Glossary of Terms
A
allowable amount
The maximum amount a health care benefits plan will reimburse a doctor or hospital for a covered service.
annual deductible
The amount you are required to pay annually before reimbursement by your health care benefits plan begins.
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 is met.
B
C
claim
An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.
claim form
A form you or your doctor fill out and submit to your health care benefits plan for payment.
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 and 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 group 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.
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
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)
The form sent to you after a claim has been processed by your health care plan. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, reasons for denying payment and the claims appeal process.
exclusions
Specific medical conditions or services that are not covered under a health care plan.
F
family coverage
Health care coverage for a member and his or her 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.
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 which outlines certain 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; most recently amended to add privacy rules which became effective April 14, 2003.
I
individual health insurance
Health care coverage for an individual with no covered dependents.
individual lifetime maximum
The maximum amount of benefits your policy will pay over the course of your lifetime.
in-network
Services provided or coordinated by your primary care physician (PCP) 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
maximum annual benefit
The maximum dollar amount your health care plan will pay for health care services provided to you during one year.
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.
Medicare
The federal program established to provide health care coverage for eligible beneficiaries.
Medicare Part A
The federal program established to provide health care coverage for eligible beneficiaries. Medicare Part A provides basic hospital insurance coverage automatically for most eligible persons.
Medicare Part B
The federal program established to provide health care coverage for eligible beneficiaries. Medicare Part B provides benefits to cover the costs of doctors' services.
Medicare Part C
The federal program established to provide health care coverage for eligible beneficiaries. Medicare Part C (also known as Medicare+Choice) expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries.
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 maximum
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 services
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
Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.
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, including specific procedures, age categories of patients, specific body systems or certain types of diseases.
Stop-loss Limit
A specified dollar amount of covered services which are reimbursed at less than 100 percent of the allowable charge to or on behalf of a subscriber during a benefit period. When the stop-loss limit is reached, the level of benefits is increased as state in the member’s contract.
