Point of Service (POS)

A plan that is less restrictive than a HMO (and allows patients more choice in choosing a practitioner) but is more restrictive and less expensive than a PPO, generally.

Policy

The written contract of insurance detailing what is covered (or paid for) by an insurance plan and what is not.

Policy Limit

The maximum amount a policy will pay. Policies often have annual or lifetime limits.

Pre-existing Conditions

Health conditions (such as diabetes, high blood pressure, high cholesterol, etc) that were present before the current term of insurance. Under the ACA, insurers may not exclude or limit coverage of pre-existing conditions.

Precious Metal Categories

A category system used in health insurance to understand the value of a plan across different insurance providers. Categories include bronze, silver, gold, and platinum. Bronze plans cover 60% of health care costs, silver plans cover 70%, gold plans cover 80%, and platinum cover 90%. All precious metal plans are estimated to have the same Actuarial Value, but actual costs may vary by year. See Actuarially Fair Premium.

Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers to create a network of participating providers. Costs are lower within the network and higher outside of the network. Generally allow patients to see a wider range of providers for a higher cost than an HMO.

Premium

A fixed amount of money an insurance company charges for basic coverage, usually billed monthly. Similar to a gym membership or cable subscription. Composed of two parts: the actuarially fair premium and the loading charge. Paid regardless of whether the patient uses healthcare or not. Larger groups of people and healthier groups of people tend to pay lower premiums (since they will likely use less healthcare and be less expensive for an insurance company).

Premium Tax Credit

A health insurance marketplace subsidy to reduce monthly premium costs for individuals who meet criteria. Individuals are eligible if their annual household income is between 100% and 400% of the federal poverty level, if this individual does not qualify for public coverage, and if no employment coverage is available. The credit can be claimed in advance or received as a tax credit in the following year.

Prior Authorization

Requirement by an insurance plan that a patient seeks specific approval for a procedure to determine if it will be covered by insurance. Facilitated by a physician's office. Abbreviated "prior auth."

Private Health Insurance

A state-licensed health insurer or self-funded employee health benefit plan that takes on financial risk, administers benefits, and pays claims as associated with healthcare costs for individuals and their families.

Private Health Insurers

Insurers that offer plans without the assistance of state or federal governments. There are generally three types: commercial (for-profit) health insurers, non-profit (Blue Cross Blue Shield) health insurers, and HMOs.

Professional Fee

Fee paid by an insurer to a clinician performing services. For example, if you stay in the hospital for three days to have gallbladder surgery, your insurer will pay a professional fee to the surgeon for performing the surgery and consulting with you pre- and post-operatively.