Glossary – Insurance Related Terms

Exclusive Provider Organization (EPO): a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Preferred Provider Organizations (PPOs): means You can see “preferred” providers or “out-of-network” providers. A PPO has a network (or group) of preferred providers. You pay less if you go to these providers. Preferred providers are also called in-network providers.

With a PPO, you can go to a doctor or hospital that is not on the preferred provider list. This is called going out-of-network. However, you pay more to go out-of-network.

When you are shopping for insurance, be sure to ask what hospitals, doctors, and other providers are “preferred” or “in-network”.

Health Maintenance Organizations (HMOs): You must use providers within your network. Usually, you must have a primary care doctor. This doctor provides your basic care and makes referrals to specialists. If you see a provider outside of your HMO’s network, they will not pay for those services (except in the case of emergency and urgent care).

Deductible: the set amount of out-of-pocket spending that is set by the insurance company. Once you’ve reached your deductible, your insurance company will start to contribute to the cost of therapy.

Individual Deducible: the amount that you, as an individual, are responsible for paying until your insurance takes on some of the costs.

Family Deductible: if you are in a group plan with family members or are dependent, everyone’s payments will contribute to the deductible total. Once met, the insurance will then take on the percentage of the costs for reach of you.

Coinsurance: is the percentage of the cost you are responsible for paying after your deductible has been met. Your insurance covers this remaining percentage.

Copay: is the flat rate per session set by your insurance plan. With a copay, you will pay the same amount per session type or length.

Out-of-pocket Max: the maximum amount you can spend during a given plan cycle. If you meet that maximum, this means you won’t have any expenses until your plan resets. Please reach out to your provider for plan policies and restrictions.