BenefitsAll

Health Insurance Terms

BenefitsAll

Everyone can understand health insurance and health care better.
dictionary page for word insurance

Health Insurance information is confusing, especially if you don't know the lingo. Traditional health insurance dictionaries work fine for employee benefit and other human resources professionals. Non-HR pros should not have to learn confusing health insurance terms, but do need to recognize them. Simplified health insurance dictionaries help workers better understand health insurance jargon.

Have a better definition for a commonly-used health insurance term? Send it to me, and if I agree, I’ll add it to the Simplified Dictionary of Health Insurance Terms.
Common Health Insurance Terms Defined:
A
  • Actively-at-work - Most group health insurance policies state that if an employee is not "actively-at-work" on the day the policy goes into effect, the coverage will not begin until the employee returns to work
  • Actual Charge - The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge
  • Allowable Charge - Also referred to as the Allowed Amount, Approved Charge or Maximum Allowable. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge. It may be helpful to consider an example: You have just visited your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company's network of providers, he or she may be required to accept $80 as payment in full for the visit—this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. If, however, the doctor you visit is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100. term may also be used within a Medicare context to refer to the amount that Medicare considers payment in full for a particular, approved medical service or supply
  • Ancillary Fee - An extra fee sometimes associated with obtaining prescription drugs that are not listed on a health insurance plan's formulary of covered medications
  • Ancillary Products - Additional health insurance products (such as vision or dental insurance) that may be added to a medical insurance plan for an additional fee
  • Ancillary Services - Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care
  • Approved Health Care Facility or Program - A medical facility or healthcare program (often organized through a hospital or clinic) that has been approved by a health insurance plan to provide specific services for specific conditions
  • Assignment of Benefits - The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan

B
  • Benefit - A general term referring to any service (such as an office visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by a health insurance plan in the normal course of a patient's healthcare
  • Benefit Level - The maximum amount a health insurance company agrees to pay for a specific covered benefit
  • Benefit Year - The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall
  • Brand-name drug - Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company that develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies

C
  • Carry-over Provision - A provision of some health insurance plans allowing medical expenses paid for by the member in the last three months of the year to be carried over and applied toward the next year's deductible
  • Case Management - When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient's healthcare providers to assist in the management of the patient's long-term needs, with appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member's health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible
  • Centers for Medicare and Medicaid Services - Part of the federal government's Department of Health and Human Services, and is responsible for the administration of the Medicare and Medicaid programs
  • Certificate of Coverage - A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company
  • Claim - A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider
  • Coinsurance - The amount that you are obliged to pay for covered medical services after you've satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance
  • Coordination of Benefits (COB) - This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy
  • Copayment - A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "co-pay." For example, your health insurance plan may require a $15 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges
  • Cost-sharing - Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance, and copayments. Balance-billed charges from out-of-network physicians are not considered cost-sharing.
  • Credit for prior coverage - Credit for coverage may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met while you were under an employer’s (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines

D
  • Date of Service - The date that a healthcare service was provided
  • Deductible - A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do
  • Denial of claim - The refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional
  • Dependent - A dependent is a person or persons relying on the policyholder for support; may include the spouse and/or children (whether natural, adopted or step) of an insured
  • Drug Formulary - A list of prescription medications selected for coverage under a health insurance plan. Drugs may be included on a drug formulary based upon their efficacy, safety and cost-effectiveness. Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered. Other health insurance plans may require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription
  • Drug Utilization Review (DUR) - The process by which health insurance companies evaluate or review the use of prescription drugs for appropriateness in the treatment of a patient
  • Durable Medical Equipment (DME) - Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc. Coverage levels for DME often differ from coverage levels for office visits and other medical services

E
  • Effective Date - The effective date is the date your insurance coverage starts
  • Eligible Dependent - A dependent (usually spouse or child) of an insured person who is eligible for insurance coverage
  • Eligible Employee - An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan
  • Eligible Expenses - Expenses defined by the health insurance plan as eligible for coverage/payment
  • Eligibility Date - The date on which a person becomes eligible for insurance benefits
  • Eligibility Requirements - Conditions that must be met in order for an individual or group to be considered eligible for insurance coverage
  • Emergency Condition - An emergency condition is any medical condition of recent onset and severity, including but not limited to severe pain, that would lead to a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organ or part
  • Enrollee - An eligible person or eligible employee who is enrolled in a health insurance plan. Dependents are not referred to as enrollees
  • Enrollment Period - The period of time during which an eligible employee or eligible person may sign up for a group health insurance plan
  • Explanation of Benefits (EOB) - A statement sent from the health insurance company to a member listing services that were billed by a healthcare provider, how those charges were processed, and the total amount of patient responsibility for the claim
  • Exclusions - Specific conditions, services or treatments for which a health insurance plan will not provide coverage
  • Exclusive Provider Organization (EPO) - As a member of an EPO plan, you can use any of the doctors and hospitals within the EPO network (typically without a referral), but cannot go outside of the network for care. There are no out-of-network benefits
  • Experimental or Investigational Procedures - Any healthcare services, supplies, procedures, therapies or devices the effectiveness of which a health insurance company considers unproven. These services are generally excluded from coverage

F
  • Fee-for-service - Also called Indemnity plans, typically allow you to direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Fee-for-service or Indemnity plans typically require that you fulfill an annual deductible. Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans

G
  • Gatekeeper - A term used to describe the role of the primary care physician in an HMO plan. In an HMO plan, a primary care physician serves as the patient's main point of contact for healthcare services and refer patients to specialists for specific needs
  • Generic Drug - A drug which is exactly the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug's patent has expired. Generic drugs are usually less expensive than brand name drugs
  • Grievance Procedure - The procedure by which a member or healthcare provider is allowed to file a complaint with a health insurance company and seek a remedy
  • Guaranteed issue - Refers to health insurance coverage that is guaranteed to be issued to applicants regardless of their health status, age, or income—and guarantees that the policy will be renewed as long as the policy holder continues to pay the policy premium

H
  • Health Maintenance Organization (HMO) - HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician ("PCP") who will provide most of your health care and refer you to HMO specialists as needed. Most HMO plans only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency
  • High Deductible Health Plan (HDHP) - A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower. The plan must have a certain deductible amount and limit the total amount of out-of-pocket cost-sharing for covered benefits (these amounts are adjusted annually)
  • Hospice Care - Care rendered either on an inpatient basis or in the home setting for a terminally ill patient. Often referred to as "palliative" or "supportive" care, hospice care emphasizes the management of pain and discomfort and the emotional support of the patient and family
  • Hospital Benefits - Benefits payable for hospital room and board and other miscellaneous charges resulting from hospitalization
  • Hospitalization - Include services related to staying at a hospital for scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child

I
  • In-network - Refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts
  • Inpatient - A term used to describe a person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours
  • Integrated Delivery System - A group of doctors, hospitals and other providers who work together to deliver a broad range of healthcare services

J

K

L
  • Lab/X-Ray - Typically, lab/x-ray is any diagnostic lab test or diagnostic/therapeutic x-ray performed in support of basic health services. Lab services typically include services like blood panels and urinalysis. X-ray services typically include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan. Prostate cancer screening, mammograms, and pap smears may be covered by Lab/X-Ray benefit, or they may be covered by Periodic OB-GYN benefit or Preventative Care benefits. Typically, dental x-rays are not included in Lab/X-ray benefits
  • Length of Stay (LOS) - It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility
  • Lifetime Maximum Benefit (or maximum lifetime benefit) - The maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime
  • Limitations - A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance
  • Long-Term Care (LTC) Policy - Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care
  • Long-Term Disability (LTD) Insurance - Pays an insured a percentage of their monthly earnings if they become disabled and unable to work

M
  • Major Medical Insurance - A type of medical insurance plan that provides benefits for a broad range of healthcare services, both inpatient and outpatient. Major medical insurance plans often carry a high deductible
  • Managed Care - A general term used to describe a variety of healthcare and health insurance systems that attempt to guide a member's use of benefits, typically by requiring that a member coordinate his or her healthcare through a primary care physician, or by encouraging the use of a specific network of healthcare providers. The management of healthcare is intended to keep costs and monthly premiums as low as possible. There are several different types of managed care health insurance plans, including HMO, PPO, and POS plans
  • Maternity Coverage - Maternity coverage means the insurance covers part or all of the medical cost during a woman's pregnancy. Coverage is broken down into inpatient and outpatient services. Typically, inpatient coverage includes hospitalization and physician fees associated with childbirth. Outpatient coverage pays for prenatal and postnatal OB-GYN office visits
  • Maximum Dollar Limit - The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year
  • Maximum Out-Of-Pocket Costs - An annual limitation on all cost-sharing for which patients are responsible under a health insurance plan. This limit does not apply to premiums, balance-billed charges from out of network health care providers or services that are not covered by the plan
  • Medicaid - A state-funded healthcare program for low income and disabled persons
  • Medical Necessity - A basic criterion used by health insurance companies to determine if healthcare services should be covered. A medical service is generally considered to meet the criteria of medical necessity when it is considered appropriate, consistent with general standards of medical care, consistent with a patient's diagnosis, and is the least expensive option available to provide a desired health outcome. Of course, preventive care services that may be covered under a health insurance plan are not always subject to the criteria of medical necessity
  • Medical Underwriting - Medical underwriting is a process used by insurance companies to evaluate whether to accept an applicant for health coverage and/or to determine the premium rate for the policy
  • Medicare - A national, federally-administered health insurance program that covers the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals
  • Medicare Supplement Insurance/Medigap Insurance Policies- Health insurance provided to an individual or group that is intended to help fill in the gaps in the coverage (e.g., coinsurance, deductibles, and some Medicare-excluded benefits) provided by Medicare
  • Member - Anyone covered under a health insurance plan, an enrollee or eligible dependent

N
  • Network - A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider

O
  • Office Visit (OV) - Typically, an office visit is an outpatient visit to a physician's office for illness or injury
  • Open-ended HMO - HMO plan that allows enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional’s services under a traditional indemnity plan
  • Open Enrollment Period - A time period during which eligible persons or eligible employees may opt to sign up for coverage under a group health insurance plan or change coverage. During an open enrollment period, applicants typically will not be required to provide evidence of insurability
  • Out-of-network - This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part
  • Out-of-pocket maximum - A predetermined limited amount of money that an individual must pay before an insurance company or (self-insured employer) will pay 100 percent of an individual’s health care expenses
  • Outpatient - An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed
  • Over-the-counter (OTC) Drugs - Drugs that may be obtained without a prescription

P
  • Partial Disability - A condition in which, as the result of an illness or injury, a group health insurance member cannot perform all the duties of his or her occupation, but can perform some
  • Participating Provider - Generally, this term is used in a sense synonymous with Network Provider. However, not all healthcare providers contract with health insurance companies at the same level. Some providers contracting with insurers at lower levels may sometimes be referred to as “participating providers" as opposed to "preferred providers"
  • Point of Service (POS) - Plan that combines elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, or may not be covered at all
  • Pre-existing condition - A pre-existing condition is a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company
  • Preadmission testing - Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility
  • Preauthorization/Precertification - These are terms that are often used interchangeably, they refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some surgeries or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient's doctor submit notes and/or lab results documenting the patient's condition and treatment history. The term "precertification" may also apply to the process by which a hospital notifies a health insurance company of a patient's inpatient admission. This may also be referred to as "pre-admission authorization." The individual often must obtain pre-admission certification. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are not medically necessary)
  • Preferred Provider Organization - Like the name implies, with a PPO plan you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out-of-network providers may not be covered or may be paid at a lower level
  • Premium (insurance premium) - the amount you must pay on a monthly or yearly basis for health insurance coverage
  • Primary care provider (PCP) - A health care professional, usually a physician, who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP refers the individual to more specialized physicians for specialist care

Q
  • Qualifying Event - An event (such as termination of employment, divorce or the death of the employee) that triggers a group health insurance member's protection under COBRA

R
  • Reasonable and customary fees - The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary
  • Referral - The process through which a patient under a managed care health insurance plan is authorized by his or her primary care physician to a see a specialist for the diagnosis or treatment of a specific condition
  • Rider - An amendment or modification to an insurance contract

S
  • Second Surgical Opinion - Some health insurance companies may require a second opinion from a qualified physician or specialist before extending coverage for certain surgical procedures
  • Secondary Coverage - When a person is covered under more than one health insurance plan, this term describes the health insurance plan that provides payment on claims after the primary coverage
  • Self-funded Health Insurance Plan - A health insurance plan that is funded by an employer rather than through a health insurance company. A health insurance company will typically handle the administration of such a plan, but the cost of claims will be paid for by the employer through a fund set up for this purpose
  • Short-term disability - An injury or illness that keeps a person from working for a short time. Short-term disability insurance coverage is partial or full income replacement when you are unable to work due to a non work-related injury or illness
  • Specialist - A doctor who does not serve as a primary care physician, but who provides secondary care, specializing in a specific medical field
  • Subrogation - The process by which a health insurance company determines whether medical bills should be paid for by the health insurance company itself or by another insurer or third party. For example, claims are frequently subject to subrogation when medical care is rendered as the result of an automobile accident. In most cases the automobile insurer is considered the primary payer. When a health insurance company has determined through the subrogation process that the automobile insurer will no longer pay on medical claims, then the health insurance company will typically become the primary payer

T
  • Temporary Partial Disability - This term is used to describe the condition of a person who due to injury is unable to work at full capacity but who is able to work at reduced efficiency and is expected to fully recover
  • Temporary Total Disability - This term describes the condition of a person who due to injury is unable to work, but who is expected to fully recover
  • Tertiary Care - This term is used to describe services rendered by such specialized providers as intensive care units, neurologists, neurosurgeons and thoracic surgeons. Such services frequently require highly sophisticated equipment and facilities

U
  • Utilization - This term refers to how frequently a group uses the benefits associated with a particular health insurance plan or healthcare program
  • Utilization Management/Review - This term is often used to describe a group (or the work performed by a group) of nurses and doctors who work with health insurance plans to determine if a patient's use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice. Utilization Management/Review may also be referred to as Medical Review

V
  • Vision Care Coverage - An insurance plan typically offered only on a group basis, which covers routine eye examinations and which may also cover all or part of the costs associated with contact lenses or eyeglasses, and frames

W
  • Waiting Period - A period of time (often 12 months) beginning with your effective date during which your health insurance plan does not provide benefits for pre-existing conditions. This period may be reduced or waived based on any prior health care coverage you had before applying for your new health insurance plan
  • Waiver (Exclusion Endorsement) - An agreement under which a member agrees to waive coverage for specific pre-existing conditions or for specific future conditions
  • Waiver of Premium - In some cases, a waiver of premium may be granted, allowing a member to maintain health insurance coverage in full force without payment. A waiver of premium is typically only granted in cases of permanent and total disability
  • Well-Baby/Well-Child Care - Regularly scheduled, preventive care services, including immunizations, provided to children up to an age specified by a health insurance company or mandated by a government agency. HMO and POS plans typically provide coverage for well-baby care, though coverage for these services may be limited under a PPO plan
  • Well-Woman Care - A term sometimes used by insurance companies and healthcare providers to refer to mammograms and pap smears and other preventive care services rendered to a woman

X

Y

Z
A

B
  • Benefit - Refers to health care services such as an office visit, laboratory test, surgical procedure, prescription drugs, medical equipment, etc. covered by a health insurance plan
  • Brand-name drug - Prescription drugs marketed with a specific brand name

C
  • Coinsurance - The amount you must pay for medical services (for example, 20% of the cost…)
  • Copayment - The amount you must pay for medical services (for example, $25 copay…)

D
  • Deductible - The amount you must pay for medical services each year before your health insurance plan pays for any care (for example, you may have to cover the first $5,000 of your medical care costs before your health insurance pays anything). If you do not receive any medical care in a given year, you do not have to pay a deductible
  • Dependent - Your spouse and/or children (natural, adopted or step)
  • Drug Formulary - A list of prescription medications covered by your health insurance plan
  • Durable Medical Equipment (DME) - Medical equipment such as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.

E
  • Effective Date - The day your health insurance starts. Insurance will not pay for care received before this date. If you receive your insurance ID before this date, you have to wait until this date before you can use your health insurance plan to cover the costs of care
  • Exclusions - Health care services not paid for by your health insurance plan

F

G
  • Generic Drug - A drug which is exactly the same as a brand name prescription drug but is less expensive than the brand name drug

H

I
  • In-network - Doctors, hospitals, pharmacists and other health care providers who have an agreement with your health insurance plan to provide medical care services, prescription drugs and medical equipment at discounted rates
  • Inpatient - Person (you or a dependent on your health plan) who has been admitted to a hospital for at least 24 hours

J

K

L
  • Lab/X-Ray - Lab services typically include blood panels and urinalysis. X-ray services typically include outpatient ultrasound, GI series, MRI, and CT scan. ALSO: Prostate cancer screening, mammograms, and pap smears may be covered by the Lab/X-Ray benefit

M
  • Maximum Out-Of-Pocket Costs - An annual dollar limit on what you have to pay for health care services. The limit does not apply to: (1) monthly premium you pay for health insurance; (2) charges for care received for services not covered by your plan; (3) charges from doctors and hospitals not in your health plan network
  • Medical Necessity - Not all medical care you receive will be paid for by your health insurance plan. Health insurance companies determine if medical care services should be covered (or are medically necessary)
  • Member - Your, your spouse and/or children

N
  • Network - A group of doctors, hospitals and other health care providers who have a current, signed agreement with your specific health insurance plan to provide their services for less than their usual fees

O
  • Out-of-network - Doctors, hospitals, pharmacists and other health care professionals who do not have an agreement with your particular health insurance plan to provide services at a discount. These individuals and facilities charge their usual fees. Your insurance plan may pay some or none of the costs for services performed by out-of-network doctors and hospitals. You may have to pay the full cost of care or the balance of what your insurance plan does not pay
  • Over-the-counter (OTC) Drugs - Drugs that you can get without a prescription

P
  • Preauthorization/Precertification - Your health plan may require that you obtain approval from the plan before having a particular medical procedure or receiving a particular prescription drug. This means that you have to call the number on your health insurance plan ID card (before you receive the services)… Your health plan booklet will include a list of the services that require preauthorization/precertification. Failure to get pre-approval for these services may delay care or you may have to pay the full cost of care
  • Premium (insurance premium) - amount you must pay every monthly (monthly bill) for health insurance even if you do not receive any medical care services

Q
  • Qualifying Event - An event such as termination of employment, having a baby, or getting a divorce that allows you to enroll or cancel health insurance coverage

R
  • Referral - Permission from a primary care doctor to see a specialist for additional care or diagnosis

S
  • Specialist - A doctor who specializes in a specific medical field such as gynecology, cardiology, pediatrics, psychiatry, oncology, orthopedic surgery, etc.

T

U

V

W

X

Y

Z