Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary
See an example below showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation.
Maximum amount on which payment is based for covered health care 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.
A request for your health insurer or plan
to review a decision or a grievance
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
balance bill you for covered services.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount
for the service. You pay co-insurance plus
you owe. For example,
if the health insuranc
e or plan’s
allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% 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.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider
for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
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.
Evaluation of an emergency medical condition
and treatment to keep the condition from getting worse.
Health care services that your health insurance
doesn’t pay for or cover.
A complaint that you communicate to your health insurer or plan.
Health care 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.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
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.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
The percent (for example, 20%) you pay of the allowed amount
for covered health care services to providers
who contract with your health insurance
. In-network co-insurance usually costs you less than out-of-network co-insurance
A fixed amount (for example, $15) you pay for covered health care services to providers
who contract with your health insurance
. In-network co-payments usually are less than out-of-network co-payments
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
The facilities, providers
and suppliers your health insurer or plan
has contracted with to provide health care services.
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 if your health insurance or plan has a “tiered” network
and you must pay extra to see some providers.
The percent (for example, 40%) you pay of the allowed amount
for covered health care services to providers who do not contract with your health insuranc
e or plan
. Out-of-network co-insurance usually costs you more than in-network co-insurance.
A fixed amount (for example, $30) you pay for covered health care services from providers who do not
contract with your health insurance
. Out-of-network co-payments usually are more than in-network co-payments
The most you pay during a policy period (usually a year) before your health insurance
begins to pay 100% of the allowed amount
. This limit never includes your premium, balance-billed
charges or health care your health
insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance
payments, out-of-network payments or other expenses toward this limit.
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
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.
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.
The amount that must be paid for your health insurance
. You and/or your employer usually pay it monthly, quarterly or yearly.
Prescription Drug Coverage Health insurance
that helps pay for prescription drug
s and medications.
Drugs and medications that by law require a prescription
Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care 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.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Health care 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.
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.
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.
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.
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.