Health Insurance Terms Glossary

In dealing with health and insurance matters, you may come across a number of unfamiliar terms. This glossary, adapted from U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services, can help you decipher some of them. Terms may vary from one location to another and from one provider to another, of course, so for specific questions about what a particular term means in your individual case, ask your doctor or insurance provider.

Accessibility of Services :

Your ability to get medical care and services when you need them.

Accredited (Accreditation) :

A "seal of approval." Being accredited means that a facility has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at healthcare facilities.

Actual Charge :

The amount of money a doctor or supplier charges for a certain medical service or supply.

Admitting Physician :

The doctor responsible for admitting you to a hospital or other inpatient health facility.

Advance Coverage Decision :

A decision that your plan makes on whether or not it will pay for a certain service.

Advance Directives :

Written ahead of time, this is your statement of how you want to get health care, in case you can't say how. Such health care could include routine treatments and life-saving methods. You can also choose someone to make medical decisions in case you can't. Advance Directives are also called a Living Will.

Advocate :

A person who gives you support or protects your rights.

Affiliated Provider :

A healthcare provider or facility that is paid by a health plan to give services to plan members.

Ambulatory Care :

All types of health services that do not require an overnight hospital stay.

Ambulatory Surgical Center :

A separate part of a hospital that does outpatient surgery.

Ancillary Services :

Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services. (Read about "X-rays" "Laboratory Testing")

Anesthesia :

Drugs that a person is given before and during surgery so he or she will not feel pain. Anesthesia should always be given by a doctor or a specially trained nurse. (Read about "Anesthesia")

Assisted Living Facility (ALF) :

A homelike place with staff who give help to residents, including: help with dressing, bathing, feeding, and housekeeping. Assisted Living Facilities usually give a less skilled level of care than you would get in skilled nursing facilities.

Benefits :

The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.

Board-Certified :

This means a doctor has special training in a certain area of medicine and has passed an ADVANCED exam in that area of medicine. Both primary care doctors and specialists may be board-certified.

Capitation :

A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's healthcare services for a certain length of time.

Care Plan :

A written plan for your care.

Case Management :

A process used by a doctor, nurse, or other health professional to manage your health care.

Case Manager :

A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.

Catastrophic Illness :

A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.

Catastrophic Limit :

The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges.

Certified (Certification) :

This means a hospital has passed a survey done by a state government agency. Being certified is not the same as being accredited.

Certified Registered Nurse Anesthetist :

A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain.

Claim:

A claim is a request for payment for services and benefits you received.

Clinical Practice Guidelines :

Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

Cognitive Impairment :

A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly. (Read about "Mental Health")

Coinsurance :

The percentage of a charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service plan, the coinsurance payment is a percentage of the cost of the service .

Comprehensive Outpatient Rehabilitation Facility (CORF) :

A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation. (Read about "Rehabilitation")

Confidentiality :

Your right to talk with your healthcare provider without anyone else finding out what you have said.

Consolidated Omnibus Budget Reconciliation Act (COBRA) :

A law that can help if you lose your job or if your hours are reduced to the point where the employer no longer provides health coverage. Depending on the size of your former employer and other factors, COBRA can provide a temporary extension of your health coverage. Usually, you pay the entire cost of coverage.

Coordination of Benefits Clause :

A written statement that tells which health plan or insurance policy pays first if two health plans or insurance policies cover the same benefits. If one of the plans is Medicare, federal law may decide who pays first.

Copayment :

The amount you pay for each medical service, like a doctor visit. A copayment is usually a set amount you pay for a service. For example, this could be $5.00 or $10.00 for a doctor visit. Copayments are also used for some hospital outpatient services.

Cost Sharing :

The cost for medical care that you pay yourself, like a copayment, coinsurance, or deductible.

Covered Benefit :

A health service or item that is included in your health plan, and that is paid for either partially or fully.

Covered Charges :

Services or benefits for which a health plan makes either partial or full payment.

Creditable Coverage :

Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period.

Critical Access Hospital :

A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

Custodial Care:

Personal care, such as bathing, cooking, and shopping.

Deductible :

The amount you must pay for health care before the plan begins to pay. This amount can change every year.

Diagnosis :

The name for the health problem that you have.

Discharge Planning :

A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other healthcare professional.

Disenroll :

Ending your healthcare coverage with a health plan.

Emergency Care :

Care given for a medical emergency when you believe that your health is in serious danger - when every second counts. (Read about "Emergency" "Emergency Room")

Employer Group Health Plan (GHP)

A GHP is a health plan that gives health coverage to employees, former employees, and their families, and is from an employer or employee organization

Enroll :

To join a health plan.

Episode of Care :

The healthcare services given during a certain period of time, usually during a hospital stay.

Exclusion Period :

A period of time when an insurance company can delay coverage of a pre-existing condition. Sometimes called a pre-existing condition waiting period.

Fee Schedule :

A complete listing of fees used by health plans to pay doctors or other providers.

Flexible Spending Account (FSA) :

An arrangement that lets employees save pretax dollars from their paychecks, to spend on medical expenses such as deductibles, co-pays and/or uninsured expenses. Some other types of FSA's also allow money to be used for dependent care, such as child or adult day care. Flexible spending accounts are "use-it-or-lose-it" plans. This means that amounts in the account at the end of the plan year cannot be carried over to the next year. However, the plan can provide for a grace period of up to two-and-a-half months after the end of the plan year. If there is a grace period, any qualified medical expenses incurred in that period can be paid from any amounts left in the account at the end of the previous year. Your employer is not permitted to refund any part of the balance to you.

Formulary:

A list of certain drugs and their proper dosages. In some health plans, doctors must order or use only drugs listed on the health plan's formulary.

Gag Rule Laws :

Special laws that make sure that health plans let doctors tell their patients complete healthcare information. This includes information about treatments not covered by the health plan.

Gatekeeper :

In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

Group Health Plan :

A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

Group or Network HMO :

A health plan that contracts with group practices of doctors to give services in one or more places.

Health Employer Data and Information Set (HEDIS) :

A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans.

Health Insurance Portability & Accountability Act (HIPAA) :

A law passed in 1996, which is also sometimes called the "Kassebaum-Kennedy" law. This law can help protect your healthcare coverage if you have lost your job, or if you move from one job to another. HIPAA also offers protections for pre-existing medical conditions.

Health Maintenance Organization (HMO) :

A group of doctors, hospitals, and other healthcare providers who agree to give health care to beneficiaries for a set amount of money every month. In an HMO, you usually must get all your care from the providers that are part of the plan.

HMO with a Point of Service (POS) Option :

A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost.

Health Savings Account (HSA) :

A Health Savings Account allows individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax free basis. To be eligible for a Health Savings Account, an individual must be covered by a High Deductible Health Plan (HDHP), must not be covered by other health insurance, is not eligible for Medicare, and can't be claimed as a dependent on someone else's tax return.

Inpatient Care :

Health care that you get when you stay overnight in a hospital.

Maximum out-of-pocket expense :

The maximum dollar amount a group member is required to pay out of pocket during a year.

Maximum plan dollar limit :

The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan. Plans can have a yearly and/or a lifetime maximum dollar limit.

Medicaid :

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.

Medically Necessary :

Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor.

Medicare :

The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). (Read about "End Stage Renal Disease" "Transplants")

National Committee for Quality Assurance (NCQA) :

A non-profit organization that accredits and measures the quality of care in Medicare health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system.

Network :

A group of doctors, hospitals, pharmacies, and other healthcare experts hired by a health plan to take care of its members.

Organization Determination :

A health plan's decision on whether to pay all or part of a bill, or to give medical services, after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process.

Out-of-Pocket Costs :

Healthcare costs that you must pay on your own, because they are not covered by insurance.

Outpatient Services :

A service you get in one day (24 hours) at a hospital outpatient department or community mental health center.

Preferred Provider Organization (PPO) :

A managed care plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Primary Care Doctor :

A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she also may talk with other doctors and healthcare providers about your care and refer you to them. In many managed care plans, you must see your primary care doctor before you see any other healthcare provider.

Primary Payer :

An insurance policy, plan, or program that pays first on a claim for medical care.

Proxy, healthcare :

A legal document that gives the person you choose as your agent the authority to make healthcare decisions for you, in the event you cannot make them for yourself. These decisions can include end-of -life issues, such as the decision to provide or remove life-sustaining treatment.

Referral :

An OK from your primary care doctor for you to see a specialist or get certain services. In many managed care plans, you need to get a referral before you get care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for your care.

Second Opinion :

This is when another doctor gives his or her view about what you have and how it should be treated.

Service Area :

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.

Treatment Options :

The choices you have when there is more than one way to treat your health problem.

Unforeseen Out-of-Area Urgently Needed Care:

Care you get for a sudden illness or injury that needs medical care right away, but is not life threatening, while you are out of your health plan's service area for a short time, and cannot wait until you return home.

Urgently Needed Care :

Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care.

Workers Compensation :

Insurance that employers are required to have to cover employees who get sick or injured on the job.

Adapted from the U.S. Department of Health and Human Services.

Related Information:

    Learn About Your Procedure

    At The Hospital: For Patients

    At The Hospital: For Visitors