DEFINITIONS OF HEALTH INSURANCE TERMS

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Download free Definitions Of Health Insurance Terms pdf. In February 2002, the Federal Government’s Interdepartmental Committee on Employment-based Health Insurance Surveys approved the following set of definitions for use in Federal surveys collecting employer-based health insurance data. The BLS National Compensation Survey currently uses these definitions in its data collection procedures and publications. These definitions will be periodically reviewed and updated by the Committee.

ASO (Administrative Services Only) – An arrangement in which an employer hires a third party to deliver administrative services to the employer such as claims processing and billing; the employer bears the risk for claims.
  • This is common in self-insured health care plans.
Coinsurance - A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.
  • Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be “usual, customary and reasonable”.
  • Coinsurance rates may differ if services are received from an approved provider (i.e., a provider with whom the insurer has a contract or an agreement specifying payment levels and other contract requirements) or if received by providers not on the approved list.
  • In addition to overall coinsurance rates, rates may also differ for different types of services.
Copayment - A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement.
  • There may be separate copayments for different services.
  • Some plans require that a deductible first be met for some specific services before a copayment applies.
Deductible - A fixed dollar amount during the benefit period - usually a year - that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles.
  • Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission.
  • Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.
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