Health Insurance Terms and Definitions ⚕️
Please note that some of the terminology and definitions in this glossary may differ from what is in the plan you have. Also, some of these terms might not have the same meaning when used in your policy or plan, and in such cases, the policy or plan will govern.
Health Insurance Terms By Letter
Health Insurance Terms Starting With A
Allowed Amount – Payment for covered health care services is based on a maximum amount. There may be a term for this called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may be responsible for the difference. (See Balance Billing.)
Appeal – Reconsideration of a decision or grievance by your health insurer or plan.
Health Insurance Terms Starting With B
Balance Billing – You are billed for the difference between the provider’s charge and the allowed amount. As an example, if the provider charges you $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Preferred providers cannot balance bill you for covered services.
Health Insurance Terms Starting With C
Co-insurance – Share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount. Your co-insurance plus any deductibles you owe are the costs of co-insurance. For example, if an office visit costs $100 and you’ve met your deductible, your co-insurance payment is $20. The rest is covered by your health plan.
Complications of Pregnancy – Pregnancy, labor and delivery conditions require medical attention to prevent serious harm to the mother or the fetus. Morning sickness and a non-emergency cesarean section are not pregnancy complications.
Co-payment – A fixed amount (for example, $15) you pay when you receive a covered health care service. There may be a difference in amount based on which health care service you receive.
Covid-19 – COVID-19 is a disease caused by a virus called SARS-CoV-2. Most people with COVID-19 have mild symptoms, but some people can become severely ill.
Health Insurance Terms Starting With D
Deductible – It is the amount you owe before your health insurance begins to pay for the health care services you receive. If you have a $1000 deductible, for example, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services. Your deductible may not apply to all health care services.
Durable Medical Equipment (DME) – Health care providers order supplies and equipment for daily or extended use. DME may include oxygen equipment, wheelchairs, crutches, or blood test strips for diabetics.
Dental Care – Dental care entails maintaining healthy teeth and may include oral hygiene, the practice of keeping the mouth and teeth clean to prevent dental problems.
Health Insurance Terms Starting With E
Emergency Medical Condition – A serious illness, injury, symptom, or condition that would prompt a reasonable person to seek medical care right away to avoid severe harm.
Emergency Medical Transportation – An ambulance for an emergency medical situation.
Emergency Room Care – Emergency services you get in an emergency room.
Emergency Services – Assessment of a medical emergency and treatment to prevent the condition from worsening.
Excluded Services – Healthcare services that your insurance or plan doesn’t cover or pay for.
Health Insurance Terms Starting With G
Grievance – A complaint you make to your health insurer or plan.
Health Insurance Terms Starting With H
Habilitation Services – An individual can retain, learn or improve his or her ability to function for daily living with the help of health care services. One example is therapy for a child who cannot walk or speak by the expected age. Services for people with disabilities may include physical and occupational therapy, speech therapy, and other services in a variety of inpatient and outpatient settings.
Health Insurance – In exchange for a premium, your health insurer pays some or all of your health care costs.
Home Health Care – Health care services provided to a patient at home.
Hospice Services – Support and comfort to terminally ill patients and their families
Hospitalization – Hospital care requires admission as an inpatient and typically requires an overnight stay. Overnight observation can be provided as outpatient care.
Hospital Outpatient Care – Hospitalization that doesn’t require a night’s stay.
Health Insurance Terms Starting With I
In-network Co-insurance – Paying a percentage (for example, 20%) of the allowed amount of covered health care services to providers who contract with your health insurance. In-network co-insurance is usually less expensive than out-of-network co-insurance.
In-network Co-payment – It is the fixed amount you pay to your health insurance provider each month for covered health care services. In-network co-payments are usually lower than out-of-network co-payments.
Health Insurance Terms Starting With M
Medically Necessary – An illness, injury, condition, disease, or its symptoms need to be prevented, diagnosed, or treated with medical supplies and services that meet accepted standards.
Health Insurance Terms Starting With N
Network – Health care facilities, providers, and suppliers your health insurer or plan contracts with.
Non-Preferred Provider – Providers without contracts with your health insurer or plan. You will pay more if you see a nonpreferred provider. See if you can see all providers who have contracted with your health insurance or plan, or if you have to pay extra to see some providers because your insurance or plan has a “tiered” network.
Health Insurance Terms Starting With O
Out-of-network Co-insurance – Providers who are not contracted with your health insurance plan and for whom you pay a percentage (for example, 40%) of the allowed amount for covered health care services. Out-of-network co-insurance is usually more expensive than in-network co-insurance.
Out-of-network Co-payment – For covered health care services from providers who do not contract with your health insurance or plan, you pay a fixed amount (for example, $30). The copayments for out-of-network services are usually higher than those for in-network services.
Out-of-Pocket Limit – The most you can pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. The limit does not include your premium, balance billed charges or health care your health insurance or plan does not cover. Co-payments, deductibles, co-insurance payments, out-of-network payments, and other expenses may not count towards this limit in some insurance plans.
Open enrollment – Annually, open enrollment allows you to start, stop, or change your health insurance plan. You usually sign up at the end of one calendar year for coverage that lasts a full year.
Health Insurance Terms Starting With P
Physician Services – A licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates health care services.
Plan – You receive this benefit from your employer, union, or another group sponsor in order to pay for your health care services.
Preauthorization – Providing you with health care services, prescription drugs, or durable medical equipment as deemed medically necessary by your health insurer. This process is sometimes referred to as prior authorization, prior approval, and pre-certification. For certain services, your health insurance plan may require preauthorization, except in an emergency. A preauthorization doesn’t guarantee that your health insurance will cover the cost.
Preferred Provider – A provider who has a contract with your health insurer or plan to provide you with services at a discount. To find out if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you have to pay extra to see certain providers check your policy. Participating providers may be preferred providers on your health insurance or plan. The participating providers also contract with your health plan or insurer, but you may not receive as great of a discount.
Premium – The amount that you must pay for your health insurance. Your employer or you usually pay it monthly, quarterly, or annually.
Prescription Drug Coverage – Prescription drug insurance or pharmaceutical plan that pays for medications.
Prescription Drugs – Medications and drugs that require a prescription by law.
Primary Care Physician – The physician (M.D. or D.O.) who directly provides or coordinates the patient’s health care.
Primary Care Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathy), nurse practitioner, clinical nurse specialist, or physician assistant, depending on state law, who provides, coordinates, or helps a patient access a range of health care services.
Provider – Licensed, certified, or accredited health care provider (includes physicians, dentists, and osteopathic doctors), health care facility, or health care facility operator.
Health Insurance Terms Starting With R
Reconstructive Surgery – Surgery and follow-up treatment are needed to correct or improve a part of the body that is affected by birth defects, accidents, injuries, or medical conditions.
Rehabilitation Services – The provision of health care services to help a person maintain or improve skills and functioning for daily living that has been lost or impaired as a result of illness, injury, or disability. A wide range of inpatient and outpatient rehabilitation services may be available, including physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation.
Health Insurance Terms Starting With S
Skilled Nursing Care – Nursing services provided by licensed nurses at home or in a nursing home. Technical and therapeutic care is provided to you at home or in a nursing home.
Specialist – Physician specialists specialize in a specific area of medicine or a specific group of patients in order to diagnose, manage, prevent, or treat certain symptoms and conditions. A non-physician specialist is a provider who specializes in a specific area of health care.
Health Insurance Terms Starting With U
UCR (Usual, Customary and Reasonable) – Medical services are priced in a geographic area according to what providers in the area usually charge for the same or similar services. Sometimes the UCR amount is used to determine the allowed amount.
Urgent Care – Treatment for illnesses, injuries, or conditions highly serious enough to warrant immediate attention, but not so severe as to require emergency room treatment.