This Glossary has many commonly used terms, but isn't a full list.
The amount your health plan pays for a covered service
This may be called “eligible expense,” “payment allowance" or "negotiated rate"
A request for your health plan to take another look at a decision or a complaint Benefit
Your health plan’s payment(s) for covered services or medicine
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:
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.
The services or medicines your health plan pays for
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:
An illness, injury, symptom or condition that needs care right away to avoid severe harm or death
Ambulance service for a person who needs hospital care right away
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.
The care your health plan will not pay for
The care, services or items your health plan will not pay for
A list from your health plan that shows:
Medicines without a brand-name
Generic medicines include:
formula 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.
Health care services you get at home
A provider of comfort, care and support to people who are near death
Hospice Services may also help the patients’ families.
An inpatient hospital stay
Sometimes patients are not admitted to the hospital, but stay for observation. Observation is hospital outpatient care.
Care given in a hospital before the patient is admitted
Hospital Outpatient Care may include:
The most your health plan will pay for a covered service
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.
The doctors, hospitals and other health care providers who agree to discount their services for health plan members
Doctors, hospitals and other health care providers not under contract with the health plan
The care from or directed by a licensed doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine)
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.
A health plan that helps pay for prescription medicines
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.
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.
A person or facility that offers health care services or prescription medicines
Surgery and follow-up treatment to correct or improve a damaged part of the body
The damage may be due to:
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:
You can receive Rehabilitation Services:
Schedule of Benefit or Summary of Benefits and Coverage
A list of your health plan’s covered benefits
The services you receive from technicians and therapists in your home or in a nursing home
The services from licensed nurses in your home or in a nursing home
A facility that provides inpatient nursing care, rehabilitation or other related health services
“Skilled nursing” does not include a convalescent home or custodial care.
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:
Medicines used to treat complex, chronic conditions
You or your provider must use special handling and administration of specialty medicines.
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