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Health Insurance Glossary

  • Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage.
    Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company begins to pay for care.
  • Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.

  • Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.

  • Exclusions: Not all services are covered. Generally the insured is expected to pay the full cost of non-covered services out of pocket.

  • Coverage Limits: The Affordable Care Act removed coverage limits.

  • Out-of-pocket Maximum: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and health insurance pays all further covered costs. Out-of-pocket maxima can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

  • Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.

  • In-Network Provider: (U.S. term) A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.

  • Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.

  • Explanation of Benefits: A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.
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Need to Make a Claim?

Acadia Insurance
800-244-9446

Allstate
Report Online
800-255-7828

Dairyland Insurance
Auto: 800-225-1390
Cycle: 800-325-9559

Foremost Insurance Group
Report Online
800-527-3907

The Hanover Insurance Group
Report Online
800-628-0250

The Hartford
Report Online
800-243-5860
Business Insurance: 800-327-3636

Jewelers Mutual Insurance Company
Report Online
800-558-6411

MEMIC
Report Online
800-636-4292

MMG Insurance
888-343-0533 (M-F, 8:00-4:30)
888-869-8700 (after hours)

Patriot Insurance Company
Report Online
866-460-1776

Patrons Insurance
800-542-7032

Peerless Insurance
800-522-7152

Philadelphia Insurance Companies
800-873-4552

Progressive
Report Online
800-776-4737

Travelers
Report Online (Personal)
Personal Insurance: 800-252-4633
Report Online (Business)
Business Insurance: 800-832-7839

Union Mutual of Vermont
Report to GHM: 207-873-5101

Want to Pay a Bill?

Acadia Insurance 
Call GHM: 800-244-9046

Allstate
Pay Online
800-901-1732

Dairyland Insurance
Auto: Pay Online
Auto: 800-2334-0090
Cycle: Pay Online
Cycle: 866-324-7952

Foremost Insurance Group
Pay Online
800-532-4221

The Hanover Insurance Group
Pay Online
800-573-1187

The Hartford
Pay Online
800-624-5578

Jewelers Mutual Insurance Company
800-558-6411

MEMIC
Pay Online
800-660-1306

MMG Insurance
Pay Online
888-664-2455

Patriot Insurance Company
Personal: Pay Online
Business: Pay Online

Patrons Insurance
Pay Online
866-611-7887

Peerless Insurance
Pay Online
800-228-7830

Philadelphia Insurance Companies
Pay Online
877-438-7459

Progressive
Pay Online
800-776-4737

Travelers
Pay Online
800-842-5075

Union Mutual of Vermont
Pay Online

 

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