Glossary cf Health Coverage and Medical Terms r This glossary has many commonly used terms, but isn't a full lisl 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 exacdy 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.) . Berld blue text indicates a terrn defined in this Glossary. I See page 4 for an example showing how deductibles, cc-instrance and out-of-pocket limix work togerher in a real life situation. Allowed Amount Co-palznerrt Maximum amount on which payment is based for A fixed amount (for example, $I5) you pay for a covered covered health care seryices. This may be called "eligible health care service, usually when you receive the service. expense," "payment allowancett or "negotiated rate.tt If The amount can vary by the type of covered health care your ptovider charges more chan che allowed amount, you service. may have to pay the difference. (See Bala*ce Bi[iog.) Deductible App.rl The amount you owe for :o A requesc for yoor health insurer or plan to review a health care services your decision or a grievance again. health irx*ranee or plan covers before your healrh Balance Billing insurance or plan begins pavs Hcr plan pavs When a prt:vider bills you for the difference between the to pay. For example, if lirnc o% provider's charge and the aliowed amount. For example, your deductible is $I000, r00% if che provider's charge is $I00 and the allowed amounr your plan won't pay i.Sct' ;,agc 4 lbr a Jr:taibd rr.rnrplc, i is $70, the provider may bill you for the remaining $30. anything until you've met A prefrrred prcvid* may notbalance bill you for covered your $ 1000 deductible for covered healch care services services. subject to the deduccible. The deductible mav nor apply to all services. Co-insurance Your share of the costs Drrable Medical Equipment (DI!C) ofa covered health care Equipment and supplies ordered by a health care provider service, calculated as a for cveryday or extended use. Coverage for DME may percent (for example, include: oxygen equipment, wheelchairs, crutches or 20%) of the atrlowed blood testing strips for diabetics. afirou{lf for the service. |ane pirvs Hr:r pl:rn pavs You co-insurance pay 2Ao/o 8}o/o Emergency Mefical Confition plusany deductibles i,Scc pagc -1 ibr .r .1i:rai[cd cr,rr,plc.) An illness, injury, symptom or condition so serious rhat a you owe. For example, reasonable person would seek care right away to avoid if the health insuracre or plan's allowed amount for an severe harm. office visit is $I00 and you've met your deductible, your co-insurance payment of 20o/o would be $20. The healch Emergency Medical Transportation insurance or plan pays the rest of the allowed amount. Ambulance services for an ex:rrgency me<{ieal conetrition.
Complications of Pregnancy Emetgency Room Care Conditions due to pregnancy,labor and delivery that Yrx*zg*nc'V seryices you get in an emergency room. require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- Emergency Services emergency caesarean seccion aren't complications of Evaluation of an ernergency medical condition and Pregnancy. treatment to keep the condition from getting worse.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-l 146 Glossary of Hrakh Coverage and Medical Terms Page 1 of 4 Exduded Services Medically Necessary Health care services that your health insurance or plan Health care seryices or supplies needed to prevent, doesn't pay for or cover. diagnose or treat an illness, injury, condition, disease or its sympcoms and that meet accepred standards of C,rievance medicine. A complaint that you communicate to your health insurer or plxr. Network The facilities, providers and suppliers your health insurer Habilitation Services or pla* has contracted with to provide health care Health care services char help a person keep, learn or services. improve skills and functioning for daily living. Examples include therapy for a child who isn'c walking or talking ar Non-Prefered Provider the expected age. These services may include physical and A provider who doesn't have a concract with your health occupational therapy, speech-language pathology and insurer or plan to provide services ro you. You'll pay other services for people with disabilities in a variety of more to see a non-preferred provider. Check your policy inpatient and/ or outpatient settings. to see if you can go to all providers who have contracted with your hraltlr:irxurance or plan, or if your heakh Heakh Insurance insurance or plan has a "ciered" netwofk and you must A contract that requires your health insurer to pay some paF extra to see some providers. or all ofyour health care costs in exchange for a premi*m. Out-of-netwofk Co-insutance The percent (for example,4OYo) you pay of the allowed Home Heakh Care exlount for covered health care services to providers who Health care services a person receives ac home do not contract with your heakh insurance or plan. Out- of-network co-insurance usually coscs you more chan in- Hospice Services neiwork co-insurance. Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Out-of-network Co-palim.ent A fixed amount (for example, $30) you pay for covered Hospitalization health care services from providers who do notcontract Care in a hospical that requires admission as an inpatient with your healch insurance or plan. Out-of-network co- and usually requires an ovemight shy. An overnight stay payments usually are more than in-c?erwork co*pa1':nents. for observation could be outpatient care. Out-of-Pocket Limit Hospitd Outpatient Care The most you pay during a Care in a hospital that usually doesn't require an policy period (usually a overnight stay. year) before your health irsura::ee or plar: begins to In-network Co-insurance pay IOOo/o of the allcwed arerolrnL This limit never The percent (for exampl e, 2O%) you pay of the allowed J;rnc pavs t-lcr plan plrr's ar:louna for covered health care services to pror.iders who includes your premiu:a, Oalo I0O% contract with your health irxurance or plan. In-nerwork baiance-billed charges or I sc* p:rge { to. rr dctrrileil c't;rrrrple ') co-insurance usually costs you less than out*af-network health care your h"dtl-r" c*-irxgrane*. insurance or plan doesn't cover. Some health insurance or plans don't count all of your co-peyraerts, deductibles, In-network Co-palment cc*inscrance payments, out-of-network payments or other expenses A fixed amount (for example, $I5) yo:u pay for covered toward this limir. health care services to prcviders who contract wirh your health ilsurance or plan. In-network co-paymenrs usually Physician Services are Iess than out*of*network co-pafmenfs. Health care services a licensed medical physician (M.D.- Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinares.
Gloss*ry cf Health Coverage and Medical Terms Page 2 of 4 Ptan Provider A benefit your employer, union or other group sponsor A physician (M.D.- Medical Doctor or D.O. - Doctor provides to you to pay for your health care services. of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredircd as Preagthorization required by state law. A decision by your health insurer or plan that a health care service, treatment plan, pres*:ipri*n drug or drerable Reconstnrctive Strrgery metiie*3 equipment is arredically neeessary. Sometimes Surgery and follow-up treatment needed to correct or called prior authorization, prior approval or improve a parc of the body because of birth defecrc, precertification. Your health insrrance or plan may accidents, injuries or medical conditions. require preauthorization for certain services before you receive them, except in an emergency. Preauchorization Rehabilitation Services isn't a promise your healch insurance or plan will cover Health care services that help a person keep, get back or the cost. improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or Preferred Provider disabled. These services may include physical and A pr*vi&*r who has a contract with your health insurer or occupational therapy, speech-language pathology and plan to provide services to you ac a discount. Check your psychiatric rehabilitation services in a variety of inpatient policy to see ifyou can see all preferred providers or if and/ or outpatienr setrings. your h*alth insurance or plan has a "tiered" nefwork and you musc pay extra to see some providers. Your health Skilled Nursing Care insurance or plan may have preferred providers who are Services from licensed nurses in your own home or in a also "participating" providers. Participating providers nursing home. Skilled care services are from technicians also contract with your health insurer or plan, but the and therapists in your own home or in a nursing home. discount may not be as great, and you may have to pay more. Specialist A physician specialist focuses on a specific area of Premium medicine or a group of patients to diagnose, manage, The amount that must be paid for your health ir:srrance prevent or treat certain types of symptoms and or pla:1. You and/or your employer usually pay it conditions. A non-physician specialist is a provider who monthly, quarterly or yearly, has more training in a specific area of health care.
Prescription Drug Covetage UCR Qrr"l, Customary and Reaso*bl, Health jnsurance or plan that helps pay for prescription The amount paid for a medical service in a geographic drugs and medications. area based on what pr*viders in the area usually charge for the same or similar medical service. The UCR Prescription Dnrgs amount sometimes is used to determine che allowed Drugs and medications that by law require a prescription. amount.
Pdmary Care Physician Urgent Care A physician (M.D.- Medical Doctor or D.O. - Doctor Care for an illness, injury or condition serious enough of Osteopathic Medicine) who directly provides or that a reasonable person would seek care right away, buc coordinates a range ofhealth care services for a parient. not so severe as co require frnergency roocl care,
Pfttrar,, Cate Provider A physician (M.D.- Medical Doctor or D.O. - Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assiscant, as allowed under state law, who provides, coordinates or helps a parienr access a range ofhealth care services.
Glossary of Heakh Coverage and Medical Terms Page 3 of 4 How You and Your lnsmrer Share Costs - Exampte Jane's Plan Deductible: $1,500 Go-insurance:20o/o Out-of-Pocket Limit: $5,000
January I"t Aecember 31 Beginning of Cov*rage End af Coverage Feriod Period
+ r+> more more costs costs -fanc per,s Hcr 1;l,rn pavs Jenc pl,s Hcr plan pa.r's {arrr plvs Her: plan pa,r's rca% Oo/o 8Ao/o @ 2oo/o @ Oo/o t00% Jane hasn't reached her Jane reaches her $1,500 Jane reaches her $5,000 $1,500 deductible yet @ deductible, co-insurance begins @ out-of-pocket limit Hcr Plirl d.r,:sn'f p;11' anl' c,l: the cost-s. Janc has sccn a docr.,l' scycral timcs :rLrcl Jrrn.: h;rs s*cil thrr dc,ctcrr oti,,:r-r irnd p;rir{ Office visit costs: $ 125 @ paid $1,500 iu rotal. I-{cr plan pa.vs sor}}rl @ $.5,0U) in roral. I"{er plarr prr-s th.'flll ]ane pays: $I25 ,,if [h.' c,"rsts lor ]rcr nexr visit. cr.rst of hcr covcrrrd hcaith cerc sr:ryices Het plan pays: $0 Offi.ce visit costs: $75 lirl thc rcst trf'tlre \.'lr. |ane pays:2096 of$75 = SI5 Office visit costs: $200 (r0 Her plan pays: B0')(r of $75 = l,f Jane pays: $t) Her plan p*ys: $100
Glossary of Health Covemge and Medical Terrns Page 4 of 4