Glossary of Health Coverage and Medical Terms

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 differ from your plan. Some terms may not have the same meaning in your plan; in such cases, your policy governs. (See your Summary of Benefits and Coverage for more information.)

Note: Bold blue text indicates a term defined in this Glossary.

Glossary Terms

Allowed Amount: Maximum amount on which payment is based for covered services. Also called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more, you may pay the difference. (See Balance Billing.)

Appeal: A request to review a decision or grievance again.

Balance Billing: When you’re billed for the difference between the provider’s charge and the allowed amount. Preferred providers may not balance bill.

Co-insurance: Your percentage of costs for a covered service (e.g., 20%). You pay this plus any deductible owed.

Complications of Pregnancy: Health conditions during pregnancy, labor, or delivery requiring medical care. Morning sickness and non-emergency C-sections are excluded.

Co-payment: A fixed dollar amount (e.g., $15) you pay for a covered service, often at time of service.

Deductible: The amount you pay for covered services before your plan starts to pay.

Durable Medical Equipment (DME): Equipment and supplies ordered by a provider for everyday/extended use (e.g., oxygen, wheelchairs, test strips).

Emergency Medical Condition: A condition so serious that a reasonable person would seek care immediately to avoid severe harm.

Emergency Medical Transportation: Ambulance services for emergency conditions.

Emergency Room Care: Emergency services received in an emergency room.

Emergency Services: Evaluation/treatment to prevent worsening of an emergency condition.

Excluded Services: Services not covered by your plan.

Grievance: A formal complaint to your insurer.

Habilitation Services: Help keeping, learning, or improving skills for daily living (e.g., speech therapy for children).

Health Insurance: A contract requiring the insurer to cover some or all of your health care costs in exchange for a premium.

Home Health Care: Health care services provided at home.

Hospice Services: Support and comfort for terminally ill individuals and families.

Hospitalization: Inpatient hospital care requiring admission and usually overnight stay.

Hospital Outpatient Care: Hospital care not requiring overnight stay.

In-network Co-insurance: Your share of costs for services by providers in the plan network.

In-network Co-payment: A set dollar amount for services by in-network providers.

Medically Necessary: Services/supplies needed to prevent, diagnose, or treat a condition and meet accepted medical standards.

Network: Facilities/providers contracted with your insurer to provide care.

Non-Preferred Provider: Not contracted with your insurer; costs more than preferred providers.

Out-of-network Co-insurance: Your share of costs for non-network provider services.

Out-of-network Co-payment: Set dollar amount for services from non-network providers.

Out-of-Pocket Limit: Maximum you pay in a year before insurer pays 100% of covered services.

Physician Services: Services from licensed M.D. or D.O. providers.

Plan: Health coverage offered by an employer, union, or other group.

Preauthorization: Prior approval that a service is medically necessary.

Preferred Provider: A provider contracted to offer discounted services.

Premium: The monthly, quarterly, or annual cost of coverage.

Prescription Drug Coverage: A plan’s help paying for prescribed medications.

Prescription Drugs: Medications requiring a prescription.

Primary Care Physician: Doctor who provides/coordinated health care services.

Primary Care Provider: Doctor, nurse, or PA coordinating/accessing care.

Provider: Licensed health care professional or facility.

Reconstructive Surgery: Surgery to correct or improve a body part due to defect, injury, or condition.

Rehabilitation Services: Services to regain or improve daily living skills.

Skilled Nursing Care: Licensed nurse or therapist services at home or in a facility.

Specialist: A provider focused on specific medical areas or conditions.

UCR (Usual, Customary, and Reasonable): Rate based on typical charges for services in an area.

Urgent Care: Immediate care needed for less severe conditions than emergencies.