Medical and coverage definitions
This glossary has many commonly used terms, but isn’t a full list. These terms and definitions are intended to be educational. They 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. If so, the policy or plan is what you should go by. Check your Summary of Benefits and Coverage (SBC). It has information on how to get a copy of your policy or plan document.
- Allowed amount
The most that the plan will pay for a covered healthcare service. If your provider charges more than the allowed amount, you may have to pay the difference. (See balance billing.) It can also be called:
- Eligible expense
- Payment allowance
- Negotiated rate
- A request for your plan to review a decision or a grievance again.
- Balance billing
When a provider bills you for the difference between what they charge and the allowed amount. A preferred provider may not balance bill you for covered services.
- The provider charges $100.
- The allowed amount is $70.
- You may get a bill for the other $30.
Your part of the cost of a covered health care service. It’s calculated as a percent of the allowed amount for the service (for example, coinsurance can be 20%).
- The allowed amount for an office visit is $100.
- Your co-insurance is 20%. You would pay $20.
- Your 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.
- A fixed amount that you pay for a covered health care service (for example: $15). You usually pay this when you get 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 plan begins to pay.
- Your deductible is $1,000.
- Your plan won’t pay anything until you pay $1,000 for covered health care services that require a deductible.
- The deductible may not apply to all services.
- Durable medical equipment (DME)
Equipment that helps you with a health condition. For example, if you have problems breathing, you may get oxygen equipment. Your doctor orders these devices for you to use at home. It is used every day, or for a long period of time.
Examples of DME include:
- oxygen equipment
- blood testing strips for diabetics.
- Emergency medical condition
- An illness, injury, symptom or condition so serious that it requires 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.
- Excluded services
- Health care services that your plan doesn’t pay for or cover.
- 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 functions for daily living. For example, 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 to people in the last stages of a terminal illness and their families.
- Care in a hospital that requires admission as an inpatient. It 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 you pay of the allowed amount for covered health care services to providers who have a contact with your plan (for example, 20%). In-network co-insurance usually costs less than out-of-network co-insurance.
- In-network co-payment
- A fixed amount you pay for covered health care services to providers who have a contract with your plan (for example, $15). In-network co-payments are usually less than out-of-network co-payments. This is often called an “in-network copay.”
- Medically necessary
- Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms. They must also meet accepted standards of medicine.
- The facilities, providers and suppliers the plan has contracts with to provide your health care services.
- Non-preferred provider
A provider who doesn’t have a contract with the plan to provide your services. 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 you pay of the allowed amount for covered health care services to providers who don’t have a contract with the plan (for example, 40%). Out-of-network co-insurance usually costs more than in-network co-insurance.
- Out-of-network co-payment
- A fixed amount you pay for covered health care services from providers who don’t have a contract with your plan (for example, $30). Out-of-network co-payments are usually more than in-network co-payments. This is often called an “out-of-network copay.”
- 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.
Your out-of-pocket limit never includes your:
- balance-billed charges
- non-covered services
It may also not include all of your:
- co-insurance payments
- out-of-network payments or
- other expenses toward this limit
- Physician services
Health care services that are provided or coordinated by a licensed medical physician such as:
- M.D. – Doctors of Medicine
- D.O. – Doctors of Osteopathic Medicine
- A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
- Preferred provider
A provider who has a contract with your 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 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.
- Prescription drug coverage
- A plan that helps pay for prescription drugs and medications.
- Prescription drugs
- Drugs and medications that by law require a prescription.
- Primary care physician
A physician who directly provides or coordinates a range of health care services for a patient such as:
- M.D. — Doctors of Medicine or
- D.O. — Doctors of Osteopathic Medicine
- Primary care provider
A physician who provides, coordinates or helps a patient access a range of health care services such as:
- M.D. — Medical Doctor
- D.O. — Doctor of Osteopathic Medicine
- N.P. — Nurse practitioner
- C.N.S. — Clinical nurse specialist
- P.A. — Physician assistant
- Prior authorization
- A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or item of durable medical equipment is medically necessary. Sometimes called “preauthorization,” “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 physician, health care professional or health care facility that’s licensed, certified or accredited as required by state law.
- Reconstructive surgery
- Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
- Rehabilitation services
Health care services that help a person keep, get back or improve skills and functions for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include:
- physical and occupational therapy
- speech-language pathology
- psychiatric rehabilitation services
- Skilled care services
- Services from technicians and therapists in your own home or in a nursing home.
- Skilled nursing care
- Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
- A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
- UCR (Usual, Customary and Reasonable)
- The amount paid for a medical service in a geographic area. It’s based on what providers in the area usually charge for the same or similar medical services. The UCR amount is sometimes used to determine the allowed amount.
- Urgent care
- Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.