10 insurance terms you need to know

1. Broker

A broker, or an agent, is a licensed individual who helps individuals decide, apply, and enroll in coverage. They are licensed and regulated by state and federal laws and can make specific recommendations about which plan(s) to enroll in.

2. Coinsurance

Coinsurance is the share of the costs for a covered health care service, calculated as a percent of the allowable amount for the service after the deductible has been met.
Example: If the policy's allowed amount for an office visit is $100 and you've met your deductible, if your coinsurance is 20%, your payment would be $20. The insurance carrier would pay 80%, which is $80.

3. Copayment

A copayment is a fixed amount notated in the summary of benefits that is paid by the insured member for a covered health care service.

4. Deductible

A deductible is the amount paid by an insured member prior to the insurance carrier or policy beginning to cover services. After the deductible, a member is typically responsible for a copayment or coinsurance up to plan maximum. A deductible may not apply to all services.
Example: If the deductible is $1,000, the member pays the first $1,000. Then the carrier would pay a percentage of the balance due and the member would pay the copayment or coinsurance listed per their policy rules.

5. Network

An insurance network (in-network coverage) includes facilities, providers, and suppliers that the plan is contracted with to provide health care services to you at a lower cost.

6. Open Enrollment Period (OEP)

An Open Enrollment Period (OEP) is the annual period when a member is allowed to enroll in a health insurance plan or make changes to your existing coverage for the new plan year.

7. Out-of-Pocket Maximum

An out-of-pocket maximum is the maximum amount of responsibility a member will have to pay for covered services. When the member reaches their out-of-pocket maximum, the health plan pays 100% of the costs. Premiums do not count toward the out-of-pocket maximum.

8. Primary Care Physician (PCP)

A primary care physician is the provider that coordinates a member's medical care.

9. Special Enrollment Period (SEP)

A Special Enrollment Period (SEP) is the time outside of the annual open enrollment period that a member is able to enroll in health insurance or make changes to an existing policy. One may qualify upon specific life events, including but not limited to: losing health coverage, aging out, getting married, having a baby, moving, etc. There is a 30 or 60 day time limit following the event to enroll in coverage, depending on the employer.

10. Waiting Period

A waiting period is the time immediately following the hire date that an employee must wait until benefits are effective.
Example: If an employee is hired on 1/5/23 and the waiting period is 1st of the month after 30 days, their benefits would be effective on 3/1/23.

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