Glossary of Terms
A
allowable charge
The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
annual deductible
The amount you are required to pay annually before reimbursement by your health care benefits plan begins.
The deductible requirement does not apply to preventive services.
annual out-of-pocket maximum
The maximum amount, per year, you are required to pay out of your own pocket for covered health care services after the deductible and coinsurance requirements are met.
B
C
claim form
A form you or your doctor fill out and submit to your health care benefits plan for payment.
claim
An itemized bill for services provided to a member.
COBRA
A federal act (Consolidated Omnibus Budget Reconciliation Act of 1985) which requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming an over-aged dependent, Medicare eligibility, death or divorce of a covered employee.
coinsurance
A percentage of a covered service that you are responsible for paying or the percentage paid by your plan.
contracting hospital
A hospital that has contracted with a particular health care plan to provide hospital services to members of that plan.
copayment
A fixed dollar amount you are required to pay for covered services at the time you receive care.
covered person
The eligible person enrolled in the health care benefits plan and any enrolled eligible family members.
covered service
A service which is covered according to the terms in your health care benefits plan.
D
deductible
A fixed amount you are required to pay before health care benefits begin. The deductible requirement does not apply to preventive care services.
dependent
An eligible person, other than the member (generally a spouse or child), who has health care benefits under the member's policy.
drug formulary
A list of preferred drugs chosen by a panel of doctors and pharmacists. Both brand and generic medications are included on the formulary.
E
effective date of coverage
The date your coverage begins. Please note: The effective date can also represent the date a change in your coverage took effect. If you have questions, please call the number on the back of your ID card for more information.
emergency medical care
Services provided for the initial outpatient treatment of an acute medical condition, usually in a hospital setting. Most health care plans have specific guidelines to define emergency medical care.
Explanation of Benefits (EOB)
An EOB is created after a claim payment has been processed by your health care plan. It explains the actions taken on a claim such as the amount that will be paid, the benefit available, reasons for denying payment and the claims appeal process. EOBs are available both as a paper copy and online.
exclusions
Specific medical conditions or circumstances that are not covered under a health care plan.
F
family coverage
Health care coverage for a primary policyholder (called a "subscriber") and his or her spouse and any eligible dependents.
G
generic drug
A prescription drug that is the generic equivalent of a brand name drug listed on your health plan's formulary and costs less than the brand name drug.
generic substitute
A prescription drug which is the generic equivalent of a drug listed on your health plan's formulary.
group
A group of people covered under the same health care plan and identified by their relation to the same employer or organization.
H
Health Maintenance Organization (HMO)
An organization that provides health care coverage to its members through a network of doctors, hospitals and other health care providers.
HIPAA
A federal law that outlines the rules and requirements employer-sponsored group insurance plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups.
I
individual health insurance
Health care coverage for an individual with no covered dependents. Also knows as individual coverage.
in-network
Services provided by a physician or other health care provider with a contractual agreement with the insurance company and paid at a higher benefit level.
inpatient services
Services provided when a member is registered as a bed patient and is treated as such in a health care facility such as a hospital.
J
K
L
M
Medicaid
A joint federal and state funded program that provides health care coverage for low-income children and families, and for certain aged and disabled individuals.
medical group
A licensed health care facility, program, agency, doctor or health professional that contracts with a health plan to deliver health care services to plan members.
member
The person to whom health care coverage has been extended by the policyholder (generally their employer) or any of their covered family members. Sometimes referred to as the insured or insured person.
N
network
The group of doctors, hospitals and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.
non-contracting hospital
A hospital that has not contracted with a particular health care plan to provide hospital services to members in that plan.
O
out-of-network
Services provided by doctors and hospitals who have not contracted with your health plan.
out-of-pocket maximim
The maximum amount you have to pay for expenses covered under your health care plan, after any deductible is met, during a defined benefit period.
outpatient
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
P
Participating Provider Option (PPO)
A health care plan that supplies services at a higher level of benefits when members use contracted health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network, however the plan member generally shares a greater portion of the cost for such services.
pre-existing condition
A health condition for which an individual received medical care during a specified period of time immediately prior to the effective date of coverage.
pre-notification
The process by which a plan member or their doctor notifies the plan, before the member undergoes a course of care such as a hospital admission or a complex diagnostic test.
prescription drugs
Prescription drugs must be ordered by a doctor and obtained at a pharmacy. They are reviewed and approved through a formal process set by the U.S. Food and Drug Administration (FDA).
prescription drug list
A list of commonly prescribed drugs (also known as a drug formulary). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.
primary care physician (PCP)
The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all health plans require a PCP.
provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services.
Q
R
referral
As applicable to HMO or point of service (POS) coverage, a written authorization from a member's primary care physician (PCP) to receive care from a different contracted doctor, specialist or facility.
S
specialist
A health care professional whose practice is limited to a certain branch of medicine such as specific procedures, age categories of patients, specific body systems or certain types of diseases.
