Glossary of Terms

This Glossary has many commonly used terms, but isn't a full list.

Allowed Amount

The amount your health plan pays for a covered service
This may be called “eligible expense,” “payment allowance" or "negotiated rate"

Appeal

A request for your health plan to take another look at a decision or a complaint Benefit

Benefit

Your health plan’s payment(s) for covered services or medicine

Complications of Pregnancy

Problems during pregnancy, labor and delivery that must have special care to prevent serious harm to the mother or unborn baby

Complications of pregnancy do not include:

  • Non-emergency Caesarean section (C-section), OR
  • Normal morning sickness that does not affect regular daily activities

Note: If the mother has morning sickness, is very sick to her stomach or throwing up, she may become dehydrated. Dehydration means your body does not have enough water to work properly. If ignored, severe morning sickness and dehydration can threaten the life of the mother and child and becomes a complication of pregnancy.

Coverage

The services or medicines your health plan pays for

Durable Medical Equipment (DME)

Equipment and supplies your health care provider orders for you to use at home so you can have a better quality of living

Examples of DME coverage includes:

  • Oxygen equipment
  • Wheelchairs, crutches
  • Blood testing strips for diabetics

Emergency Medical Condition

An illness, injury, symptom or condition that needs care right away to avoid severe harm or death

Emergency Medical Transportation

Ambulance service for a person who needs hospital care right away

Emergency Room Care

This is care you get in an emergency room
An Emergency Services Evaluation will be done to keep the condition from getting worse and/or to plan treatment.

Excluded Services

The care your health plan will not pay for

Exclusions

The care, services or items your health plan will not pay for

Explanation of Benefits (EOB)

A list from your health plan that shows:

  • The amounts paid to your provider for your care
  • The amount you owe your provider

Generic Drugs (Medicines)

Medicines without a brand-name

Generic medicines include:

  • Generic equivalents - prescription medicines with the same ingredient

formula as brand-name medicines

  • Generic alternatives - prescription medicines that have the same effect as brand-name medicines

Generic medicines usually cost less than brand-name medicines. The Food and Drug Administration (FDA) makes sure generic medicines are as safe and effective as brand-name medicines.

Home Health Care

Health care services you get at home

Hospice Services

A provider of comfort, care and support to people who are near death
Hospice Services may also help the patients’ families.

Hospitalization

An inpatient hospital stay

Sometimes patients are not admitted to the hospital, but stay for observation. Observation is hospital outpatient care.

Hospital Outpatient Care

Care given in a hospital before the patient is admitted

Hospital Outpatient Care may include:

  • Tests, medicines or other treatments, and/or
  • A close watch by health care providers

Maximum Allowable Charge (MAC)

The most your health plan will pay for a covered service

Medically Necessary

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

Network

The doctors, hospitals and other health care providers who agree to discount their services for health plan members

Out-of-Network

Doctors, hospitals and other health care providers not under contract with the health plan

Physician Services

The care from or directed by a licensed doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine)

Pre-authorization

  • Approval from your health plan before you get certain care or services
  • A decision by your health plan about the medical necessity of care

This may be called “prior authorization,” “prior approval” or “pre-certification.” Your health insurance or plan may require pre-authorization before you get certain services. Pre-authorization is not needed for emergency care. Preauthorization is not a promise your health plan will cover the cost.

Prescription Drug (Medicine) Benefits

A health plan that helps pay for prescription medicines

Preventive Services

Health care services to find an illness or condition at an early stage or to keep you from getting an illness or condition

Preventive service examples include cancer screenings and flu vaccines.

Primary Care Provider (PCP)

A provider in family practice, internal medicine, general practice, nurse practitioner or children’s care

A PCP may be an M.D. (Medical Doctor), a D.O. (Doctor of Osteopathic Medicine), or a N.P. (Nurse Practitioner). A PCP provides or coordinates a range of health care services for patients.

Provider

A person or facility that offers health care services or prescription medicines
Providers include:

  • People such as doctors, nurses, therapists, technicians, counselors, physician assistants, chiropractors and more
  • Facilities like hospitals, rehabilitation clinics, community health centers and more
  • Pharmacies

Reconstructive Surgery

Surgery and follow-up treatment to correct or improve a damaged part of the body

The damage may be due to:

  • Birth defect
  • Accident
  • Injury
  • Illness or disease

Rehabilitation Services (also called Habilitation Services)

The services that help get back or improve skills and function for daily living

The loss or damage of skills and functions may be because you were sick, hurt or disabled. These services may include:

  • Physical and occupational therapy
  • Speech-language pathology
  • Psychiatric rehabilitation services.

You can receive Rehabilitation Services:

  • In a health care facility (inpatient), or
  • At home, in a clinic, other facility, or provider’s office (outpatient)

Schedule of Benefit or Summary of Benefits and Coverage

A list of your health plan’s covered benefits

Skilled Care Services

The services you receive from technicians and therapists in your home or in a nursing home

Skilled Nursing Care

The services from licensed nurses in your home or in a nursing home

Skilled Nursing Facility

A facility that provides inpatient nursing care, rehabilitation or other related health services

“Skilled nursing” does not include a convalescent home or custodial care.

Specialist

A person in health care with a focus on a certain area of medicine or group of patients

A specialist finds, manages, prevents or treats certain types of symptoms and conditions.

A specialist may be a physician (doctor). Examples of physician specialists include:

  • Cardiologist (doctor who treats heart diseases and conditions)
  • Neurologist (doctor who treats disorders of the nervous system)

Specialty Drugs (Medicines)

Medicines used to treat complex, chronic conditions

You or your provider must use special handling and administration of specialty medicines.

Urgent Care

Services for an illness, injury or condition that does not risk severe harm or death, but needs quick treatment

Urgent Care is for health issues that do not need emergency room care.



This page was updated on Aug 05, 2014