SlideShare a Scribd company logo
1 of 4
Download to read offline
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-payment
Maximum amount on which payment is based for                        A fixed amount (for example, $15) you pay for a covered
covered 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 care
your provider charges more than the allowed amount, you             service.
may have to pay the difference. (See Balance Billing.)
                                                                    Deductible
Appeal                                                              The amount you owe for
A request for your health insurer or plan to review a               health care services your
decision or a grievance again.                                      health insurance or plan
                                                                    covers before your health
Balance Billing                                                     insurance or plan begins
                                                                                                    Jane pays      Her plan pays
When 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 met
A preferred provider may not balance bill you for covered           your $1000 deductible for covered health care services
services.                                                           subject to the deductible. The deductible may not apply
                                                                    to all services.
Co-insurance
Your share of the costs                                             Durable Medical Equipment (DME)
of a covered health care                                            Equipment and supplies ordered by a health care provider
service, calculated as a                                            for everyday or extended use. Coverage for DME may
percent (for example,                                               include: oxygen equipment, wheelchairs, crutches or
20%) of the allowed                                                 blood testing strips for diabetics.
amount for the service.       Jane pays      Her plan pays
You pay co-insurance            20%             80%                 Emergency Medical Condition
plus any deductibles (See page 4 for a detailed example.)           An illness, injury, symptom or condition so serious that a
you owe. For example,                                               reasonable person would seek care right away to avoid
if the health insurance or plan’s allowed amount for an             severe harm.
office visit is $100 and you’ve met your deductible, your
co-insurance payment of 20% would be $20. The health                Emergency Medical Transportation
insurance or plan pays the rest of the allowed amount.              Ambulance services for an emergency medical condition.

Complications of Pregnancy                                          Emergency Room Care
Conditions due to pregnancy, labor and delivery that                Emergency services you get in an emergency room.
require medical care to prevent serious harm to the health
of the mother or the fetus. Morning sickness and a non-             Emergency Services
emergency caesarean section aren’t complications of                 Evaluation of an emergency medical condition and
pregnancy.                                                          treatment to keep the condition from getting worse.


                                                         OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Glossary of Health Coverage and Medical Terms                                                                      Page 1 of 4
Excluded Services                                             Medically Necessary
Health 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 of
Grievance                                                     medicine.
A complaint that you communicate to your health insurer
or plan.                                                      Network
                                                              The facilities, providers and suppliers your health insurer
Habilitation Services                                         or plan has contracted with to provide health care
Health care services that help a person keep, learn or        services.
improve skills and functioning for daily living. Examples
include therapy for a child who isn’t walking or talking at   Non-Preferred Provider
the expected age. These services may include physical and     A provider who doesn’t have a contract with your health
occupational therapy, speech-language pathology and           insurer or plan to provide services to you. You’ll pay
other services for people with disabilities in a variety of   more to see a non-preferred provider. Check your policy
inpatient 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 health
Health Insurance                                              insurance or plan has a “tiered” network and you must
A 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 a
premium.                                                      Out-of-network Co-insurance
                                                              The percent (for example, 40%) you pay of the allowed
Home Health Care                                              amount for covered health care services to providers who
Health 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 in
the last stages of a terminal illness and their families.     Out-of-network Co-payment
                                                              A fixed amount (for example, $30) you pay for covered
Hospitalization                                               health care services from providers who do not contract
Care 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 Limit
Hospital Outpatient Care                                      The most you pay during a
Care in a hospital that usually doesn’t require an            policy period (usually a
overnight stay.                                               year) before your health
                                                              insurance or plan begins to
In-network Co-insurance                                       pay 100% of the allowed
The percent (for example, 20%) you pay of the allowed         amount. This limit never         Jane pays      Her plan pays
amount 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 health
co-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 or
A fixed amount (for example, $15) you pay for covered         other expenses toward this limit.
health care services to providers who contract with your
health insurance or plan. In-network co-payments usually      Physician Services
are 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
Plan                                                         Provider
A benefit your employer, union or other group sponsor        A physician (M.D. – Medical Doctor or D.O. – Doctor
provides to you to pay for your health care services.        of Osteopathic Medicine), health care professional or
                                                             health care facility licensed, certified or accredited as
Preauthorization                                             required by state law.
A decision by your health insurer or plan that a health
care service, treatment plan, prescription drug or durable   Reconstructive Surgery
medical equipment is medically necessary. Sometimes          Surgery and follow-up treatment needed to correct or
called 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 you
receive them, except in an emergency. Preauthorization       Rehabilitation Services
isn’t a promise your health insurance or plan will cover     Health care services that help a person keep, get back or
the cost.                                                    improve skills and functioning for daily living that have
                                                             been lost or impaired because a person was sick, hurt or
Preferred Provider                                           disabled. These services may include physical and
A provider who has a contract with your health insurer or    occupational therapy, speech-language pathology and
plan to provide services to you at a discount. Check your    psychiatric rehabilitation services in a variety of inpatient
policy to see if you can see all preferred providers or if   and or outpatient settings.
your health insurance or plan has a “tiered” network and
you must pay extra to see some providers. Your health        Skilled Nursing Care
insurance or plan may have preferred providers who are       Services from licensed nurses in your own home or in a
also “participating” providers. Participating providers      nursing home. Skilled care services are from technicians
also contract with your health insurer or plan, but the      and therapists in your own home or in a nursing home.
discount may not be as great, and you may have to pay
more.                                                        Specialist
                                                             A physician specialist focuses on a specific area of
Premium                                                      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 and
or plan. You and or your employer usually pay it             conditions. A non-physician specialist is a provider who
monthly, 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 geographic
drugs and medications.                                       area based on what providers in the area usually charge
                                                             for the same or similar medical service. The UCR
Prescription Drugs                                           amount sometimes is used to determine the allowed
Drugs and medications that by law require a prescription.    amount.

Primary Care Physician                                       Urgent Care
A physician (M.D. – Medical Doctor or D.O. – Doctor          Care for an illness, injury or condition serious enough
of Osteopathic Medicine) who directly provides or            that a reasonable person would seek care right away, but
coordinates a range of health care services for a patient.   not so severe as to require emergency room care.

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.




Glossary of Health Coverage and Medical Terms                                                                  Page 3 of 4
How You and Your Insurer Share Costs - Example
Jane’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: $200




Glossary of Health Coverage and Medical Terms                                                                                                   Page 4 of 4

More Related Content

More from Center for Public Health Practice & Leadership at UC Berkeley

More from Center for Public Health Practice & Leadership at UC Berkeley (20)

The Art of Listening Social Media Toolkit for Nonprofits - CALPACT New Media ...
The Art of Listening Social Media Toolkit for Nonprofits - CALPACT New Media ...The Art of Listening Social Media Toolkit for Nonprofits - CALPACT New Media ...
The Art of Listening Social Media Toolkit for Nonprofits - CALPACT New Media ...
 
CALPACT New Media Webinar: Building a Social Media Communications Plan
CALPACT New Media Webinar: Building a Social Media Communications PlanCALPACT New Media Webinar: Building a Social Media Communications Plan
CALPACT New Media Webinar: Building a Social Media Communications Plan
 
CALPACT Webinar: Applying Health Literacy to Health Insurance: How We Can Hel...
CALPACT Webinar: Applying Health Literacy to Health Insurance: How We Can Hel...CALPACT Webinar: Applying Health Literacy to Health Insurance: How We Can Hel...
CALPACT Webinar: Applying Health Literacy to Health Insurance: How We Can Hel...
 
CALPACT Webinar: Tips and Tricks for An Engaging PPT Presentation
CALPACT Webinar: Tips and Tricks for An Engaging PPT PresentationCALPACT Webinar: Tips and Tricks for An Engaging PPT Presentation
CALPACT Webinar: Tips and Tricks for An Engaging PPT Presentation
 
Health 3.0 Leadership Conference: Using Public Health Strategies to Reduce Cr...
Health 3.0 Leadership Conference: Using Public Health Strategies to Reduce Cr...Health 3.0 Leadership Conference: Using Public Health Strategies to Reduce Cr...
Health 3.0 Leadership Conference: Using Public Health Strategies to Reduce Cr...
 
Health 3.0 Leadership Conference: Community Centered Health Systems with Larr...
Health 3.0 Leadership Conference: Community Centered Health Systems with Larr...Health 3.0 Leadership Conference: Community Centered Health Systems with Larr...
Health 3.0 Leadership Conference: Community Centered Health Systems with Larr...
 
Health 3.0 Leadership Conference: Building and Maintaining Multi-Sector Partn...
Health 3.0 Leadership Conference: Building and Maintaining Multi-Sector Partn...Health 3.0 Leadership Conference: Building and Maintaining Multi-Sector Partn...
Health 3.0 Leadership Conference: Building and Maintaining Multi-Sector Partn...
 
Health 3.0 Leadership Conference: HealthFirst Primary Care Redesign with Russ...
Health 3.0 Leadership Conference: HealthFirst Primary Care Redesign with Russ...Health 3.0 Leadership Conference: HealthFirst Primary Care Redesign with Russ...
Health 3.0 Leadership Conference: HealthFirst Primary Care Redesign with Russ...
 
Health 3.0 Leadership Conference: City of Richmond Health in all Policies wit...
Health 3.0 Leadership Conference: City of Richmond Health in all Policies wit...Health 3.0 Leadership Conference: City of Richmond Health in all Policies wit...
Health 3.0 Leadership Conference: City of Richmond Health in all Policies wit...
 
Health 3.0 Leadership Conference: Healthy Food in Health Care with Lucia Sayre
Health 3.0 Leadership Conference: Healthy Food in Health Care with Lucia SayreHealth 3.0 Leadership Conference: Healthy Food in Health Care with Lucia Sayre
Health 3.0 Leadership Conference: Healthy Food in Health Care with Lucia Sayre
 
Health 3.0 Leadership Conference: Healthier and Sustainable Food In a Large A...
Health 3.0 Leadership Conference: Healthier and Sustainable Food In a Large A...Health 3.0 Leadership Conference: Healthier and Sustainable Food In a Large A...
Health 3.0 Leadership Conference: Healthier and Sustainable Food In a Large A...
 
Health 3.0 Leadership Conference: Transportation, Equity and Community Health...
Health 3.0 Leadership Conference: Transportation, Equity and Community Health...Health 3.0 Leadership Conference: Transportation, Equity and Community Health...
Health 3.0 Leadership Conference: Transportation, Equity and Community Health...
 
Health 3.0 Leadership Conference: Innovating Upstream with Clark Kellogg
Health 3.0 Leadership Conference: Innovating Upstream with Clark KelloggHealth 3.0 Leadership Conference: Innovating Upstream with Clark Kellogg
Health 3.0 Leadership Conference: Innovating Upstream with Clark Kellogg
 
Health 3.0 Leadership Conference: Glide Health Services with Pat Dennehy
Health 3.0 Leadership Conference: Glide Health Services with Pat DennehyHealth 3.0 Leadership Conference: Glide Health Services with Pat Dennehy
Health 3.0 Leadership Conference: Glide Health Services with Pat Dennehy
 
Health 3.0 Leadership Conference: Bay Area Hospital Sourcing Project with Ari...
Health 3.0 Leadership Conference: Bay Area Hospital Sourcing Project with Ari...Health 3.0 Leadership Conference: Bay Area Hospital Sourcing Project with Ari...
Health 3.0 Leadership Conference: Bay Area Hospital Sourcing Project with Ari...
 
Health 3.0 Leadership Conference: Our Path to Sustainability with Alison Negrin
Health 3.0 Leadership Conference: Our Path to Sustainability with Alison NegrinHealth 3.0 Leadership Conference: Our Path to Sustainability with Alison Negrin
Health 3.0 Leadership Conference: Our Path to Sustainability with Alison Negrin
 
Health 3.0 Leadership Conference: RENEWing School Meals with Ariana Oliva
Health 3.0 Leadership Conference: RENEWing School Meals with Ariana OlivaHealth 3.0 Leadership Conference: RENEWing School Meals with Ariana Oliva
Health 3.0 Leadership Conference: RENEWing School Meals with Ariana Oliva
 
Health 3.0 Leadership Conference: Population Health in Detroit with David Law
Health 3.0 Leadership Conference: Population Health in Detroit with David LawHealth 3.0 Leadership Conference: Population Health in Detroit with David Law
Health 3.0 Leadership Conference: Population Health in Detroit with David Law
 
Health 3.0 Leadership Conference: Collective Impact for Upstream Innovation w...
Health 3.0 Leadership Conference: Collective Impact for Upstream Innovation w...Health 3.0 Leadership Conference: Collective Impact for Upstream Innovation w...
Health 3.0 Leadership Conference: Collective Impact for Upstream Innovation w...
 
Health 3.0 Leadership Conference: Health Career Connections with Tony Iton
Health 3.0 Leadership Conference: Health Career Connections with Tony ItonHealth 3.0 Leadership Conference: Health Career Connections with Tony Iton
Health 3.0 Leadership Conference: Health Career Connections with Tony Iton
 

Recently uploaded

See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...
See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...
See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...bkling
 
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...rightmanforbloodline
 
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...poonam rawat$V15
 
parliaments-for-health-security_RecordOfAchievement.pdf
parliaments-for-health-security_RecordOfAchievement.pdfparliaments-for-health-security_RecordOfAchievement.pdf
parliaments-for-health-security_RecordOfAchievement.pdfDr. Nasir Mustafa
 
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...deepakkumar115120
 
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...anshu khanak#N06
 
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...rano khanrk#N06
 
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...golu varma
 
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...deepakkumar115120
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024locantocallgirl01
 
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...deepakkumar115120
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptxclaviclebrown44
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialSherrylee83
 
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...chaddanishu186
 
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...Dharvi Mehra$I11
 
Benefits of Chanting Hanuman Chalisa .pdf
Benefits of Chanting Hanuman Chalisa .pdfBenefits of Chanting Hanuman Chalisa .pdf
Benefits of Chanting Hanuman Chalisa .pdfLearnyoga
 
spinal cord disorders and paraplegia .
spinal cord disorders  and  paraplegia .spinal cord disorders  and  paraplegia .
spinal cord disorders and paraplegia .Mohamed Rizk Khodair
 
Physiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdfPhysiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdfMedicoseAcademics
 
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...patanjali9823#S07
 
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7grandmotherprocess99
 

Recently uploaded (20)

See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...
See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...
See it and Catch it! Recognizing the Thought Traps that Negatively Impact How...
 
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
 
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Thane West Mumbai 9930245274 WhatsApp: Me All Time Serviℂe Ava...
 
parliaments-for-health-security_RecordOfAchievement.pdf
parliaments-for-health-security_RecordOfAchievement.pdfparliaments-for-health-security_RecordOfAchievement.pdf
parliaments-for-health-security_RecordOfAchievement.pdf
 
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...
VIP ℂall Girls Kothanur {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hours Se...
 
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Miyapur Hyderabad 7014168258 WhatsApp: Me All Time Serviℂe Ava...
 
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...
VIP ℂall Girls Korremula Hyderabad 9079923931 WhatsApp: Me All Time Serviℂe A...
 
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
 
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Arekere Bangalore 6378878445 WhatsApp: Me All Time Serviℂe Ava...
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024
 
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptx
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw material
 
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
 
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...
Unsatisfied Bhabhi ℂall Girls Surat Book Sneha 8849756361 Top Class ℂall Girl...
 
Benefits of Chanting Hanuman Chalisa .pdf
Benefits of Chanting Hanuman Chalisa .pdfBenefits of Chanting Hanuman Chalisa .pdf
Benefits of Chanting Hanuman Chalisa .pdf
 
spinal cord disorders and paraplegia .
spinal cord disorders  and  paraplegia .spinal cord disorders  and  paraplegia .
spinal cord disorders and paraplegia .
 
Physiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdfPhysiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdf
 
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
 
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7
High Purity 99% PMK Ethyl Glycidate Powder CAS 28578-16-7
 

Glossary of Health Coverage and Medical Terms

  • 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-payment Maximum amount on which payment is based for A fixed amount (for example, $15) you pay for a covered covered 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 care your provider charges more than the allowed amount, you service. may have to pay the difference. (See Balance Billing.) Deductible Appeal The amount you owe for A request for your health insurer or plan to review a health care services your decision or a grievance again. health insurance or plan covers before your health Balance Billing insurance or plan begins Jane pays Her plan pays When 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 met A preferred provider may not balance bill you for covered your $1000 deductible for covered health care services services. subject to the deductible. The deductible may not apply to all services. Co-insurance Your share of the costs Durable Medical Equipment (DME) of a covered health care Equipment and supplies ordered by a health care provider service, calculated as a for everyday or extended use. Coverage for DME may percent (for example, include: oxygen equipment, wheelchairs, crutches or 20%) of the allowed blood testing strips for diabetics. amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% Emergency Medical Condition plus any deductibles (See page 4 for a detailed example.) An illness, injury, symptom or condition so serious that a you owe. For example, reasonable person would seek care right away to avoid if the health insurance or plan’s allowed amount for an severe harm. office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health Emergency Medical Transportation insurance or plan pays the rest of the allowed amount. Ambulance services for an emergency medical condition. Complications of Pregnancy Emergency Room Care Conditions due to pregnancy, labor and delivery that Emergency services you get in an emergency room. require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- Emergency Services emergency caesarean section aren’t complications of Evaluation of an emergency medical condition and pregnancy. treatment to keep the condition from getting worse. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Glossary of Health Coverage and Medical Terms Page 1 of 4
  • 2. Excluded Services Medically Necessary Health 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 of Grievance medicine. A complaint that you communicate to your health insurer or plan. Network The facilities, providers and suppliers your health insurer Habilitation Services or plan has contracted with to provide health care Health care services that help a person keep, learn or services. improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at Non-Preferred Provider the expected age. These services may include physical and A provider who doesn’t have a contract with your health occupational therapy, speech-language pathology and insurer or plan to provide services to you. You’ll pay other services for people with disabilities in a variety of more to see a non-preferred provider. Check your policy inpatient 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 health Health Insurance insurance or plan has a “tiered” network and you must A 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 a premium. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed Home Health Care amount for covered health care services to providers who Health 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 in the last stages of a terminal illness and their families. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered Hospitalization health care services from providers who do not contract Care 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 Limit Hospital Outpatient Care The most you pay during a Care in a hospital that usually doesn’t require an policy period (usually a overnight stay. year) before your health insurance or plan begins to In-network Co-insurance pay 100% of the allowed The percent (for example, 20%) you pay of the allowed amount. This limit never Jane pays Her plan pays amount 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 health co-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 or A fixed amount (for example, $15) you pay for covered other expenses toward this limit. health care services to providers who contract with your health insurance or plan. In-network co-payments usually Physician Services are 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. Plan Provider A benefit your employer, union or other group sponsor A physician (M.D. – Medical Doctor or D.O. – Doctor provides to you to pay for your health care services. of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as Preauthorization required by state law. A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable Reconstructive Surgery medical equipment is medically necessary. Sometimes Surgery and follow-up treatment needed to correct or called 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 you receive them, except in an emergency. Preauthorization Rehabilitation Services isn’t a promise your health insurance or plan will cover Health care services that help a person keep, get back or the cost. improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or Preferred Provider disabled. These services may include physical and A provider who has a contract with your health insurer or occupational therapy, speech-language pathology and plan to provide services to you at a discount. Check your psychiatric rehabilitation services in a variety of inpatient policy to see if you can see all preferred providers or if and or outpatient settings. your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health Skilled Nursing Care insurance or plan may have preferred providers who are Services from licensed nurses in your own home or in a also “participating” providers. Participating providers nursing home. Skilled care services are from technicians also contract with your health insurer or plan, but the and therapists in your own home or in a nursing home. discount may not be as great, and you may have to pay more. Specialist A physician specialist focuses on a specific area of Premium 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 and or plan. You and or your employer usually pay it conditions. A non-physician specialist is a provider who monthly, 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 geographic drugs and medications. area based on what providers in the area usually charge for the same or similar medical service. The UCR Prescription Drugs amount sometimes is used to determine the allowed Drugs and medications that by law require a prescription. amount. Primary Care Physician Urgent Care A physician (M.D. – Medical Doctor or D.O. – Doctor Care for an illness, injury or condition serious enough of Osteopathic Medicine) who directly provides or that a reasonable person would seek care right away, but coordinates a range of health care services for a patient. not so severe as to require emergency room care. 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. Glossary of Health Coverage and Medical Terms Page 3 of 4
  • 4. How You and Your Insurer Share Costs - Example Jane’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: $200 Glossary of Health Coverage and Medical Terms Page 4 of 4