A legal document issued by an insurer or healthcare provider to an individual or group, confirming their enrollment in a particular insurance plan and outlining the benefits, limitations, and terms of coverage.
A contract between an individual or group and an insurance provider, outlining the terms of coverage, including benefits, premiums, deductibles, and copayments.
The process of signing up for or joining an insurance plan, typically requiring the completion of forms and submission of personal information.
The company or organization that provides insurance coverage and assumes the financial risk associated with providing benefits to the insured.
A person or organization that delivers medical services, including doctors, hospitals, clinics, and other healthcare facilities.
The services, treatments, and supplies covered by an insurance plan, which may include doctor visits, hospitalization, prescription medications, and preventive care.
Restrictions or conditions placed on coverage by an insurance plan, such as exclusions for certain medical conditions or treatments, or limits on the number of visits or procedures covered.
The specific conditions, obligations, and rights outlined in the insurance policy, including provisions related to eligibility, premiums, claims processing, and appeals.
The amount of money paid by the insured to the insurer to maintain coverage under an insurance plan, typically paid on a regular basis (e.g., monthly, quarterly, annually).
The amount of money that the insured must pay out of pocket for covered services before the insurance plan begins to pay for eligible expenses.
A fixed amount that the insured must pay for certain covered services, typically due at the time of service (e.g., a copayment for a doctor’s visit or prescription medication).
The administrative process by which insurance claims are submitted, reviewed, and paid by the insurer, involving verification of coverage, determination of eligibility, and calculation of benefits.
The process by which an insured individual or healthcare provider challenges a decision made by the insurer regarding coverage or payment for medical services, typically involving a review by an independent third party.
Healthcare services and screenings intended to prevent illness or detect medical conditions at an early stage, often covered at little or no cost under insurance plans to encourage wellness and disease prevention.
Specific medical services, treatments, or conditions that are not covered by an insurance plan, requiring the insured to pay for these expenses out of pocket.
The group of healthcare providers, facilities, and pharmacies that have contracted with an insurance plan to provide services to its members at discounted rates, often requiring insured individuals to seek care within the network to receive full coverage.
Healthcare providers, facilities, or pharmacies that have not contracted with an insurance plan, resulting in higher costs for services rendered to insured individuals who receive care from these providers.
A standardized document required by law to be provided to consumers by insurers, summarizing key features of an insurance plan, including coverage, costs, and limitations, to facilitate comparison shopping and informed decision-making.
The designated period during which individuals and groups can sign up for or make changes to their insurance coverage without a qualifying life event, typically occurring annually.
A significant life change, such as marriage, birth/adoption of a child, loss of other coverage, or relocation, that allows individuals to enroll in or make changes to their insurance coverage outside of the regular open enrollment period.