Glossary of Health Insurance Concepts and Terminology


  • Preferred (In-Network) Provider: Provider that has contracted to provide services for a negotiated rate. An insured individual who receives care from a preferred provider will be charged only the negotiated rate (co-pay) that is applicable to them.
  • Non-Preferred (Out-Of ´┐ŻNetwork) Provider: Provider that has not contracted to provide services for a negotiated charge. An insured individual who receives care form a non-preferred provider can be charged the difference between the actual charge and the part paid by the insurance carrier.
  • Co-Pay: Fixed dollar amounts (for example $15) you pay for covered healthcare by an in-network (preferred provider), usually when you receive the service. For example you pay your portion (co-pay) and the insurance company covers the rest.
  • Co-Insurance: The percentage of covered medical expenses paid by the insurance carrier. Co-Insurance is calculated based on allowable and reasonable charges. Your share of the costs of a covered service will vary depending on if the care is in-network or out-of-network.
  • Deductible: Amount of care expenses that must be paid by you before an insurer will pay any expenses. Different deductibles may apply for in-network and out-of-network care. The deductible is typically annual (must be paid each year).
  • Out ´┐Żof-Pocket Maximum: Maximum amount the insured individual (you) would be expected to pay during the policy year. This may or may not include the deductible and co-pays. After you have reached your out-of-pocket maximum, your medical bills will be covered by your health insurance company for the rest of the year with some exceptions.
  • Dependent: One who relies on another for financial support such as a spouse or a child.
  • Clinical Fee: Full-time students are automatically charged this fee. This fee makes students eligible for provider visits at Student Health Service for no additional charge.
  • Referral: The recommendation by a medical professional to see a specialist. Sometimes this is required by an insurance company for them to pay the bills for a specialist.
  • Maximum Benefits: Maximum amounts that insurance will pay for medical expenses. After reaching the maximum benefits the insured individual is responsible for paying the negotiated charges.