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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 page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation.
Allowed Amount
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.)
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 maynot balance bill you for covered
services.
Co-insurance
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 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 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.
Co-payment
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.
Deductible
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.
Emergency Services
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
(See page 4 for a detailed example.)
Jane pays 100%
Her plan pays 0%
(See page 4 for a detailed example.)
Jane pays 20%
Her plan pays 80%
OMB Control Numbers 1545- 2229 , 1210- 0147 , and 0938- 1146
Excluded Services
Health care services that your health insurance or plan doesn’t pay for or cover.
Grievance
A complaint that you communicate to your health insurer or plan.
Habilitation Services
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.
Health Insurance
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.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
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.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
In-network Co-insurance
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
In-network Co-payment
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Medically Necessary
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.
Network
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care 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.
Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who
donot contract with your health insurance or plan. Out-
of-network co-insurance usually costs you more than in- network co-insurance.
Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered
health care services from providers who donot contract
with your health insurance or plan. Out-of-network co- payments usually are more than in-network co-payments.
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% 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.
Physician Services
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
(See page 4 for a detailed example.)
Jane pays 0%
Her plan pays 100%
How You and Your Insurer Share Costs - Example
Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,
Jane reaches her $1, deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $ Jane pays: 20% of $75 = $ Her plan pays: 80% of $75 = $
Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs. Office visit costs: $ Jane pays: $ Her plan pays: $
January 1st Beginning of Coverage Period
December 31st End of Coverage Period
more costs
more costs
Jane reaches her $5, out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $ Jane pays: $ Her plan pays: $
Jane pays
Her plan pays
Jane pays
Her plan pays
Jane pays
Her plan pays
