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 the same meaning when used in your policy or plan and, in any such case, the policy or plan it governs. See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan documents.
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.
A request for your health insurer or plan to review a decision or a grievance again.
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.
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 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 covered health care services 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 health care services. The deductible may not apply to all services.
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.
An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Ambulance service for an emergency medical condition.
Treatment you receive 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 or plan 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 premium.
Health care services a person receives at home.
Service to provide comfort and support for persons and their families in the last stages of a terminal illness.
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.
Treatment 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 or plan. 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 or plan. 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.
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.]
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 insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
The fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. 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 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.
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 and is 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.
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.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.
A health insurance benefit that helps pay for prescription drugs and medications.
A drug that by law requires a medical prescription.
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.
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 condition.
"Surprise billing" occurs when a person receives health care in a facility or from a provider that is covered by the person's health plan, but a portion of their care is rendered by an out-of-network provider. In some instances, the person receives an unexpected bill for these out-of-network services. For example, a person who undergoes surgery may receive a bill from an anesthesiologist who was out-of-network even though the surgeon and hospital were in-network with the person's health plan. These "surprise" bills are often for significant amounts of money that exceed charges that would be covered in-network and can cause confusion for patients who had assumed their health plan would cover their medical care at agreed to in-network rates. For more information regarding surprise billing, please visit:
