CALPACT Training: Glossary of Health Coverage and Medical Terms


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This training resource is part of the "Health Communication Matters! The Ongoing Challenge to Implement the Affordable Care Act" webinar sponsored by the California Pacific Public Health Training Center (CALPACT) at UC Berkeley's School of Public Health.

The most sweeping health policy change in decades – the Affordable Care Act, has created a myriad of challenges in how to convey a complex subject to the public, the media, policymakers, and other professionals. Experts in ACA-related health literacy and health insurance literacy initiatives walked participants through ongoing areas of challenge after the passage of the ACA and health communication principles to deliver understandable and compelling content to diverse audiences.

To learn more, please visit the archived recording at:

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CALPACT Training: Glossary of Health Coverage and Medical Terms

  1. 1. Glossary of Health Coverage and Medical Terms 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 your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation.Allowed Amount Co-paymentMaximum amount on which payment is based for A fixed amount (for example, $15) you pay for a coveredcovered health care services. This may be called “eligible health care service, usually when you receive the service.expense,” “payment allowance" or "negotiated rate." If The amount can vary by the type of covered health careyour provider charges more than the allowed amount, you service.may have to pay the difference. (See Balance Billing.) DeductibleAppeal The amount you owe forA request for your health insurer or plan to review a health care services yourdecision or a grievance again. health insurance or plan covers before your healthBalance Billing insurance or plan begins Jane pays Her plan paysWhen a provider bills you for the difference between the to pay. For example, if 100% 0%provider’s charge and the allowed amount. For example, your deductible is $1000,if the provider’s charge is $100 and the allowed amount your plan won’t pay (See page 4 for a detailed example.)is $70, the provider may bill you for the remaining $30. anything until you’ve metA preferred provider may not balance bill you for covered your $1000 deductible for covered health care servicesservices. subject to the deductible. The deductible may not apply to all services.Co-insuranceYour share of the costs Durable Medical Equipment (DME)of a covered health care Equipment and supplies ordered by a health care providerservice, calculated as a for everyday or extended use. Coverage for DME maypercent (for example, include: oxygen equipment, wheelchairs, crutches or20%) of the allowed blood testing strips for diabetics.amount for the service. Jane pays Her plan paysYou pay co-insurance 20% 80% Emergency Medical Conditionplus any deductibles (See page 4 for a detailed example.) An illness, injury, symptom or condition so serious that ayou owe. For example, reasonable person would seek care right away to avoidif the health insurance or plan’s allowed amount for an severe visit is $100 and you’ve met your deductible, yourco-insurance payment of 20% would be $20. The health Emergency Medical Transportationinsurance or plan pays the rest of the allowed amount. Ambulance services for an emergency medical condition.Complications of Pregnancy Emergency Room CareConditions due to pregnancy, labor and delivery that Emergency services you get in an emergency room.require medical care to prevent serious harm to the healthof the mother or the fetus. Morning sickness and a non- Emergency Servicesemergency caesarean section aren’t complications of Evaluation of an emergency medical condition andpregnancy. treatment to keep the condition from getting worse. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146Glossary of Health Coverage and Medical Terms Page 1 of 4
  2. 2. Excluded Services Medically NecessaryHealth care services that your health insurance or plan Health care services or supplies needed to prevent,doesn’t pay for or cover. diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards ofGrievance medicine.A complaint that you communicate to your health insureror plan. Network The facilities, providers and suppliers your health insurerHabilitation Services or plan has contracted with to provide health careHealth care services that help a person keep, learn or services.improve skills and functioning for daily living. Examplesinclude therapy for a child who isn’t walking or talking at Non-Preferred Providerthe expected age. These services may include physical and A provider who doesn’t have a contract with your healthoccupational therapy, speech-language pathology and insurer or plan to provide services to you. You’ll payother services for people with disabilities in a variety of more to see a non-preferred provider. Check your policyinpatient and or outpatient settings. to see if you can go to all providers who have contracted with your health insurance or plan, or if your healthHealth Insurance insurance or plan has a “tiered” network and you mustA contract that requires your health insurer to pay some pay extra to see some providers.or all of your health care costs in exchange for apremium. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowedHome Health Care amount for covered health care services to providers whoHealth care services a person receives at home. do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in-Hospice Services network co-insurance.Services to provide comfort and support for persons inthe last stages of a terminal illness and their families. Out-of-network Co-payment A fixed amount (for example, $30) you pay for coveredHospitalization health care services from providers who do not contractCare in a hospital that requires admission as an inpatient with your health insurance or plan. Out-of-network co-and usually requires an overnight stay. An overnight stay payments usually are more than in-network co-payments.for observation could be outpatient care. Out-of-Pocket LimitHospital Outpatient Care The most you pay during aCare in a hospital that usually doesn’t require an policy period (usually aovernight stay. year) before your health insurance or plan begins toIn-network Co-insurance pay 100% of the allowedThe percent (for example, 20%) you pay of the allowed amount. This limit never Jane pays Her plan paysamount for covered health care services to providers who includes your premium, 0% 100%contract with your health insurance or plan. In-network balance-billed charges or (See page 4 for a detailed example.)co-insurance usually costs you less than out-of-network health care your healthco-insurance. insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles,In-network Co-payment co-insurance payments, out-of-network payments orA fixed amount (for example, $15) you pay for covered other expenses toward this care services to providers who contract with yourhealth insurance or plan. In-network co-payments usually Physician Servicesare less than out-of-network co-payments. Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.Glossary of Health Coverage and Medical Terms Page 2 of 4
  3. 3. Plan ProviderA benefit your employer, union or other group sponsor A physician (M.D. – Medical Doctor or D.O. – Doctorprovides to you to pay for your health care services. of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited asPreauthorization required by state law.A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable Reconstructive Surgerymedical equipment is medically necessary. Sometimes Surgery and follow-up treatment needed to correct orcalled prior authorization, prior approval or improve a part of the body because of birth defects,precertification. Your health insurance or plan may accidents, injuries or medical conditions.require preauthorization for certain services before youreceive them, except in an emergency. Preauthorization Rehabilitation Servicesisn’t a promise your health insurance or plan will cover Health care services that help a person keep, get back orthe cost. improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt orPreferred Provider disabled. These services may include physical andA provider who has a contract with your health insurer or occupational therapy, speech-language pathology andplan to provide services to you at a discount. Check your psychiatric rehabilitation services in a variety of inpatientpolicy to see if you can see all preferred providers or if and or outpatient settings.your health insurance or plan has a “tiered” network andyou must pay extra to see some providers. Your health Skilled Nursing Careinsurance or plan may have preferred providers who are Services from licensed nurses in your own home or in aalso “participating” providers. Participating providers nursing home. Skilled care services are from techniciansalso contract with your health insurer or plan, but the and therapists in your own home or in a nursing may not be as great, and you may have to paymore. Specialist A physician specialist focuses on a specific area ofPremium medicine or a group of patients to diagnose, manage,The amount that must be paid for your health insurance prevent or treat certain types of symptoms andor plan. You and or your employer usually pay it conditions. A non-physician specialist is a provider whomonthly, quarterly or yearly. has more training in a specific area of health care.Prescription Drug Coverage UCR (Usual, Customary and Reasonable)Health insurance or plan that helps pay for prescription The amount paid for a medical service in a geographicdrugs and medications. area based on what providers in the area usually charge for the same or similar medical service. The UCRPrescription Drugs amount sometimes is used to determine the allowedDrugs and medications that by law require a prescription. amount.Primary Care Physician Urgent CareA physician (M.D. – Medical Doctor or D.O. – Doctor Care for an illness, injury or condition serious enoughof Osteopathic Medicine) who directly provides or that a reasonable person would seek care right away, butcoordinates a range of health care services for a patient. not so severe as to require emergency room care.Primary Care ProviderA physician (M.D. – Medical Doctor or D.O. – Doctorof Osteopathic Medicine), nurse practitioner, clinicalnurse specialist or physician assistant, as allowed understate law, who provides, coordinates or helps a patientaccess a range of health care services.Glossary of Health Coverage and Medical Terms Page 3 of 4
  4. 4. How You and Your Insurer Share Costs - ExampleJane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 st January 1 st December 31 Beginning of Coverage End of Coverage Period Period more more costs costs Jane pays Her plan pays Jane pays Her plan pays Jane pays Her plan pays 100% 0% 20% 80% 0% 100% Jane hasn’t reached her Jane reaches her $1,500 Jane reaches her $5,000 $1,500 deductible yet deductible, co-insurance begins out-of-pocket limit Her plan doesn’t pay any of the costs. Jane has seen a doctor several times and Jane has seen the doctor often and paid Office visit costs: $125 paid $1,500 in total. Her plan pays some $5,000 in total. Her plan pays the full Jane pays: $125 of the costs for her next visit. cost of her covered health care services Her plan pays: $0 Office visit costs: $75 for the rest of the year. Jane pays: 20% of $75 = $15 Office visit costs: $200 Her plan pays: 80% of $75 = $60 Jane pays: $0 Her plan pays: $200Glossary of Health Coverage and Medical Terms Page 4 of 4