fixed sum and/or percentage that an enrollee pays for specific health services, regardless of the total charge for service (the insurer pays the rest of the total charge). For example, an enrollee may pay $15 co-payment and 20 percent of the total charge for each doctor’s visit, $75 for each day in the hospital, and $25 for each prescription.

predetermined  annual amount an enrollee must pay before the insurer will begin paying their portion of covered expenses. For example, if the plan has $300 deductible, the insured person would be responsible for the first $300 for his/her health care bills.

One who meets the requirements specified to qualify for coverage under a health plan.

The defined date a covered person becomes eligible for benefits under an existing contract.

A detailed description of the benefits included in the health plan. An evidence/certificate of coverage is required by state laws and representative fo the coverage provided under the contract issued to an employer.

Plan participants obtain comprehensive health care services from a specified list of in-network providers who receive a fixed periodic prepayment from the insurer. Plan participants’ access to in-network providers is controlled by a primary-care physician or gatekeeper. HMO’s typically do not have a deductible.

The evaluation of health care services to determine if they are: medically appropriate and necessary to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost effective manner; and consistent with national medical practice guidelines regarding type, frequency, and duration of treatment.

Participants in health plan (subscribers/enrollees and eligible dependents), who make up the plan’s enrollment.

Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person’s effective date of coverage under the group contract.

Plan participants may seek care from an in-network provider or from an out-of-network physician or gatekeeper. Typically, the patient pays more for services from an out-of-network provider.