Glossary A - M


Allowed Amount - 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.)

Appeal - A process available to the patient, their family member, treating provider or authorized representative to request reconsideration of a previous adverse determination.


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. An in-network provider may not balance bill you for covered services.

Benefits - Medical services for which your insurance plan will pay, in full or in part.

Brand-name drug - A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.


Case Management - Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Claim - A claim is a request for payment under the terms of a health benefits plan.

COBRA (Consolidated Omnibus Budget Reconciliation Act) - A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time.

Coinsurance - Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. There are separate coinsurances for in network and out-of-network services.

Coordination of Benefits - A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.

Copayment - A fixed amount (for example, $20) 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.

Coverage - The benefits that are provided according to the terms of a participant's specific health benefits plan.

Covered Charges - Services or benefits for which the health plan makes either partial or full payment.

Covered Services - Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.


Date of Service - The date the service was provided to the participant as specified on the claim.

Deductible - A fixed dollar amount you must pay out-of-pocket before the plan begins to pay. Separate limits are applied on a per-person and per-family basis and for in-network and out-of-network services.

Durable medical equipment - Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.


Effective date - The date that insurance coverage begins.

Elimination Period - This is the period of time between the date the disability begins and the beginning of the benefit payment period. It is the period during which an employee must be disabled before payment of benefits begins.

Emergency - An accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability. Examples of emergency situations include: uncontrolled bleeding, seizure or loss of consciousness, shortness of breath, chest pain or squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, severe burns, broken bones or severe pain.

Employee Assistance Program (EAP) - An EAP is an assessment and referral program or a short-term counseling program that is available to employees and their dependents.

Enrollee - An individual who is enrolled and eligible for coverage under a health plan contract. Also called Member.

Exclusions - Specific conditions or services that are not covered under the health plan benefits.

Explanation of benefits (EOB) - A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid.


Fee Schedule - A list of amounts to be paid for specific services or procedures by participating providers.

Flexible Spending Account (FSA) - An account that reimburses the participant for qualified medical or dependent care expenses through pre-tax savings accounts. At the end of each plan year, unused dollars are forfeited by the participant.

Formulary - A list of both generic and brand name drugs that are preferred by your health plan. Many prescription drugs produce the same results. Health plans choose formulary drugs that are medically safe and cost effective. A team including pharmacists and physicians meet to review the formulary and make changes as necessary.


Generic Drug - A prescription that is not protected by a drug patent. A generic medication is basically a copy of the brand name drug. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety. Generics generally cost less than brand name drugs.


Health Maintenance Organization (HMO) - A health plan that provides care through contracted physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live. There are no out-of-network benefits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) - The law has several parts: The first part addresses health insurance portability and is designed to protect health insurance coverage for workers and their families when they change or lose their jobs. The law also includes requirements to protect the privacy of individuals' protected health information. Health plans, providers and other organizations with access to protected health information are covered by the requirements of HIPAA.


Indemnity plan - A type of health benefits plan under which the covered person pays 100% of all covered charges up to an annual deductible. The health benefits plan then pays a percentage of covered charges up to an out-of-pocket maximum.

In-network - Describes a provider or health care facility which is part of a health plan's network.


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Lifetime maximum benefit - The maximum amount a health plan will pay in benefits to an insured individual over their lifetime.

Limitations - A restriction on the amount of benefits paid out for a particular covered expense.


Maintenance medication - Medications that are prescribed for long-term treatment of chronic conditions, such as diabetes, high blood pressure or asthma.

Managed care - The coordination of health care services in the attempt to produce high quality health care for the lowest possible cost. Examples are the use of primary care physicians as gatekeepers in HMO plans and pre-certification of care.

Glossary N - Z


Network - a group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees. Provider networks can cover large geographic markets and/or a wide range of health care services. If a health plan uses a preferred provider network, insured individuals typically pay less for using a network provider.

Non-Participating Provider/Non-Preferred Provider - A medical provider who has not contracted with the health plan. If you have any out-of-network benefits, you'll pay more to see a non-preferred provider.


Occupational Therapy - Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

Open Enrollment - A specified period of time in which employees may change insurance plans offered by their employer. Open enrollment occurs once a year.

Out-of-Network - Describes a provider or health care facility which is not part of a health plan's network. If an insured individual has out-of-network benefits, then they usually pay more when using an out-of-network provider. If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Out-of-Pocket Maximum - The most a plan member will pay per year for covered health expenses including copayments, coinsurance and deductibles but not including any prescription drug costs and/or mental health or substance abuse copayments, before the plan pays 100% of covered health expenses for the rest of that year. This maximum does not include your premium, balance-billed charges or health care the plan doesn't cover. Separate limits are applied for in-network maximum out-of-pocket and out-of-network maximum out-of-pocket amounts.


Participant - A person who is eligible to receive health benefits under a health benefits plan. This term may refer to the employee, spouse or other dependents.

Participating Provider - A physician, hospital, pharmacy, laboratory or other appropriately licensed facility or provider of health care services or supplies that has entered into an agreement with a health plan to provide services or supplies to a patient enrolled in the plan.

Physical therapy - Rehabilitation concerned with restoration of function and prevention of physical disability following disease, injury or loss of body part.

Pre-authorization - An insurance plan requirement in which you or your primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.

Precertification - The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures.

Pre-existing condition - an illness, injury or condition for which the insured individual received medical advice, treatment, services or supplies; had diagnostic tests done or recommended; had medicines prescribed or recommended; or had symptoms of within 12 months prior to the effective date of insurance coverage.

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 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.

Premiums - Payments to an insurance company providing coverage.

Prescription drug - A drug that has been approved by the Federal Food and Drug Administration which can only be dispensed according to a physician's prescription order.

Primary Care Physician - A network physician - a family practitioner, general practitioner, internist or pediatrician (for children) - who is responsible for managing and coordinating your healthcare.

Provider - A doctor, hospital, health care practitioner, pharmacy, or health care facility.

Provider Directory - Provider directories are listings of providers who have contracted with a health plan to provide care to its participants. Participants refer to the directory to select in-network providers.


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Rehabilitation - Rehabilitation means the restoration of or improvement in an employee's health and ability to perform the functions of his or her job. It usually involves a program of clinical and vocational services with the goal of returning employees to a satisfying occupation if possible.

Risk - Uncertainty of financial loss.


Service area - The geographical area covered by a network of health care providers.

Specialist - A physician who practices medicine in a specialty area. Cardiologists, orthopedists, gynecologists and surgeons are all examples of specialists. Under most health plans, family practice physicians, pediatricians and internal medicine physicians are not considered specialists.


Third Party Administrator (TPA) - An organization responsible for administering group health plans. This includes collecting premiums, paying claims and providing administrative services.


Urgent Care - When prompt medical attention is needed in a non-emergency situation, that's called "urgent" care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.


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Waiting Period - In order to become eligible for coverage under the policy, a benefited employee must satisfy a certain number of continuous days of service. This is known as the waiting period. In addition, a waiting period can also be the time period between when a disability occurs and when payments from the disability insurance policy begin.


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