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GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS

EmailPrint
 * This glossary defines 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 or health insurance
   policy. Some of these terms also might not have exactly the same meaning when
   used in your policy or plan, and in any case, the policy or plan governs.
   (See your Summary of Benefits and Coverage for information on how to get a
   copy of your policy or plan document.)
 * See an illustration showing how deductibles, coinsurance and out-of-pocket
   limits work together in a real life situation.
 * Download the complete glossary (PDF).


ALLOWED AMOUNT

This is the maximum payment the plan will pay for a covered health care service.
May also be called "eligible expense", "payment allowance", or "negotiated
rate."


APPEAL

A request that your health insurer or plan review a decision that denies a
benefit or payment (either in whole or in part).


BALANCE BILLING

When a provider bills you for the balance remaining on the bill that your plan
doesn't cover. This amount is the difference between the actual billed amount
and the allowed amount. For example, if the provider’s charge is $200 and the
allowed amount is $110, the provider may bill you for the remaining $90. This
happens most often when you see an out-of-network provider (non-preferred
provider). A network provider (preferred provider) may not bill you for covered
services.


CLAIM

A request for a benefit (including reimbursement of a health care expense) made
by you or your health care provider to your health insurer or plan for items or
services you think are covered.


COINSURANCE

Your share of the costs of a covered health care service, calculated as a
percentage (for example, 20%) of the allowed amount for the service. You
generally pay coinsurance 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 coinsurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.) See a detailed example.




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 generally aren’t complications of
pregnancy.


COPAYMENT

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.


COST SHARING

Your share of costs for services that a plan covers that you must pay out of
your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost
sharing are copayments, deductibles, and coinsurance. Family cost sharing is the
share of cost for deductibles and out-of-pocket costs you and your spouse and/or
child(ren) must pay out of your own pocket. Other costs, including your
premiums, penalties you may have to pay, or the cost of care a plan doesn’t
cover usually aren't considered cost sharing.


COST-SHARING REDUCTIONS

Discounts that reduce the amount you pay for certain services covered by an
individual plan you buy through the Marketplace. You may get a discount if your
income is below a certain level, and you choose a Silver level health plan or if
you're a member of a federally recognized tribe, which includes being a
shareholder in an Alaska Native Claims Settlement Act corporation.


DEDUCTIBLE

An amount you could owe during a coverage period (usually one year) for covered
health care services before your plan begins to pay. An overall deductible
applies to all or almost all covered items and services. A plan with an overall
deductible may also have separate deductibles that apply to specific services or
groups of services. A plan may also have only separate deductibles. (For
example, if your deductible is $1000, your plan won’t pay anything until you’ve
met your $1000 deductible for covered health care services subject to the
deductible.) See a detailed example.




DIAGNOSTIC TEST

Tests to figure out what your health problem is. For example, an x-ray can be a
diagnostic test to see if you have a broken bone.


DURABLE MEDICAL EQUIPMENT (DME)

Equipment and supplies ordered by a health care provider for everyday or
extended use. DME may include: oxygen equipment, wheelchairs, and crutches.


EMERGENCY MEDICAL CONDITION

An illness, injury, symptom (including severe pain), or condition severe enough
to risk serious danger to your health if you didn’t get medical attention right
away. If you didn’t get immediate medical attention you could reasonably expect
one of the following: 1) Your health would be put in serious danger; or 2) You
would have serious problems with your bodily functions; or 3) You would have
serious damage to any part or organ of your body.


EMERGENCY MEDICAL TRANSPORTATION

Ambulance services for an emergency medical condition. Types of emergency
medical transportation may include transportation by air, land, or sea. Your
plan may not cover all types of emergency medical transportation, or may pay
less for certain types.


EMERGENCY ROOM CARE / EMERGENCY SERVICES

Services to check for an emergency medical condition and treat you to keep an
emergency medical condition from getting worse. These services may be provided
in a licensed hospital’s emergency room or other place that provides care for
emergency medical conditions.


EXCLUDED SERVICES

Health care services that your plan doesn’t pay for or cover.


FORMULARY

A list of drugs your plan covers. A formulary may include how much your share of
the cost is for each drug. Your plan may put drugs in different cost sharing
levels or tiers. For example, a formulary may include generic drug and brand
name drug tiers and different cost sharing amounts will apply to each tier.


GRIEVANCE

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
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.


HEALTH INSURANCE

A contract that requires a health insurer to pay some or all of your health care
costs in exchange for a premium. A health insurance contract may also be called
a “policy” or “plan”.


HOME HEALTH CARE

Health care services and supplies you get in your home under your doctor’s
orders. Services may be provided by nurses, therapists, social workers, or other
licensed health care providers. Home health care usually doesn't include help
with non-medical tasks, such as cooking, cleaning, or driving.


HOSPICE SERVICES

Services to provide comfort and support for persons in the last stages of a
terminal illness and their families.


HOSPITALIZATION

Care in a hospital that requires admission as an inpatient and usually requires
an overnight stay. Some plans may consider an overnight stay for observation as
outpatient care instead of inpatient care.


HOSPITAL OUTPATIENT CARE

Care in a hospital that usually doesn’t require an overnight stay.


INDIVIDUAL RESPONSIBILITY REQUIREMENT

Sometimes called the “individual mandate,” the duty you may have to be enrolled
in health coverage that provides minimum essential coverage. If you don’t have
minimum essential coverage, you may have to pay a penalty when you file your
federal income tax return unless you qualify for a health coverage exemption.


IN-NETWORK COINSURANCE

Your share (for example, 20%) of the allowed amount for covered health care
services. Your share is usually lower for in-network covered services.


IN-NETWORK COPAYMENT

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 copayments
usually are less than out-of-network copayments.


MARKETPLACE

A marketplace for health insurance where individuals, families and small
businesses can learn about their plan options; compare plans based on costs,
benefits and other important features; apply for and receive financial help with
premiums and cost sharing based on income; and choose a plan and enroll in
coverage. Also known as an "Exchange". The Marketplace is run by the state in
some states and by the federal government in others. In some states, the
Marketplace also helps eligible consumers enroll in other programs, including
Medicaid and the Children’s Health Insurance Program (CHIP). Available online,
by phone, and in-person.


MAXIMUM OUT-OF-POCKET LIMIT

Yearly amount the federal government sets as the most each individual or family
can be required to pay in cost sharing during the plan year for covered,
in-network services. Applies to most types of health plans and insurance. This
amount may be higher than the out-of-pocket limits stated for your plan.


MEDICALLY NECESSARY

Health care services or supplies needed to prevent, diagnose, or treat an
illness, injury, condition, disease, or its symptoms, inlcuding habilitation,
and that meet accepted standards of medicine.


MINIMUM ESSENTIAL COVERAGE

Health coverage that will meet the individual responsibility requirement.
Minimum essential coverage generally includes plans, health insurance available
through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage.


MINIMUM VALUE STANDARD

A basic standard to measure the percent of permitted costs the plan covers. If
you’re offered an employer plan that pays for at least 60% of the total allowed
costs of benefits, the plan offers minimum value and you may not qualify for
premium tax credits and cost sharing reductions to buy a plan from the
Marketplace.


NETWORK

The facilities, providers and suppliers your health insurer or plan has
contracted with to provide health care services.


NETWORK PROVIDER (PREFERRED PROVIDER)

A provider who has a contract with your health insurer or plan who has agreed to
provide services to members of a plan. You will pay less if you see a provider
in the network. Also called “preferred provider” or “participating provider.”


ORTHOTICS AND PROSTHETICS

Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external
breast prostheses after a mastectomy. These services include: adjustment,
repairs, and replacements required because of breakage, wear, loss, or a change
in the patient’s physical condition.


OUT-OF-NETWORK COINSURANCE

Your share (for example, 40%) of the allowed amount for covered health care
services to providers who don't contract with your health insurance or plan.
Out-of-network coinsurance usually costs you more than in-network coinsurance.


OUT-OF-NETWORK COPAYMENT

A 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
copayments usually are more than in-network copayments.


OUT-OF-NETWORK PROVIDER (NON-PREFERRED PROVIDER)

A provider who doesn’t have a contract with your plan to provide services. If
your plan covers out-of-network services, you’ll usually pay more to see an
out-of-network provider than a preferred provider. Your policy will explain what
those costs may be. May also be called “non-preferred” or “non-particiapting”
instead of “out-of-network provider”.


OUT-OF-POCKET LIMIT

The most you could pay during a coverage period (usually one year) for your
share of the costs of covered services. After you meet this limit the plan will
usually pay 100% of the allowed amount. This limit helps you plan for health
care costs. This limit never includes your premium, balance-billed charges or
health care your plan doesn’t cover. Some plans don’t count all of your
copayments, deductibles, coinsurance payments, out-of-network payments, or other
expenses toward this limit. See a detailed example.




PHYSICIAN SERVICES

Health care services a licensed medical physician, including an M.D. (Medical
Doctor) or D.O. (Doctor of Osteopathic Medicine), provides or coordinates.


PLAN

Health coverage issued to you directly (individual plan) or through an employer,
union or other group sponsor (employer group plan) that provides coverage for
certain health care costs. Also called "health insurance plan", "policy",
"health insurance policy" or "health insurance".


PREAUTHORIZATION

A decision by your health insurer or plan that a health care service, treatment
plan, prescription drug or durable medical equipment (DME) is medically
necessary. 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.


PREMIUM

The amount that must be paid for your health insurance or plan. You and/or your
employer usually pay it monthly, quarterly, or yearly.


PREMIUM TAX CREDITS

Financial help that lowers your taxes to help you and your family pay for
private health insurance. You can get this help if you get health insurance
through the Marketplace and your income is below a certain level. Advance
payments of the tax credit can be used right away to lower your monthly premium
costs.


PRESCRIPTION DRUG COVERAGE

Coverage under a plan that helps pay for prescription drugs. If the plan’s
formulary uses “tiers” (levels), prescription drugs are grouped together by type
or cost. The amount you'll pay in cost sharing will be different for each "tier"
of covered prescription drugs.


PRESCRIPTION DRUGS

Drugs and medications that by law require a prescription.


PREVENTIVE CARE (PREVENTIVE SERVICE)

Routine health care, including screenings, check-ups, and patient counseling, to
prevent or discover illness, disease, or other health problems.


PRIMARY CARE PHYSICIAN

A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic
Medicine), who provides or coordinates a range of health care services for you.


PRIMARY CARE PROVIDER

A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic
Medicine), nurse practitioner, clinical nurse specialist, or physician
assistant, as allowed under state law and the terms of the plan, who provides,
coordinates, or helps you access a range of health care services.


PROVIDER

An individual or facility that provides health care services. Some examples of a
provider include a doctor, nurse, chiropractor, physician assistant, hospital,
surgical center, skilled nursing facility, and rehabilitation center. The plan
may require the provider to be 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.


REFERRAL

A written order from your primary care provider for you to see a specialist or
get certain health care services. In many health maintenance organizations
(HMOs), you need to get a referral before you can get health care services from
anyone except your primary care provider. If you don’t get a referral first, the
plan may not pay for the services.


REHABILITATION SERVICES

Health care services that help a person keep, get back, or improve skills and
functioning 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, and psychiatric rehabilitation
services in a variety of inpatient and/or outpatient settings.


SCREENING

A type of preventive care that includes tests or exams to detect the presence of
something, usually performed when you have no symptoms, signs, or prevailing
medical history of a disease or condition.


SKILLED NURSING CARE

Services performed or supervised by licensed nurses in your home or in a nursing
home. Skilled nursing care is not the same as “skilled care services”, which are
services performed by therapists or technicians (rather than licensed nurses) in
your home or in a nursing home.


SPECIALIST

A provider focusing on a specific area of medicine or a group of patients to
diagnose, manage, prevent, or treat certain types of symptoms and conditions.


SPECIALTY DRUG

A type of prescription drug that, in general, requires special handling or
ongoing monitoring and assessment by a health care professional, or is
relatively difficult to dispense. Generally, specialty drugs are the most
expensive drugs on a formulary.


UCR (USUAL, CUSTOMARY AND REASONABLE)

The amount paid for a medical service in a geographic area based on what
providers in the area usually charge for the same or similar medical service.
The UCR amount sometimes is 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.


HOW YOU AND YOUR INSURER SHARE COSTS - EXAMPLE




JANE’S PLAN DEDUCTIBLE: $1,500


 * Jane hasn’t reached her $1,500 deductible yet
 * Her plan doesn’t pay any of the costs.
 * Office visit costs: $125
 * Jane pays: $125
 * Her plan pays: $0


COINSURANCE: 20%


 * Jane reaches her $1,500 deductible, coinsurance begins
 * Jane has seen a doctor several times and paid $1,500 in total, reaching her
   deductible. So her plan pays some of the costs for her next visit.
 * Office visit costs: $125
 * Jane pays: 20% of $125 = $25
 * Her plan pays: 80% of $125 = $100


OUT-OF-POCKET LIMIT: $5,000


 * Jane reaches her $5,000 out-of-pocket limit
 * Jane has seen the doctor often and paid $5,000 in total. Her plan pays the
   full cost of her covered health care services for the rest of the year.
 * Office visit costs: $125
 * Jane pays: $0
 * Her plan pays: $125

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