question 17

Name the term that meets the following definition: a federal insurance program that provides healthcare coverage to eligible individuals aged 65 and older and certain disabled people (such as those with end-stage renal disease).

Answer 17

Medicare

Question 18

Name the term that meets the following definition: a group of physicians, hospitals, and other providers who participate in a particular managed care plan.

Answer 18

Network

Question 19

Name the term that meets the following definition: the maximum amount that an insured person can pay, after which the insurance plan pays all further covered costs. Out-of-pocket maxima may be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

Answer 19

Out-of-pocket maxima

Question 20

Name the term that meets the following definition: a form of managed care in which insurance policyholders have more flexibility in choosing physicians and other providers than in an HMO. Both participating and nonparticipating providers may be seen, however the out-of-pocket expenses paid by the policyholder will vary.

Answer 20

Preferred provider organization (PPO)

Question 21

Name the term that meets the following definition: the amount the insurance policyholder pays to belong to a health plan. In general under employer-sponsored health insurance, the employee’s share of premiums is usually deducted from their pay.

Answer 21

Premium

Question 22

Define the following term:

Accountable Care Organization (ACO)

Answer 22

Name the term that meets the following definition: groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated, high-quality care.

Question 23

Define the following term:

Beneficiary

Answer 23

The person that receives any of the benefits of insurance coverage.

Question 24

Define the following term:

Capitulation

Answer 24

The payment of a fee to a healthcare provider providing services to a number of people, such that the amount paid is determined by the number of total patients.

Question 25

Define the following term:

Coinsurance

Answer 25

The amount a beneficiary must pay for medical care after they have met their deductible. For instance, the insurance company may pay for 80% of an approved amount, and the patient’s coinsurance will be for 20%.

Question 26

Define the following term:

Copayment

Answer 26

The flat fee that a beneficiary must pay each time they receive medical care. For example, a patient may pay a $10 copay for every doctor visit, while the insurance plan covers the rest of the cost.

Question 27

Define the following term:

Coverage limits

Answer 27

The maximum amount that a health insurance plan may pay for certain healthcare services. Some health insurance policies may also have a maximum annual or lifetime coverage amount. After any of these limits are reached, then the policyholder may have to pay for all remaining costs.

Question 28

Define the following term:

Deductible

Answer 28

The amount the beneficiary must pay each year before their health insurance coverage plan begins paying.

Question 29

Define the following term:

Exclusions / limitations

Answer 29

Services that are not covered by the specific insurance plan. These must be clearly defined in the plan literature.

Question 30

Define the following term:

Fee-for-service

Answer 30

A payment system where healthcare services are unbundled and paid for separately.

Question 31

Define the following term:

Formulary

Answer 31

An insurance provider’s list of covered drugs.

Question 32

Define the following term:

Health maintenance organization (HMO)

Answer 32

A form of managed care in which all care is received from participating providers within the network. A referral from a primary care provider needs to be obtained prior to seeing specialists.

Question 33

Define the following term:

Health reimbursement account (HRA)

Answer 33

An account established by an employer to pay an employee’s medical expenses. Only the employer can contribute to an HRA.

Question 34

Define the following term:

Health savings account (HSA)

Answer 34

An account established by an employer or an individual to save money toward medical expenses on a tax-free basis.

Question 35

Define the following term:

High-deductible health plan (HDHP)

Answer 35

A plan that provides comprehensive coverage for high-cost medical events but features a high deductible coupled with a limit on annual out-of-pocket expense.

Question 36

Define the following term:

Individual health insurance

Answer 36

Insurance coverage purchased independently (as opposed to as part of a group), usually directly from an insurance company.

Question 37

Define the following term:

Medicaid

Answer 37

A federal program administered by individual States to provide healthcare for certain poor and low-income individuals and families.

Question 38

Define the following term:

Medicare

Answer 38

A federal insurance program that provides healthcare coverage to eligible individuals aged 65 and older and certain disabled people (such as those with end-stage renal disease).

Question 39

Define the following term:

Network

Answer 39

A group of physicians, hospitals, and other providers who participate in a particular managed care plan.

Question 40

Define the following term:

Out-of-pocket maxima

Answer 40

The maximum amount that an insured person can pay, after which the insurance plan pays all further covered costs. Out-of-pocket maxima may be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

Question 41

Define the following term:

Preferred provider organization (PPO)

Answer 41

A form of managed care in which insurance policyholders have more flexibility in choosing physicians and other providers than in an HMO. Both participating and nonparticipating providers may be seen, however the out-of-pocket expenses paid by the policyholder will vary.

Question 42

Define the following term:

Premium

Answer 42

The amount the insurance policyholder pays to belong to a health plan. In general under employer-sponsored health insurance, the employee’s share of premiums is usually deducted from their pay.