Health Insurance Terms Glossary

To enhance your understanding of your insurance benefits, please find the definitions of commonly used health insurance terms below.

ACA Complaint
Refers to the Affordable Care Act (ACA), which mandates that health insurance plans must provide essential covered benefits, when seen by an in-network provider.

Allowed Amount
The maximum dollar amount covered by an insurance company.

Benefits or Member Benefits
Services or items covered by a health insurance plan that determine your out-of-pocket costs, if any including deductibles, co-insurance, and copayments.

Benefit Verification
For certain services (IUD and Nexplanon insertions, nutrition services, and physical therapy care) University Health Services contacts your insurance carrier directly on your behalf to determine your out-of-pocket costs and provides this information via your MyUHS/CMHC portal.)

For any service not mentioned above, it is your responsibility to verify your insurance member benefits directly with your health plan. You can do this by calling the member services phone number listed on your insurance card OR referring to your policy plan booklet

Claim
A formal request sent to your insurance company for service reimbursement. Many healthcare providers will send claims on your behalf to your insurance company.

Co-insurance
The amount you are required to pay for medical care after you have met your deductible. This amount is usually expressed as a percentage, for example if your co-insurance is 80%/20%, your insurance will pay 80% of your claim and you will be responsible for 20% of your claim.

Contractual Adjustments or Contractual Allowance
When you see a provider that is in-network with your insurance, your insurance carrier has already negotiated a prior maximum amount that their members will pay for services. The provider’s office is unable to bill a member for the excess amount over this allowable due to this agreement. This only applies when you remain in-network.

Coordination of Benefits
A practice that determines which insurance plan pays first (and afterward) in a situation where you have more than one insurance policy. It also eliminates the duplication of benefits when you are covered by more than one plan so that benefits do not exceed paying more than 100% of your claim.

It is very important that you respond to your insurance company when they contact you to ask if you have additional insurance. They will often do this on the first claim of the year, or if a claim is secondary to an accident. If you do NOT respond to their request for other insurance information, the insurer will NOT pay your claims until they receive that information.

University Health Services does not file to secondary insurance, however Coordination of Benefits rules still apply.

Copayment or Copay
A flat fee that you customarily pay at the time of service. For services rendered at University Health Services, copayment responsibilities are sent to your “What I Owe”.

Deductible
The annual amount you must pay towards your healthcare services before the insurance company starts to pay. Example: If your deductible is $1,000, this amount must be met/paid by you before your benefits are payable by insurance.

EPO
Or Exclusive Provider Organization. A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network. This can sometimes be a regional area or clinic/hospital network only.

We recommend those with EPOs, confirm their in-network status directly with their health insurance carrier.

Exclusion or Plan Exclusion
Specific conditions or circumstances for which your insurance company will not provide benefits, this could be a particular diagnosis or service that is restricted. These exclusions will be listed in your insurance plan booklet, or you can confirm them directly with your health insurance.

Explanation of Benefits (EOB)
A statement, not a bill, sent by a health insurance company to their policy holders (student, parent/family member, spouse) explaining what medical treatment and/or services were paid for on their behalf and what their expected out of pocket costs will be.

you are insured and we can file a claim to your health plan, University Health Services will not send charges to your “What I Owe” until we receive the provider version of your Explanation of Benefits. This document outlines what your insurance has deemed as the amount we are allowed to charge you. Claim processing time can take up to 30 days, however we will reach out to you if we are unsuccessful in reaching your health insurance.

Health Insurance Carrier
Often also referred to as your Health Insurance Plan, Health Insurance Company, or Underwriter. This is the company that has assumed the risk and payment of your claims under an insurance policy. Common insurance carriers are Blue Cross Blue Shield, United Healthcare, Aetna, and Cigna, though there are many others.

Health Share Plans
These plans are not considered valid health insurance and are instead a collection of individuals who share the cost of medical bills between one another through a monthly contribution.

Payment for services is not guaranteed and some plans have restrictions on contraceptive care or other services.

HMO
Or Health Maintenance Organization. A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally will not cover out-of-network care. Refer to your insurance carrier for specific details. HMO plans will make you coordinate your care with your designated primary care provider who is on file with your insurance plan.

UHS is not contracted with any HMO plans, however we will file a courtesy claim with your HMO plan, and you can still be seen at UHS. For the lowest out of pocket costs, we recommend reaching out to your insurance carrier for assistance in finding an in-network primary care provider near campus or seeing if your insurance allows any temporary arrangements for students attending college out of their primary region.

UHS will not obtain any prior authorizations or referrals on your behalf to be seen at UHS.

In-Network
A group of doctors, hospitals, and other healthcare providers contracted to provide services to an insurance company’s members at a negotiated rate. Please refer to the list of in-network insurance plans.

Out of Network
A group of doctors, hospitals, and other healthcare providers who do not offer pre-negotiated rates. Out of network care will always be higher. Please refer to the list of in-network insurance plans.

Out of Pocket Costs
Also referred to as your financial responsibility. The total you pay out of pocket for a policy year. These costs include the deductible, co-insurance, and amounts considered by the insurance company to be above the “usual and customary” charges. Some plans do not include your copayments towards your total out of pocket costs.

Plan Administrator
The third-party intermediary between the insurance buyer and the insurance company. For example, the Student Health Insurance Plan’s plan administrator is Academic HealthPlans (AHP), as they provide administrative support to UT and facilitate the student enrollment in this plan. (Not all health plans have plan administrators.)

Plan Benefit Period
The time period your health plan provides coverage. Plans are either on a calendar year (January 1-December 31) or a service/contract year (starting on your enrollment date and running concurrently afterwards) that runs for a predetermined period. If you are unsure of your plan benefit period, please reach out to your health insurance carrier for assistance.

If you are a voluntary enrollee in the Student Insurance Plan, your coverage terminates when your plan benefit period ends – you are not automatically renewed. Please contact Academic Health Plans if you have further questions or concerns.

POS
Or Point-of-Service plan. These typically are a hybrid of HMO and PPO plans, where you have access to in-network providers, but may require referrals for specialists or out of network care.

PPO
Or Preferred Provider Organization. A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Members with PPO plans can also typically self-refer themselves for specialty care.

UHS is contracted with several PPO plans, please refer to the list of in-network insurance plans.

Primary Care Physician/PCP
The physician primarily responsible for your acute and chronic care, making referrals to other specialists as necessary.

You can designate your preferred provider in your MyUHS/CMC portal, however if you have an HMO or EPO plan that requires you to designate your PCP directly with your insurance then UHS providers should not be selected if they are out of network with your plan. Your insurance should not allow you to select a PCP who is out of network with your plan.

Primary Policy Holder or Primary Subscriber
If you have insurance through your parent’s, spouse’s, or registered domestic partner’s employer OR they have enrolled you as a dependent on a Health Insurance Marketplace plan, the parent/spouse/domestic partner who is covering you as a dependent under their health insurance plan would be the primary subscriber, sometimes called the primary enrollee.

Health insurance carriers need healthcare providers to submit certain demographic information about the primary subscriber, as well as the patient on a patient’s claim.

Provider
A doctor, hospital, clinic, pharmacy, laboratory, or other licensed facility that provides healthcare services.

SHIP
The acronym for the Student Health Insurance Plan.

For enrollees in this plan, their deductible, co-insurance, and copayment are waived for covered services at University Health Services. Enrollment is administered by Academic Health Plans.

Subsidy Adjustments
The amount covered by UT tuition under the Student Administrative Health Fee. The SAHF provides a cost reduction for some services at UHS.

Subsidy adjustments are not reflected on your Explanation of Benefits from your health plan, as this is an agreement between you and University Health Services.

For those with insurance, subsidy adjustments are applied after we receive an Explanation of Benefits from your health plan and before charges are sent to your “What I Owe”.

These definitions are provided as a reference only and do not replace the official definitions as listed in your insurance plan documents. Not all terms will be applicable to all insurance plans.

If you have any additional questions on your insurance member benefits or if any of the above concepts apply to your plan, please reach out to your health plan directly by calling the member services phone number found on your health insurance card.