Glossary

Acute Care

Medical care, frequently in a hospital or by nursing professionals, to treat a serious injury or illness, or when recovering from surgery. Medical conditions requiring acute care are usually temporary, rather than chronic.

Allowed Amount

Maximum amount on which payment is based for covered healthcare services. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Ambulatory Care

Medical care that occurs on an outpatient basis.

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Benefit

Any service (such as an office visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by a health insurance plan.

Benefit Level

The maximum amount a health insurance company agrees to pay for a specific covered benefit.

Benefit Year

The 12-month period a health insurance plan is in effect.

Board-Certified

A physician who successfully completed an educational program and evaluation process approved by the American Board of Medical Specialties, including an exam to determine the knowledge, skills and experience required to provide quality patient care in a specific specialty.

Case Management

When a member needs considerable medical care, a health insurance company may assign a case manager who will work with the member's healthcare providers to help manage the patient's long-term needs, including appropriately recommending care, monitoring and follow-up. A case manager will also help ensure the member's health insurance benefits are being properly and fully used and non-covered services are avoided when possible.

Chemical Dependency Inpatient

Services to treat a chemical dependency that requires a stay at a hospital or other medical facility.

Chronic

A medical condition that is permanent, recurring or long lasting.

Claim

A bill for medical services provided, typically submitted to the insurance company by a healthcare provider.

Coinsurance

Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20 percent would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren't complications of pregnancy.

Copayment

A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered health care service.

Cost-Sharing

Healthcare charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance, and copayments. Premium payments are not part of cost-sharing.

Deductible

The amount you owe for healthcare services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible. The deductible may not apply to all services.

Dependent Coverage

Health insurance coverage for the spouse and children (through age 25) of the primary insured member.

Dependent Coverage

Health insurance coverage for the spouse and children (through age 25) of the primary insured member.

Drug Formulary

A list of prescription medications that a health insurance plan covers.

Durable Medical Equipment (DME)

Medical equipment such as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.

Effective Date

The date on which health insurance coverage takes effect.

Emergency Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation

Ambulance services for an emergency medical condition.

Emergency Room Care

Emergency services you get in an emergency room.

Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Employee Contribution

The portion of the health insurance premium the employee pays, usually deducted from wages by the employer.

Employer Contribution

The portion of an employee’s health insurance premium the employer pays.

Enrollment Period

The period of time during which an eligible employee or eligible person may sign up for a health insurance plan.

Excluded Services

Healthcare services that your health insurance or plan doesn’t pay for or cover.

Explanation of Benefits (EOB)

A statement sent from a health insurance company to a member listing services that were billed by a healthcare provider, how the health insurance company processed those charges and how much the member is responsible for paying.

There are no terms listed for the letter "F".

Generic Drug

A drug that has the same effective ingredients as a brand-name prescription drug, but which can be produced by other manufacturers after the brand-name drug’s patent has expired. Generic drugs are generally less expensive than brand-name drugs.

Grievance

A complaint that you communicate to your health insurer or plan.

Group

A number of individuals covered under a single health insurance contract, usually a group of employees.

Group Health Insurance

A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.

Habilitation Services

Healthcare services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

High Deductible Health Plan (HDHP)

A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower.

Home Healthcare

Healthcare services a person receives at home.

Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

HSA (Health Savings Account)

A savings account used with certain high-deductible health insurance plans to pay for qualifying medical expenses. Money may be put into the savings accounts on a tax-free basis. Money remain in the account from year to year, and you also can choose to invest the funds. Interest or investment returns are tax-free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses.

In-Network Coinsurance

The percent (for example, 20 percent) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

In-Network Copayment

A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Individual and Family Health Insurance

A type of health insurance purchased by an individual or family – not through any employer group or organization.

Inpatient

When a person is admitted to a hospital for at least 24 hours.

There are no terms listed for the letter "J".

There are no terms listed for the letter "K".

Lab/X-Ray

Lab services typically include services such as blood panels and urinalysis. X-ray services typically include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan.

Limitations

Any maximums a health insurance plan imposes on specific benefits.

Maternity (Inpatient)

Usually, hospitalization and physician fees associated with the birth of a child.

Maternity (Outpatient)

Usually OB-GYN office visits during pregnancy and right after giving birth.

Maximum Out-Of-Pocket Costs

An annual limit on all cost-sharing responsibilities for a member under a health insurance plan. This limit doesn’t apply to premiums, balance-billed charges from out-of-network healthcare providers or services that are not covered by the plan.

Medically Necessary

Healthcare services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Member

Anyone (enrollee or eligible dependent) covered under a health insurance plan.

Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide healthcare services.

Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Office Visit

An outpatient visit to a physician's office for illness or injury.

Open Enrollment Period

A time period when eligible people or eligible employees can sign up for coverage under a health insurance plan.

Out-of-Network Coinsurance

The percent (for example, 40 percent) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Out-of-Network Copayment

A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount. This limit never includes your premium, balance-billed charges or healthcare your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.

Outpatient

When a patient receives care at a medical facility but is not admitted to the facility overnight, or for 24 hours or less.

Outpatient Surgery

Generally, any surgical procedure not requiring an overnight stay in a hospital.

Over-the-Counter (OTC) Drugs

Drugs you get get without a prescription.

Physician Services

Healthcare services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Plan

A benefit your employer, union or other group sponsor provides to you to pay for your healthcare services.

PPO

PPO means "Preferred Provider Organization." With this type of health insurance, you need to get medical care from doctors or hospitals on the insurance company's list of preferred providers if you want claims paid at the highest level.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs

Drugs and medications that by law require a prescription.

Preventive Benefits

Covered services, such as vaccinations and screenings, that are intended to prevent disease or to identify disease while it is more easily treatable.

Preventive Care

Medical care focused on prevention and early-detection of disease. Examples include routine examinations and immunizations. Under the Affordable Care Act, preventive care is provided at no out-of-pocket costs to the member.

Primary Care Physician

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), healthcare professional or healthcare facility licensed, certified or accredited as required by state law.

There are no terms listed for the letter "Q".

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Rehabilitation Services

Healthcare services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Renewal

When a member decides to continue coverage under a health insurance plan after the original contract expires.

Skilled Nursing Care

Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Tertiary Care

Services from specialized providers such as intensive care units, neurologists, neurosurgeons and thoracic surgeons. Such services often require highly sophisticated equipment and facilities.

Treatment Facility

Any facility, either residential or non-residential, authorized to treat mental illness or substance abuse.

Triage

Classifying sick or injured patients according to how severe their conditions are to make sure medical facilities and staff are used most effectively.

UCR (Usual, Customary and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Utilization Management/Review (AKA Medical Review)

The work of a group of nurses and doctors who work with health insurance plans to determine if a patient's use of healthcare services was medically necessary, appropriate and within standard medical practice guidelines.

There are no terms listed for the letter "V".

There are no terms listed for the letter "W".

There are no terms listed for the letter "X".

There are no terms listed for the letter "Y".

There are no terms listed for the letter "Z".