Learn
Short, plain-language guides to help patients and caregivers feel less lost when talking to providers and insurance companies.
Deductibles, coinsurance & out-of-pocket maximum
How the three numbers that drive your bills actually work — with a worked example.
Read →Non-duplication of benefits
Why having two health plans often doesn't mean double coverage.
Read →Medical necessity, explained
What insurers actually mean by this phrase, and what they typically review.
Read →How prior authorization works
Who submits it, how long it takes, and what to do if it's denied.
Read →Why something might be called "investigational"
What this term means in insurance policies — and how it changes.
Read →How to call your insurance plan
Exactly what to ask, what to write down, and how to escalate.
Read →Full insurance glossary
Every term grouped by topic: what you pay, coverage rules, plan mechanics, and policy terminology.
Open glossary →Provider specialties
Who does what — primary care, internal medicine subspecialties, surgical specialties, and behavioral & rehab providers. When to see each, and how referrals usually flow.
Browse specialties →Quick glossary by category
What you pay
The monthly amount you (or your employer) pay just to have the plan.
What you pay out of pocket before your plan starts sharing most costs.
A flat dollar amount you pay at the time of a visit or prescription.
Your percentage share of a covered cost after the deductible is met.
The most you'll pay for covered, in-network care in a plan year.
The negotiated price your insurer recognizes for a service.
When an out-of-network provider bills you for the gap above what your plan paid.
The statement from your insurer showing what was billed, allowed, paid, and what you owe.
A written estimate of expected charges you can request before scheduled care.
Coverage rules & reviews
The insurer is reviewing whether the service is clinically appropriate for your situation.
Some services may need plan approval before they are performed.
The insurer considers the service still under study for this use.
Lower-risk care that insurers may want documented before a bigger procedure.
The insurer may view the service as appearance-related rather than treating a medical condition.
How insurers review whether services are clinically appropriate and efficient.
Trying a preferred (often lower-cost) treatment first before a different one is approved.
A formal written decision from your insurer about whether a specific service will be covered.
The insurer's published document defining exactly when a service is considered medically necessary.
The specific clinical requirements a service must satisfy to meet medical necessity.
A physician letter explaining, in clinical terms, why a specific treatment is necessary for you.
How your plan works
Providers who contract with your plan cost less than those who don't.
A written order from your primary care provider to see a specialist.
The doctor who manages your overall care and coordinates referrals.
When you have two plans, the secondary will not pay more than it would have if it were primary.
Rules that decide which of your plans pays first when you have more than one.
Some plans group in-network providers into preferred and standard tiers.
The 12-month window your deductible and OOP max reset on.
How a family plan's deductible applies to one member vs the whole family.
Lower premiums, but you must stay in-network and usually need a referral for specialists.
More flexibility to see any provider — in or out of network — without a referral.
No referrals needed, but out-of-network care is not covered except in emergencies.
A tax-advantaged savings account paired with a qualifying high-deductible health plan.
A pre-tax spending account for eligible medical expenses — but usually 'use it or lose it'.
Policy & billing terminology
The list of medications your plan covers, often with tiers.
A formal request for payment submitted to your insurer for a medical service.
A 5-digit code describing the specific procedure or service that was performed.
A code representing your diagnosis. Must support the procedure code for coverage.
A unique 10-digit ID for every licensed healthcare provider in the US.
Your insurer bears the financial risk — and that's what gives your state regulator authority.
Your employer bears the risk, not the insurer — which changes who you'd complain to.
A private policy that fills gaps in Original Medicare, standardized across insurers.
Federal coverage for 65+ — appeals go through Medicare's own process, not your state.
State-run, income-based coverage — complaints go to your state's Medicaid agency, not the DOI.
The federal law behind most employer plans — and why some plans fall outside state protection.
Appeals & denials
The formal legal term for an insurance denial.
Your first formal challenge to a denial — filed directly with the insurance company.
An independent, binding review of your denial by a neutral third party.
The neutral third party that conducts external reviews of insurance denials.
A fast-tracked appeal for urgent clinical situations — decision within 72 hours.
A formal complaint about a coverage decision, quality of care, or service problem.
Laws & patient rights
Federal protection against surprise out-of-network bills in emergencies and at in-network facilities.
The federal law that guaranteed appeal rights, essential benefits, and pre-existing condition protection.
The right to continue employer coverage after leaving a job — at your own cost.
The annual window when you can enroll in or change your health plan.
A window to change coverage outside open enrollment after a qualifying life event.