Summary of Benefits and Coverage

Glossary of Health Coverage and Medical Terms
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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
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.)

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.

Appeal

The amount you owe for
health care services your
health insurance or plan
covers before your health
insurance or plan begins
Jane pays
Her plan pays
to pay. For example, if
100%
0%
your deductible is $1000,
(See page 4 for a detailed example.)
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.

A request for your health insurer or plan to review a
decision or a grievance again.

Balance Billing

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.

Co-insurance

Deductible

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.
Jane pays
Her plan pays
You pay co-insurance
20%
80%
plus any deductibles (See page 4 for a detailed example.)
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.

Durable Medical Equipment (DME)

Complications of Pregnancy

Emergency Room Care

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.

Glossary of Health Coverage and Medical Terms

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

An illness, injury, symptom or condition so serious that a
reasonable person would seek care right away to avoid
severe harm.

Emergency Medical Transportation

Ambulance services for an emergency medical condition.
Emergency services you get in an emergency room.

Emergency Services

Evaluation of an emergency medical condition and
treatment to keep the condition from getting worse.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

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Excluded Services

Health care services that your health insurance or plan
doesn’t pay for or cover.

Grievance

A complaint that you communicate to your health insurer
or plan.

Habilitation Services

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.

Health Insurance

A contract that requires your health insurer to pay some
or all of your health care costs in exchange for a
premium.

Home Health Care

Health care services a person receives at home.

Hospice Services

Services to provide comfort and support for persons in
the last stages of a terminal illness and their families.

Hospitalization

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.

In-network Co-insurance

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.

In-network Co-payment

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.

Glossary of Health Coverage and Medical Terms

Medically Necessary

Health care services or supplies needed to prevent,
diagnose or treat an illness, injury, condition, disease or
its symptoms and that meet accepted standards of
medicine.

Network

The facilities, providers and suppliers your health insurer
or plan has contracted with to provide health care
services.

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.

Out-of-network Co-insurance

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. Outof-network co-insurance usually costs you more than innetwork co-insurance.

Out-of-network Co-payment

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 copayments usually are more than in-network co-payments.

Out-of-Pocket Limit

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
Jane pays
Her plan pays
includes your premium,
0%
100%
balance-billed charges or
(See page 4 for a detailed example.)
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.

Physician Services

Health care services a licensed medical physician (M.D. –
Medical Doctor or D.O. – Doctor of Osteopathic
Medicine) provides or coordinates.
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Plan

A benefit your employer, union or other group sponsor
provides to you to pay for your health care services.

Preauthorization

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.

Preferred Provider

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.

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.

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or
improve a part of the body because of birth defects,
accidents, injuries or medical conditions.

Rehabilitation Services

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.

Specialist

The amount that must be paid for your health insurance
or plan. You and/or your employer usually pay it
monthly, quarterly or yearly.

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.

Prescription Drug Coverage

UCR (Usual, Customary and Reasonable)

Premium

Health insurance or plan that helps pay for prescription
drugs and medications.
Drugs and medications that by law require a prescription.

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.

Primary Care Physician

Urgent Care

Prescription Drugs

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.

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.

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

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How You and Your Insurer Share Costs - Example
Jane’s Plan Deductible: $1,500

Co-insurance: 20%

Out-of-Pocket Limit: $5,000
December 31st
End of Coverage Period

st

January 1
Beginning of Coverage
Period

more
costs

Jane pays

100%

Her plan pays

0%

Jane hasn’t reached her
$1,500 deductible yet
Her plan doesn’t pay any of the costs.
Office visit costs: $125
Jane pays: $125
Her plan pays: $0

Glossary of Health Coverage and Medical Terms

more
costs

Jane pays

20%

Her plan pays

80%

Jane reaches her $1,500
deductible, co-insurance begins
Jane has seen a doctor several times and
paid $1,500 in total. Her plan pays some
of the costs for her next visit.
Office visit costs: $75
Jane pays: 20% of $75 = $15
Her plan pays: 80% of $75 = $60

Jane pays

0%

Her plan pays

100%

Jane reaches her $5,000
out-of-pocket limit
Jane has seen the doctor often and paid
$5,000 in total. Her plan pays the full
cost of her covered health care services
for the rest of the year.
Office visit costs: $200
Jane pays: $0
Her plan pays: $200

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