Health Insurance Terms to Know
 
 

Care

Preventive Care

Health care that focuses on preventing disease and keeping you healthy. Common examples include screening tests, health education, and immunizations.

Primary Care Provider (PCP)

The doctor or other provider you see first for most health problems. They make sure you get the care you need to stay healthy. They also may talk with other doctors and health care providers about your care and refer you to them.

Prior Authorization

The approval needed before you receive a certain procedure or service. Your doctor submits a request to us and we review it for medical necessity. We check to make sure you receive the appropriate level of care, at the appropriate time, in the right setting, and in the most efficient manner.

Referrals

A referral is written permission from your Primary Care Provider to see a specialist for care. Certain plans, such as HMO and POS plans, require you to get a referral. Other plans, including PPO plans, do not require a referral. If you’re uncertain about whether or not you need a referral, call the Member Services number on your ID card.

Specialist

A doctor who provides health care services for a specific disease or part of the body.

Costs

Coinsurance

The percentage of costs you pay for certain covered services. As an example, if your plan has 20% coinsurance, Tufts Health Plan will pay 80% of the cost, and you’ll be responsible for paying 20% of the cost.

Copayment

There are some services that may require a copayment with your plan. A copayment is the cost-share that you pay for certain covered pharmacy or medical services. Depending on your plan, you might have a copayment for a doctor’s office visit or for a prescription drug.

Deductible

The amount you have to pay for covered health care services before Tufts Health Plan starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and Tufts Health Plan pays the rest. Please check your benefit document (located in the My Coverage section of mytuftshealthplan.com) for details. The benefit document is also called an Evidence of Coverage (EOC) or Certificate of Insurance (COI).

Out-of-Pocket Maximum

The most you can pay during your plan year for your share of covered medical, pharmacy, vision, and mental health services. After you spend this amount on deductibles, copayments, and coinsurance, Tufts Health Plan will pay 100% of remaining costs for covered services. However, your monthly premium does not count toward this total.

 

Premium

Your monthly contribution to pay for your health plan coverage. A plan with a lower premium will often have higher out-of-pocket costs (copayment, deductible and coinsurance) when you receive covered services.

Documents

Claim

A request for payment, made by you or your health care provider, after you have received medical services, procedures, or items that you or your provider believe to be covered under your health plan coverage.

Explanation of Benefits (EOB)

A report that provides you with useful information about how we processed claims from providers who rendered care for you - it is not a bill. The EOB shows what charges were submitted to us, and what amount you owe to the provider, if any.

Summary of Benefits and Coverage (SBC)

A summary about a health plan’s benefits and coverage. This information helps you make “apples-to-apples” comparisons when you’re looking at plans.

The SBC shows how you and the plan share the cost for covered health care services, and also includes details - or “coverage examples” - which show you what the plan would cover in 2 common medical situations: diabetes care and childbirth. A glossary of terms used in health coverage and medical care is also included.