This glossary has 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. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. See the linked pages for plan documents specific to County-sponsored Health Plans.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
The annual anniversary of when your health insurance coverage became effective.
A request for your health insurer or plan to review a decision or a grievance again.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Benefit Period or Benefit Plan Year
This timeframe is often a calendar year for most health plans. It defines the time period when benefits for services are covered under your plan, regardless of when your coverage took effect. This period also applies to benefit maximums, deductibles, coinsurance limits and their accumulation. For example, your plan may cover 10 physical therapy sessions per benefit period, which is specified as January 1 through December 31 in your plan’s documents. So that means if you use more than 10 sessions within that time frame, the 11th session won’t be covered.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance 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 co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.Coinsurance Limit (or Maximum) - The most you’ll pay in coinsurance costs during a benefit period.
It is an injury, ailment, disease, illness or disorder.
The agreement between an insurance company and the policyholder. The contract usually includes the group and employee applications, policy certificates and any riders or addenda.
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 nonemergency caesarean section aren’t complications of pregnancy
Co-payment, Copayment or Copay
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.
These charges for covered services that have been billed under your health plan. Insurance companies have the right to limit covered charges from providers that are outside your plan’s network.
Any person covered under the plan.
A healthcare provider’s service or supply covered under your health plan. Benefits will be provided for these services, based on your plan’s specific coverage.
Coverage of an individual under any of the following:
- a group health plan, including church and governmental plans;
- health insurance coverage;
- Part A or Part B of Title XVIII of the Social Security Act (Medicare);
- Title XIX of the Social Security Act, other than coverage consisting solely of benefits under Section 1928 (Medicaid);
- the health plan for active military personnel, including TRICARE;
- the Indian Health Service or other tribal organization program;
- a state health benefits risk pool;
- the Federal Employees Health Benefits Program;
- a public health plan as defined in federal regulations;
- a health benefit plan under section 5 (c) of the Peace Corps Act;
- or any other plan which provides comprehensive hospital, medical and surgical services.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. 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. The deductible may not apply to all services.Dependent Coverage - Coverage for all eligible dependents.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Medical Condition
A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing an individual's health in serious jeopardy, or with respect to a pregnant woman, the health of the woman or her unborn child;
- Result in serious impairment to the individual's bodily functions; or
- Result in serious dysfunction of a bodily organ or part of the individual.
Emergency Medical Transportation
Ambulance services for an emergency medical condition
Emergency Room Care
Emergency services you get in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Health care services that your health insurance or plan doesn’t pay for or cover.
Experimental or Investigational Drug, Device, Medical Treatment or Procedure
A drug, device, medical treatment or procedure not approved by the U.S. Food and Drug Administration (FDA) or not considered to be the standard of care.
FSA (Flexible Spending Account)
Typically set up through an employer plan, an FSA allows you to set pre-tax dollars aside for common medical expenses and dependent care. FSA funds typically must be used by the end of the term-year or the funds will be lost. You should always check with the FSA administrator for a complete list of FSA-qualified expenses that can be purchased directly or reimbursed. A few common FSA-eligible expenses include:
- Copayments for doctors’ visits, as well as for chiropractor and psychological sessions
- Hospital fees, medical tests and services, such as X-rays and screenings
- Physical rehabilitation
- Dental and orthodontic expenses, such as cleaning, fillings and braces
- Inpatient treatment for alcohol or drug addiction
- Immunization and flu shots
A complaint that you communicate to your health insurer or plan.
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.
A health questionnaire that evaluates your health risks and quality of life.
HMO (Health Maintenance Organization)
Offers healthcare services exclusively with HMO providers. Under an HMO plan, you may be required to choose a primary care physician (PCP) who will be your main healthcare provider and recommend other HMO specialists when needed. Typically, services received from providers outside of the HMO plan are not covered unless for emergencies.
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and 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.
HRA (Health Reimbursement Account)
A tax-advantaged account that allows an employer to set aside funds to reimburse Covered Services paid for by participating employees.
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
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 co-payments usually are less than out-of-network co-payments.
A covered person under a health plan who receives care as a registered bed patient in a hospital or other facility where a room and board charge is made.
A hospital or certain other facility.
An individual who was appointed a guardian of a child in a legal proceeding by a court having the appropriate jurisdiction.
A type of health insurance that can be purchased to cover specific services covering a specific amount of time.
Professional services received from a healthcare provider or facility to treat a condition.
Medically Necessary (or Medical Necessity)
A service, supply and/or prescription drug that is required to diagnose or treat a condition and which is:
- appropriate with regard to the standards of good medical practice and not experimental or investigational;
- not primarily for your convenience or the convenience of a provider;
- and the most appropriate supply or level of service which can be safely provided to you. When applied to the care of an inpatient, this means that your medical symptoms or condition require that the services cannot be safely or adequately provided to you as an outpatient. When applied to prescription drugs, this may mean the prescription drug is cost effective compared to alternative prescription drugs which will produce comparable effective clinical results.
A federal program that pays for certain healthcare expenses for people age 65 or older or disabled.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Billed charges for services and supplies that are not covered under the health plan.
Non-Network Provider or Non-Preferred Provider
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. 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
Services provided in a facility, such as a doctor’s office, hospital or clinic that do not require confinement in a hospital.
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs more than in-network co-insurance.
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 co-payments usually are more than in-network co-payments.
Expenses for which you are responsible.
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. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Health care services a licensed medical physician (commonly a M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
PPO (Preferred Provider Organization)
A network of providers that, when utilized, allows you to get the greatest level of benefits available under a plan. Individuals may go to out-of-network providers, but should expect to pay higher out-of-pocket costs.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment 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.
A provider who has a contract with your health insurer or 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 health insurer or 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 (Federal Legend Drug)
Any medication that by federal or state law may not be dispensed without a prescription order.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider (healthcare provider)
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
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.
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 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.
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.