Glossary of Terms
A
allowable amount
The maximum amount determined by the healthplan to be eligible for consideration of payment for a particular service, supply or procedure.
allowable charge
The maximum amount a healthplan will reimburse a doctor or hospital for a given service.
annual deductible
The amount of eligible expenses you are required to pay annually before reimbursement by your healthplan begins.
annual out-of-pocket
The maximum amount, per year, you are required to pay out of your own pocket for covered health care services.
B
C
claim form
A form generally filled out by a provider and submitted to your healthplan for consideration of payment of benefits under that healthplan.
claim
An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.
COBRA
A federal act that requires group healthplans to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee and termination of employment.
coinsurance
A percentage of an eligible expense that you are required to pay for a service covered by your healthplan.
Coordination of Benefits (COB)
An arrangement where, if you or your dependents are covered under more than one group healthplan, the plans work together to coordinate reimbursement for the medical services you received.
copayment
A fixed dollar amount you are required to pay for a covered service at the time you receive care.
covered person
The person in whose name a health care policy is issued and, in the case of family coverage, the member's/subscriber's dependents.
covered service
A service that is covered according to the terms in your health care policy.
D
deductible
A fixed amount of the eligible expenses you are required to pay before reimbursement by your healthplan begins.
dependent
A person, other than the member/subscriber (generally a spouse or child), who receives health care coverage under the member's/subscriber's policy.
domestic partner
A person with whom the member/subscriber has entered into a long-term, committed relationship. The relationship must meet the health care plan's specific criteria for a domestic partner.
drug formulary
A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.
E
effective date
The date on which your health care coverage begins.
emergency medical care
Services provided for the initial outpatient treatment of an acute medical condition, usually in a hospital setting. Most healthplans have specific guidelines to define emergency medical care.
Explanation of Benefits (EOB)
The form sent to you after a claim has been processed by your healthplan. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, reasons for denying payment and the claims appeal process.
exclusions
Specific medical conditions or circumstances that are not covered under a health plan.
F
family coverage
Health care coverage for a member/subscriber and his/her eligible dependents.
G
generic substitute
A prescription drug that is the generic equivalent of a drug listed on your health plan's formulary.
group
A group of people covered under the same health care policy and identified by their relation to the same employer.
H
Health Maintenance Organization (HMO)
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers.
HIPAA
A federal law which outlines certain rules and requirements employer-sponsored group healthplans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups; most recently amended to add privacy rules which became effective April 14, 2003.
I
individual coverage
Health care coverage for a member, but not the member's spouse and/or dependents.
in-network
Covered services provided or ordered by your primary care physician (PCP) or another network provider referred by your PCP.
inpatient services
Services provided when a member/subscriber is registered and treated as a bed patient in a health care facility such as a hospital.
insured person
The person to whom health care coverage has been extended by the contract holder, sometimes referred to as a member/subscriber.
J
K
L
M
maximum allowance
A fixed amount that providers agree to accept as payment in full for a particular covered service.
maximum annual benefit
The maximum dollar amount your healthplan will pay for a particular health care service or for all health care services provided to you during one year.
Medicaid
A joint federal and state funded program that provides health care coverage for low-income children and families, and for certain aged and disabled individuals.
medical group
A licensed group of doctors or health care providers that contract with a health plan to deliver health care services to plan members/subscribers.
Medicare
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65.
Medicare Part A
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part A provides basic hospital insurance coverage automatically for most eligible persons.
Medicare Part B
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part B provides benefits to help cover the costs of doctors' services.
Medicare Part C
The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part C (also known as Medicare+Choice) expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries.
member
The person to whom health care coverage has been extended by the contract holder (generally their employer); sometimes referred to as the insured or insured person; generally used in the health maintenance organization (HMO) context.
N
network
The doctors, hospitals and other health care providers that a health plan has contracted with to deliver health care services to its members/subscribers.
O
out-of-network
Services not provided, ordered or referred by your primary care physician (PCP).
out-of-pocket maximum
The maximum amount you have to pay for eligible expenses under your health plan during a defined benefit period.
outpatient services
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
P
preauthorization
The process by which a member/subscriber or their primary care physician (PCP) notifies the healthplan, in advance, of plans for the member/subscriber to undergo a course of care such as a hospital admission or a complex diagnostic test.
Preferred Provider Organization (PPO)
A healthplan that provides covered services at a discounted cost for subscribers who use network health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network; the subscriber generally pays a greater portion of the cost for such services.
preferred drug list
A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a healthplan's prescription drug list are automatically covered under that plan.
prescription drugs
Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.
primary care physician (PCP)
The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all healthplans require a PCP.
provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services.
