Glossary of Terms
A
Affordable-Care-Act (ACA)
Landmark health reform legislation passed in 2010. It was designed to increase the affordability of health insurance and lower the uninsured rate in the United States. Colloquially referred to as Obamacare.
Allowed Amount
The maximum amount that a carrier will consider to pay for a service, including any amount that the patient will be responsible for paying.
B
Balance Billing
When a provider bills you the difference between the provider's charge and the carrier's allowed amount.
C
Co-insurance
Your share of the costs of a covered service, calculated as a percentage of the allowable amount.
Co-payment (Co-Pay)
A set amount you pay for a covered healthcare service, usually at the same time you receive the service (e.g., A $15 co-pay for routine checkup.)
D
Deductible
The amount you owe for services before your plan begins to pay. Deductibles may not apply for all services.
Durable Medical Equipment (DME)
Equipment and/or supplies ordered by for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, and blood testing strips.
E
Emergency Medical Condition
An illness or injury so serious that one must seek care right away to avoid severe harm.
Exclusive Provider Organization (EPO)
A form of insurance where you can use the doctors and hospitals within a network but cannot go outside the network for care. There are no out-of-network benefits, except in cases considered an emergency.
Excluded Services
Healthcare services that your insurance doesn't cover.
G
Generic Drugs
A prescription drug with the same active ingredients as a brand-name drug. They typically cost less than brand-name drugs.
H
Habilitation Services
Health services that help one keep or improve skills and functioning for daily living. These include physical and occupational therapy, speech therapy, and treatments for a variety of other disabilities.
Health Maintenance Organization (HMO)
A form of insurance combining a range of coverage in a group basis. A group of doctors and other medical professionals offer care through the HMO for a monthly rate with no deductibles. Only visits to professionals within the HMO network are covered by the policy.
Hospice Services
Services to comfort and support individuals in the last stages of a terminal illness.
I
In-Network Co-Insurance
The percent you pay for covered health care services to providers who contract with your health insurance. In-network co-insurance typically costs less than out-of-network co-insurance.
In-Network Co-payment
A set amount that you pay for covered services to providers who contract with your health insurance. In-network co-payments typically cost less than out-of-network co-payments.
M
Medically Necessary
Health services or supplies needed to prevent or treat an injury, illness, or symptoms that meet accepted standards of medicine.
N
Network
The providers, suppliers, and facilities your insurance plan has contracted with to provide services.
Non-Preferred Provider
A provider without a contract with your insurance plan. You'll generally pay more to see a non-preferred provider.
O
Out-of-network Co-insurance
The percent you pay for covered health care services to providers who do not contract with your health insurance. In-network co-insurance typically costs more than out-of-network co-insurance.
Out-of-Pocket Limit
The most you'll pay before your insurance begins to pay 100% of the allowed amount. The limit never includes your premium or services that your plan doesn't cover.
P
Physician Services
Services provided by a licensed medical physical (M.D. or D.O.)
Plan
A benefit your employer or union provides to pay for your healthcare.
Preferred Provider Organization (PPO)
Plans that allow members to use any healthcare professional without a referral. Staying in-network means smaller copays and more coverage. If you go out-of-network, you'll have higher out-of-pocket costs, and not all services may be covered.
Preauthorization
A decision by your insurer that a service or drug is medically necessary. Your plan may require preauthorization for specific services before you receive them.
Premium
The amount that must be paid for your health insurance by you and your employer. Typically paid monthly.
Primary Care Physician
A physician (M.D or D.O.) who provides or coordinates a variety of healthcare services.
Provider
A physician (M.D. or D.O.), health care professional or facility that is licensed and certified as required by state law.
R
Reconstructive Surgery
Surgery and treatment needed to correct a part of the body due to birth defects, accidents, or medical conditions.
Rehabilitation Services
Services that help a person keep or reclaim skills and functioning for daily living lost due to an illness or injury. Examples include occupational therapy, speech therapy, and select psychiatric services.
S
Skilled Nursing Care
Services for licensed nurses in a nursing home or your own home.
Specialist
A physician that focuses on a specific area medicine or group of patients to diagnose, prevent, or treat certain conditions.
Summary of Benefits and Coverage (SBC)
A straightforward summary that allows you to compare costs and coverage between different health plans.
U
Usual, Customary and Reasonable (UCR)
The amount paid for a service in a geographic area based on what local providers typically charge.
Urgent Care
Care for a condition or injury serious enough that one would seek care right away, but not one severe enough to require emergency room care.
W
Waiting Period
The time that must pass before coverage becomes effective for an employee and his or her dependents.
Wellness Program
A program offered by an employer or insurance carrier to incentivize employee health and fitness through discounted gym memberships, gift certificates for preventive care, and more.
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