The following glossary terms and definitions are commonly used in health insurance and may be different from the terms and definitions used in your own plan.
Maximum payment your plan will pay for covered medical service. It is also known as “eligible expense,” “payment allowance" or "negotiated rate."
A request for your health insurer or plan to review a decision denying you a benefit or payment (either in whole or in part)
Difference between your actual billed amount and the allowed amount. For example, if the allowed amount is $50 and your provider charges $200, you will be billed the remaining $150.
The amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the healthcare charge, you pay 20%.
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 you pay for a covered health care service after receiving the service.
A fixed amount of money you must pay each year to cover eligible medical expenses before your insurer starts paying.
Durable Medical Equipment (DME)
Equipment and supplies ordered by your health care provider for everyday/extended use and may include: oxygen equipment, wheelchairs, crutches or diabetic blood testing strips.
Emergency Medical Condition
An illness, injury, symptom (including severe pain), or condition that is severe enough to cause serious danger to your health if you didn’t get medical attention right away.
Emergency Medical Transportation
Ambulance services used for an emergency medical condition.
Emergency Room Care/Emergency Services
Services used to evaluate and treat an emergency medical condition to prevent it from getting worse.
Health care services that are not covered in your health insurance.
Complaints made to your health insurer or plan.
Health care services such as physical and occupational therapy, speech-language pathology etc that will help you learn, improve, or keep skills and functioning for your daily living. Examples include therapy for a child doesn’t walk or talk at the expected age.
An agreement that covers all your health care services after you pay a premium.
Home Health Care
Health care services you receive in your home.
Services that provide comfort and support in the last stages of a terminal illness for you or your family.
Hospital care that requires admission and an overnight stay as an inpatient.
Hospital Outpatient Care
Hospital care that usually doesn’t require an overnight stay.
Your share in percent, of the allowed amount for covered healthcare services and is also usually lower than in-network covered services.
A fixed amount (for example, $25) you pay for covered health care services to providers in contract with your health insurance or plan. It is usually less than out-of-network co-payments.
Health care services or supplies that meet accepted standards of medicine required to prevent, diagnose or treat an illness, injury, disease or its symptoms.
The facilities, providers and suppliers your health insurer contract with to provide you health care services at discounted rates.
A provider that is not part of a health plan's network of preferred providers. You will see in your policy all preferred, non-preferred as well as participating providers who have contracts with your health insurer.
Your share of the allowed amount for covered health care services delivered by out-of-network providers.
A fixed amount you pay for covered health care services from providers who have no contract with your health insurer.
The highest amount you pay during a year for coverage. It includes deductibles, copayments, and coinsurance in addition to your regular premiums. Beyond this amount, the insurer pays all covered expenses.
Health care services you receive from a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine)
A benefit your employer, union or other group sponsor provides to you to cover your health care services.
A request where you seek approval from your insurer before receiving certain drugs or services except in an emergency, also called prior authorization, or precertification.
A provider who has a contract with your health insurer to provide discounted services to you.
An amount you and/or your employer must pay monthly, quarterly or yearly for your insurance coverage.
Prescription Drug Coverage
Health insurance that helps you to pay for prescription drugs.
Your drugs and medications that require a prescription by law.
Primary Care Physician
A physician who directly provides your different basic medical services.
Primary Care Provider
Your main health care provider with due certification to serve as your health care home base
Any state certified or accredited physician or licensed health care facility that provides medical care
Surgery and follow-up treatment needed to correct or improve a part of your body due to birth defects, accidents, or medical conditions.
Health care services such as physical and occupational therapy, speech-language pathology etc that help you maintain, get back or improve skills and functioning for daily living which were lost or impaired when you were sick, hurt or disabled.
Skilled Nursing Care
Services performed or supervised by licensed nurses in your home or in a nursing home.
A provider who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
UCR (Usual, Customary and Reasonable)
The standard amount charged for covered medical services and supplies in your specific geographic area
Care you receive for an illness, injury or condition serious enough for you to seek care right away, but not so severe as to require emergency room care.