Glossary of Common Virginia Health Insurance Terms

Here is a list of commonly-used Virginia health insurance terms.

Coinsurance

The percentage of health care allowable charges you must pay after you have met your deductible.

Coordination of Benefits (COB)

Method of integrating benefits payable under more than one health insurance plan so that the insured's benefits from all sources do not exceed 100 percent of allowable medical expenses.

Copayment

A specific charge you pay for a specific medical service. For example, you may pay $10 for an office visit or $5 for a prescription and the health plan covers the rest of the medical charges.

Cost Sharing

Policy provisions that require individuals to pay, through copayments, deductibles and coinsurance, a portion of their health care expenses.

Deductible

The amount of money you must pay, generally annually, to cover your medical care expenses before your insurance policy or HMO plan starts paying.

Eligible Expenses

Expenses defined in the health plan as being eligible for coverage. This could involve specified health services, fees or "usual, customary and reasonable charges."

Elimination Period

A specified number of days at the beginning of each period of disability (in disability income policies) or hospital confinement (in hospital confinement indemnity policies), during which no benefits are paid.

Enrollee

An individual who is enrolled in an MCHIP.

Evidence of Coverage (EOC)

Document that summarizes the provisions and benefits of a managed care health insurance plan.

Evidence of Insurability

A statement or proof of physical condition and/or other information affecting a person's eligibility for insurance.

Exclusions

Specific conditions or circumstances for which the policy or plan will not provide benefits.

Explanation of Benefits (EOB)

The statement sent to a participant in a health policy or managed care plan listing services, amounts paid by the plan, and total amount billed to the patient.

Fee-For-Service

A payment system for health care where the provider is paid for each service rendered rather than a pre-negotiated amount for each patient.

Formulary

List of prescription medications covered by an insurance company.

Fully Insured Plan

Employer-purchased insurance coverage from a licensed insurance company, wherein the insurance company assumes the risk.

Gatekeeper

Role of the primary care physician or PCP in HMOs and other forms of MCHIPs. The Gatekeeper coordinates care and makes referrals to specialists.

Grace Period

Specified time (usually 31 days) following the premium due date during which insurance remains in force and a policyholder may pay the premium without penalty.

Grievance Procedure

A procedure which allows a member of a health plan or a provider of benefits to express complaints, protest a decision, and seek remedies.

Group Certificate

The document provided to each member of a group plan. It describes the benefits provided under the group plan.

Guaranteed Renewable Contract

Contract under which an insured has the right, commonly up to a certain age, to continue the policy by the timely payment of premiums. Under guaranteed renewable contracts, the insurer reserves the right to change premium rates by policy class.