Glossary

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alternative care

Alternative care typically means services provided by chiropractors, naturopaths, acupuncturists and massage therapists.
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brand-name drugs

Medications that have a trade name and are protected by a patent. Brand-name drugs are often more expensive than their generic equivalents.
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catastrophic coverage

Catastrophic coverage is insurance coverage that is designed to protect the consumer from financial disaster in the case of a serious medical emergency. Because this type of coverage focuses primarily on the most expensive medical care, smaller expenses such as doctor visits or prescription drugs are usually not covered in catastrophic plans. Instead, these plans typically have high deductibles which must be met before the plan begins paying claims. Once the patient's out-of-pocket spending reaches a specified maximum amount, the plan covers all expenses beyond that amount.

COBRA

Temporary continuation of health coverage at group rates available to certain former employees, retirees, spouses, and dependent children when coverage is lost due to a qualifying event, such as loss of employment. Generally, COBRA participants pay the entire premium themselves.

coinsurance

The percentage a member pays toward the total negotiated charges for medical services.

coinsurance maximum

The coinsurance maximum is the part a member would have to pay in a year for their portion of the covered expense. After that, the carrier pays 100% of all covered expenses, up to the lifetime maximum.

comprehensive coverage

Complete coverage for hospital and physician charges subject to deductibles and coinsurance.

coordination of benefits (COB)

A person can have more than one kind of insurance coverage, say one plan from their employer and one from their spouse's employer. In that case, the two health plans work together to coordinate which one pays first, and how much. This process is called coordination of benefits.

copay

A fixed dollar amount the member pays the provider when they receive a medical service.
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deductible

A fixed, annual dollar amount that a member pays for medical services before the carrier begins paying for covered medical services.

dependent

Another person, such as a child or a spouse, who is legally eligible to benefits under a member's health plan.
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effective date

The date when coverage begins or takes effect.

endodontics

A restorative treatment for the center of a tooth, such as root canal therapy.

explanations of benefits (EOB)

A description of the benefits paid for a particular claim. A health plan sends an EOB to a patient after the patient receives services from a provider. Also called a "claims processing report."
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formulary

List of prescription medications covered by a health plan. Formularies can be open, meaning you may get some coverage for medications not on the list, or closed, meaning only medications on the list are covered. Formularies are also called Preferred Medication Lists.
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generic drugs

Prescription medications that have the exact same active ingredients and strength as brand-name medications. Generics, as they're often called, are equal in therapeutic power to their brand-name counterparts. Health plans often encourage use of generics because they are usually much less expensive.

group health plan

A plan offered by an employer or an employee organization (such as a union) to provide medical coverage to employees, retirees and/or their dependents.
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health exchange

A government-regulated market for buying health insurance coverage for individuals and families.

health maintenance organization (HMO)

A type of health plan that requires subscribers to receive all medical care from network providers, usually under the direction of a primary care physician (PCP).

health savings account (HSA)

A tax-free savings account that is paired with a high-deductible health plan. You or your employer add tax-deductible funds to the account for you to use on medical, retirement, or long-term care expenses. The funds can roll over from year to year and can grow with interest or investment returns. You can take the account with you when you change jobs or health plans.
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incentive dental

A dental plan with benefits that increase each year if you see a dentist for covered services. In other words, members have an "incentive" to receive regular dental care.

indemnity plans

Historically, this term has been used to apply to plans that pay benefits as a flat dollar amount (for example: $100 per day for a hospital room). More recently, it has come to be used for any traditional (non-PPO, non-HMO) medical plan.

individual coverage

A health insurance policy that is selected and purchased by an individual or family for their own coverage rather than one sponsored by an employer or other group.
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lifetime maximum

The maximum amount the carrier will pay for covered expenses across coverage years for each member.
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Medicare

A two-part federal program that helps with medical costs for those over 65 or permanently disabled. Medicare Part A covers some inpatient hospital expenses for everyone enrolled at no cost. Part B is optional, and covers physicians' services, outpatient care and more for a small cost to enrollees.

Medigap

A type of health plan that complements federal Medicare coverage. These plans cover costs like preventive care, prescriptions, at-home care, and more.
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network

A list of physicians and medical facilities that are contracted by the carrier to provide services to its members at agreed-upon rates.

no referrals

No referrals means a member can go directly to a specialist without first seeing their regular doctor.

non-network providers

Providers (such as hospitals and physicians) who are not part of a particular provider network. Some health plans cover non-network providers, but your costs will almost always be higher.
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office visit

A formal, face-to-face meeting between you and a health professional in a clinic, office or hospital outpatient area. Same as an "office call."

orthodontia

A branch of dentistry that deals with the prevention and correction of abnormalities of the teeth and jaw.

out-of-pocket expense

Money you spend when using health care services. Your deductible and coinsurance are kinds of out-of-pocket expenses. Your premium is not usually considered an out-of-pocket expense.

out-of-pocket maximum

A maximum amount you'll be responsible for paying toward your covered medical expenses in a calendar year, also known as stop-loss. This amount varies by plan and may not include some kinds of out-of-pocket expenses, such as deductibles and copays for office and pharmacy visits. After you have reached your out-of-pocket maximum, the carrier pays 100% of remaining covered medical expenses in a calendar year.
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participating provider network

Providers (such as hospitals and physicians) who have agreed to provide services to patients at rates pre-negotiated by the patient's health plan. Compare to preferred provider network.

pre-existing condition

A health condition that displays symptoms, or one for which a patient seeks treatment, before health insurance coverage begins. Usually, there is a limit to how far back a health plan can check for such conditions.

preferred medication list (PML)

See formulary.

preferred provider network

Providers (such as hospitals and physicians) who agree to charge a pre-negotiated rate for everyone on a particular health plan.

preferred provider organization (PPO)

A health plan that generally provides coverage for members to see any provider. Members get more coverage and lower out-of-pocket costs for seeing "preferred" network providers.

premium

The amount an individual pays for coverage. Same as rate.

preventive care

Routine services like well-child care, immunizations, adult physicals and exams, sometimes lab and x-ray services that help prevent health issues or detect them early on. Preventive care services vary from plan to plan.

primary care provider (PCP)

A doctor or health professional that provides basic care and coordinates other care through referrals to specialists as needed. Some people refer to a PCP as their personal care provider.

provider

Hospitals, clinics, physicians and other health care professionals (such as midwives and nurse practitioners) that provide care to patients.

provider network

A group of providers (such as hospitals and physicians) who agree to a pre-negotiated price for services they provide. To get that price, a patient must be covered by a particular health plan that uses that network. On some health plans, a patient has less or no insurance coverage if they see a provider who is not in their network.
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qualifying event

Something that happens to make one eligible for continued insurance coverage under COBRA or state law. Examples of qualifying events: termination of employment, death or divorce.
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rate

See premium.
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second opinion

An evaluation of a health care issue made by another doctor after a diagnosis has been made, usually when surgery is being considered. A patient may get an opinion from one provider about the best treatment, and then ask other providers for their recommendations or "second opinions." Some health plans require second opinions; others encourage them.

service area

The geographic area where an insurance company sells and delivers services. A service area can also be product-specific.

short term disability (STD)

Coverage intended to provide partial income replacement for people who are disabled for a short time.

skilled nursing facility (SNF)

A facility licensed to provide inpatient care, including round-the-clock nursing.

stop-loss

See out-of-pocket maximum.
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traditional plan

A type of health plan with no provider network limitations. These plans have the widest provider choice, but can be expensive.
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underwriting

The process of identifying and classifying the potential risk of insuring a person or group of people.

uninsurable

In health insurance, individuals who are "uninsurable" can't get coverage (or can get it only at higher rates) because of their medical history. It often refers to people who are already seriously ill when they apply for coverage.

up-front benefit

A benefit that does not apply towards the deductible. For example, an annual physical could be covered at 100% without first having to meet a deductible.
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wellness programs

Programs that promote safety and good health. For example: discounted gym fees, smoking cessation, and nurse hotline.
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