C

Claim

A formal request you submit to your insurance company asking them to pay for a medical service or treatment you received. When you go to the doctor and the bill gets sent to your insurer, that is a claim.

Coinsurance

After you have paid your deductible, coinsurance is the percentage of costs you still share with your insurance company. For example, if your plan has 20% coinsurance, you pay 20% of the bill and your insurer pays the other 80%.

Copay (Copayment)

A fixed amount you pay for a specific service, like a doctor visit or a prescription. For example, your plan might say you pay $20 every time you see a primary care doctor, regardless of what the total bill is.

Coverage

The medical services, treatments, and conditions that your insurance plan will pay for. What is covered and what is not covered is spelled out in your policy.

D

Deductible

The amount you pay out of your own pocket for covered medical services before your insurance starts to pay. For example, if your deductible is $1,000, you pay the first $1,000 of medical bills each year. After that, your insurance kicks in.

Dependent coverage

Whether a health plan covers an employee's family members, typically a spouse, children, or domestic partner. Plans vary a lot on this. Some cover dependents at no extra cost, others charge an additional premium, and some do not offer dependent coverage at all. It is usually one of the first questions employees ask when they are evaluating a new job or benefits package.

E

Employer contribution

The portion of the health insurance premium that the employer pays on behalf of the employee. For example, if the monthly premium for a plan is $500 and the employer contributes $400, the employee pays the remaining $100 out of their paycheck. The employer contribution is one of the biggest factors in how affordable a plan feels to employees.

Expatriate health insurance (expat insurance)

Health insurance designed for people who live or work outside their home country for an extended period. Standard domestic health plans usually do not cover medical expenses abroad, or cover them only in emergencies. Expat insurance fills that gap by providing coverage that works internationally. It is different from travel insurance, which is designed for short trips rather than long-term living abroad.

F

Fully insured plan

The traditional way companies buy health insurance. The company pays a fixed monthly premium to an insurance carrier, and the carrier takes on all the risk. If claims are high that year, the company still pays the same amount. If claims are low, the carrier keeps the difference. Most small companies start here because it is simple and predictable.

G

Group health insurance

A health insurance plan that covers a group of people, usually employees of the same company. The employer typically negotiates the plan terms and pays part of the premium. Because the risk is spread across many people, group plans are usually more affordable than individual plans. This is the core product that Remote Health provides to companies with distributed or remote teams.

L

Level-funded plan

A middle ground between fully insured and self-funded. The company pays a fixed monthly amount, similar to a premium. That amount covers expected claims, administrative costs, and stop-loss insurance. At the end of the year, if actual claims came in lower than expected, the company gets a refund on the unused portion. If claims were higher, the stop-loss insurance covers the difference. Level-funded plans have become popular with small and mid-size US companies because they offer the cost predictability of a traditional plan with some of the savings potential of self-funding.

M

Medically necessary

A term insurance companies use to describe services or treatments that are required to diagnose or treat a medical condition, based on accepted medical standards. If something is not considered medically necessary, your insurer may not cover it.

N

Network

A group of doctors, hospitals, and other healthcare providers that have agreed to provide services to members of a specific insurance plan at pre-negotiated rates. Staying within your network usually means lower costs for you.

Non-elective

A procedure or treatment that is urgent or medically required and cannot be postponed. This is different from elective procedures, which are planned in advance and not immediately necessary.

O

Open enrollment

A set period of time, usually once a year, when employees can sign up for health insurance or make changes to their existing plan. Outside of open enrollment, you generally need a qualifying life event to make changes.

Out-of-network

Providers or facilities that are not part of your insurance plan’s network. Using out-of-network care usually costs more, and in some cases your plan may not cover it at all.

Out-of-pocket maximum

The most you will ever have to pay for covered medical services in a given year. Once you reach this limit, your insurance covers 100% of covered costs for the rest of the year. This includes your deductible, copays, and coinsurance, but not your monthly premium.

Outpatient

Medical care that does not require you to stay overnight in a hospital. Doctor visits, lab tests, and minor procedures are all examples of outpatient care.

P

Policy

The contract between you and your insurance company. It outlines what is covered, what is not, how much you pay, and the rules you need to follow to get coverage.

Policyholder

The person or organization that owns the insurance policy. For group health insurance, the employer is typically the policyholder.

Portability

Whether your health coverage can follow you if you leave your job, change employers, or move to a different country. Most traditional employer-sponsored plans are not portable. When you leave the company, the coverage ends. This is a real problem for remote workers and digital nomads who may work across borders or change employment arrangements more frequently than the average office worker.

Pre-existing condition

A health condition or illness you had before your insurance coverage started. Under the Affordable Care Act in the US, insurers cannot deny coverage or charge more because of pre-existing conditions for individual and group plans.

Premium

The amount you or your employer pays, usually every month, to keep your health insurance active. You pay this whether or not you use any medical services that month.

Q

QLE (Qualifying Life Event)

A major life change that allows you to enroll in or change your health insurance plan outside of the regular open enrollment period. Common examples include getting married, having a baby, losing other coverage, or moving to a new area.

S

Self-funded plan (self-insured)

Instead of paying premiums to an insurer, the company pays employee health claims directly from its own funds. The company takes on the financial risk, but if claims are lower than expected, it keeps the savings. Most large US employers use some version of this model. It gives companies more control over their benefits, but it also means they are on the hook if claims are unexpectedly high. Many self-funded companies buy stop-loss insurance to protect against that scenario.

Stop-loss insurance

A type of insurance that companies buy to protect themselves when they are self-funded or level-funded. It sets a cap on how much the company has to pay in claims. If an individual employee's claims exceed a certain amount in a year (called the specific stop-loss limit), the stop-loss insurance kicks in and covers the rest. It is the safety net that makes self-funded and level-funded plans financially manageable for smaller companies.

U

UCR (Usual, Customary and Reasonable)

The standard cost for a medical service in a specific geographic area. Insurance companies use this benchmark to decide how much they will pay for a service. If a provider charges more than the UCR rate, you may be responsible for the difference.

Underwriter

The person or company that evaluates the risk of insuring a group and decides on the terms and price of the policy. The underwriter is essentially the one who decides whether to offer coverage and at what cost.

W

Waiting period

The amount of time that must pass after your coverage starts before certain benefits become available. For example, a plan might have a 12-month waiting period before it covers maternity care.