Health insurance terms defined (Glossary) – CDPHP

health coverage and defined medical terms

  • full deductible vs. integrated deductible

    An aggregate deductible is when the full family deductible for a family health care plan must be met in order to receive reimbursement from your insurance company. the deductible can be met by one family member or a combination of members within the family. A built-in deductible is when individual members in a family health care plan only need to meet their own deductible before the health insurance company will reimburse charges for service.

  • allowed amount

    This is the most money your insurance company will pay for a health care service. If your bill for a health care service exceeds the allowed amount, you may have to pay the difference. this may also be called an “eligible expense,” “payment allowance,” or “negotiated rate.”

    Reading: What does not applicable mean in health insurance

  • invoiced amount or quantity invoiced

    This is the amount your doctor bills your health plan after providing you with health care services. This is not necessarily the amount your insurance plan will pay for these services, as health plans often negotiate payments with doctors to keep health care costs affordable.

  • appeal

    An appeal is your chance to dispute your insurance company’s decision not to cover a certain health care service. In this situation, you can file an appeal directly with your insurance company.

  • balance billing

    When the bill for your health care service exceeds the allowed amount established by your insurance company, you must pay the difference between the allowed amount and your doctor’s total charge. In addition, there is a state law outside the network that requires creating greater transparency within the health care system. The law protects patients from balance billing for “surprise bills” or emergency service bills from nonparticipating physicians. The law requires health plans to send notice to both members and providers when a claim (received for services from a New York State non-participating provider) is paid at usual and customary rates.

    Example: If your doctor charges $100 for a service and the amount paid by your insurance company (the allowed amount) is $80, the doctor may send you a bill for the remaining $20.

  • benefit year or benefit period

    This is the year or time period your insurance coverage begins and ends. A benefit year can start and end at the beginning and end of a calendar year, but can also vary depending on your plan.

  • care coordination

    Care coordination involves the sharing of information between different health care providers (primary care physicians, your health insurance company, etc.) to ensure that you receive the appropriate health care services.

  • exclusion

    An employer group uses a different insurance company to administer a specific benefit instead of your primary health insurance provider.

  • coinsurance

    the percentage of the bill you pay for a covered product or service. Unlike a copay, which is a fixed amount, coinsurance is a percentage (%) of the cost of the service. If your health plan has a deductible, coinsurance is the amount you’re responsible for after you meet your deductible. If you receive services from an out-of-network doctor, you may have to pay additional charges above your coinsurance.

    Example: Let’s say you visit your doctor after you meet your deductible. now his plan requires a 20 percent coinsurance. if the doctor is paid $100 for the visit, you will owe $20. watch the video ►

  • commercial health plans

    A commercial health care plan is insurance coverage that is not provided by the state or federal government, but through a public or private company. This type of health care coverage is most often offered through an employer, giving employees the opportunity to select from different health benefit options that best meet their financial and medical needs.

  • lockdown

    If you are in a situation where you need ongoing health care support, a doctor may commit you to a hospital, nursing facility, or other health care program location. once you are stable, a doctor will formally discharge you before you can leave.

  • copay or copay

    A health insurance term that refers to the amount you pay for a health care service, such as a doctor’s visit or a trip to an urgent care center. the amount depends on your plan and the type of service you receive. Please note that if your plan has a deductible, you may be responsible for meeting your deductible first. then your copay will kick in. additionally, prescription medications also require copays, and will vary by medication.

    example: You have a $20 copay for visits to your primary care provider (pcp) and a $40 copay for urgent care visits. this means you will pay $20 each time you go to your pcp and $40 each time you go to urgent care. watch the video ►

  • deductible

    The amount of money you pay for covered health care services before your health insurance starts paying the bill. if your cost exceeds the deductible, your plan will cover the rest, or a percentage of the rest. If you’re in the process of choosing a health insurance plan, it’s helpful to know that plans with higher deductibles tend to have lower premiums. watch the video ►

    Example: If your deductible is $2,000, your insurance will pay nothing until you have paid $2,000 for covered health care services. If you need a medical service that costs $3,000, you will pay the $2,000 deductible and the plan will cover the rest or part of the remaining $1,000.

  • quantity rejected or cancellation

    This is simply the difference between what your doctor billed your insurance company and what the insurance company paid. declined or canceled amounts are not billed to the patient; instead, they are canceled by the health care provider.

  • emergency medical condition

    an illness, injury or symptom that would allow you to receive immediate attention from a medical professional.

  • emergency services

    This is simply treatment for an emergency medical condition. a medical professional would attend to the emergency immediately to prevent the condition from worsening.

  • enhanced primary care (epc)

    a unique cdphp program that increases the value and quality of patient care while offering a one-time payment model that encourages primary care physicians to spend more time with their patients.

  • er, urgent care or pcp?

    While you may be familiar with the terms emergency room (ER), urgent care, and primary care physician (PCP), do you know who to visit for a health problem and when? Deciding on the best course of action can be critical to obtaining the most effective care for your medical needs. A PCP knows your medical history and can treat you with your unique health needs in mind, while an urgent care center can be very convenient when your doctor’s office is closed. Of course, the emergency room is the best option when emergency care is needed. making the right decision can also save you money. While you should always go to the ER for serious health emergencies, visiting your PCP is a more cost-effective option under normal circumstances.

  • excluded services

    Any health care service that your health insurance company doesn’t pay for or cover.

  • explanation of benefits (eob)

    At first glance, it may look like an invoice, but it is not. An EOB is a statement that your health plan mails after you receive a health service. It tells you how much the doctor charged, how much your insurance company will allow, how much your insurance paid, and how much you may owe. watch the video ►

  • fee schedule

    a list of costs for health care services developed by your health insurance company. This list includes the maximum amounts your health insurance will pay you (the member) for specific services. A fee schedule can include everything from primary care doctor visit costs to the cost of using an ambulance to medical equipment fees.

  • form

    See also: Cancelling your Health Insurance Plan | HIA

    a list of prescription drugs that your insurance company will pay for, based on the drug’s effectiveness, safety, cost effectiveness, and overall value. A formulary is generally divided into three tiers, with different copay amounts (tier 1 has the lowest copay and tier 3 has the highest copay).

    Example: If your doctor prescribes a new medication, it’s always a good idea to ask if the medication is covered by your health insurance. Your doctor will be able to find out if the drug is covered by looking at your plan’s prescription drug formulary.

  • fund accounts

    fsas, hras and hsas are all types of funding accounts and can help you save money when it comes to your out-of-pocket medical expenses.

  • fsa

    A flexible spending account (fsa) allows employees to set aside pre-tax dollars for specific, qualified health or dependent care expenses. the money is deducted directly from the employee’s paycheck and is not subject to payroll taxes.

  • hra

    A health reimbursement arrangement (HRA) allows employers to establish and fund accounts that will reimburse employees for certain qualified medical expenses. it’s owned by your employer, so if you leave your job, the account (and the money in it) doesn’t go with you.

  • hsa

    A health savings account (HSA) is owned by the individual (not the employer) and can be used to pay for qualified medical expenses without federal tax penalties. Unlike an HRA, because it’s not owned by your employer, if you leave your job, the account (and the money in it) goes with you.

  • global billing

    Global billing was developed to simplify charging for complex healthcare services. For a specific set of health care services, you would receive one total bill instead of multiple bills from different providers.

    Example: Let’s say you have surgery in a hospital. instead of receiving individual bills from your doctor, hospital, and technicians, along with the equipment charges, you will be sent a full bill.

  • complaint

    If you have a complaint against your health insurance company, you can file a complaint. This complaint can be used to express dissatisfaction with any aspect of your health care plan.

  • enabling services

    Health care services you would get to learn or improve your skills and functioning. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities. Habilitation services are performed in a variety of inpatient and/or outpatient settings.

    example: therapy for a child who is not walking or talking at the expected age.

  • health insurance portability and accountability act (hipaa)

    a federal privacy law that sets national standards to protect people’s medical records and other personal health information. The law gives patients more control over their health information, places limits on the use and disclosure of health records, and establishes safeguards that health care providers and others must follow to protect the privacy of health information.

    Example: If you call your health plan with questions about a claim for a dependent age 18 or older, the health plan may not be able to provide you with these details, as the information is protected by federal privacy laws. privacy.

  • hospice services

    services that provide comfort and support in the last stages of a terminal illness. These services may be offered in a person’s home, in a nursing home, or in a hospital.

  • hospitalization

    admission to a hospital for health care services that usually require an overnight stay.

  • in-network coinsurance versus out-of-network coinsurance

    After you meet your deductible, in-network coinsurance is the percentage of a health care service you pay to a doctor who contracts with your health plan. Out-of-network coinsurance is the percentage you pay for covered health care services to providers who are not contracted with your health insurer. In-network coinsurance generally costs less than out-of-network coinsurance because there is a negotiated service price between the provider and your health insurance company.

  • in-network copay or copay versus out-of-network copay or copay

    The amount you pay for a health care service to providers who have a contract with your health insurance company is an in-network copay. An out-of-network copay is the amount you pay for a health care service to a provider who does not have a contract with your health insurer. In-network copays generally cost less than out-of-network copays.

    Example: You might pay a $20 copay for a sick visit to an in-network doctor, while a sick visit to an out-of-network doctor might cost a $50 copay.

  • in-network providers versus out-of-network providers

    To control costs, your health plan may create what is called a preferred provider network (or in-network providers), which may include doctors, hospitals, pharmacies, and other health care providers, where you pay less out of pocket. these networks vary by plan type, so it’s always a good idea to check with your health plan before visiting a health care provider in a non-emergency situation. Unlike a preferred provider, a non-preferred provider (or out-of-network provider) does not have an official service contract with your health plan. As a result, you will pay more when you use a non-preferred provider. check your insurance policy to see if you can go to all the providers your health plan contracts with or if your health plan has a “tiered” network where you must pay more to see select providers. watch the video ►

  • long-term care

    assistance and care of a person with chronic disability. long-term care supports chronic disabilities such as cancer, arthritis, asthma, eating disorders, and diabetes. these services are usually provided in a skilled nursing facility, intermediate care, personal care, or nursing facility care.

  • medical

    Medicaid is a federal and state health care program that provides free or low-cost health coverage for people with low incomes and people with disabilities.

  • medical diagnosis

    A medical diagnosis is simply the identification of a disease. Sometimes medical diagnoses are made when you’re not necessarily looking for them, like at your annual checkup. If this occurs, you may be charged a copay or coinsurance as this is outside of your regular checkup.

  • medically necessary

    Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, or its symptoms that meet accepted standards of care.

  • medication

    Medicare is a health care program run by the federal government for people age 65 and older. certain people with disabilities and those with end-stage renal disease are also eligible for this program. there are four basic components:

  • medicare part a (hospital insurance)

    covers inpatient services, including hospital stays, home health care, hospice care, and limited skilled nursing facility services.

  • medicare part b (medical insurance)

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    covers outpatient services, including physician services, medical supplies, and other outpatient treatment. After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

  • medicare part c (medicare advantage plans)

    a managed medicare benefits plan. With this type of plan, qualified individuals and groups would have their Medicare coverage provided through an insurer, such as CDPHP. must be eligible for medicare parts a and b. Medicare Advantage plans may provide prescription drug coverage (Part D).

  • medicare part d (prescription drug coverage)

    a federal program to help cover the costs of prescription drugs for medicare beneficiaries in the united states.

  • network

    Facilities, vendors, and medical providers that your health insurance company has contracted with to provide health care services. A network could range from a primary care physician (PCP) to a chiropractor to a nursing home.

  • non-routine/sick visit

    Unlike a routine or preventive visit, a non-routine or sick visit is used to detect or treat a medical diagnosis. care received during a sick visit is also billed differently than a preventive exam and may result in out-of-pocket costs.

  • out-of-pocket maximum

    Many people don’t realize that each health insurance plan sets a maximum amount for the amount you’ll have to pay, called the out-of-pocket maximum (oop max). Once you’ve reached your OOP maximum, your health insurance company will begin paying 100 percent of your costs for covered care. different plans have different oop maximums.

    Example: Let’s say your out-of-pocket maximum is $5,000. Once you pay $5,000 for covered health care services (this may include deductibles, copays, and coinsurance), your health insurance will pay 100 percent of the costs of covered care.

  • ambulatory care/ambulatory care

    care in a hospital that does not require an overnight stay. examples of outpatient hospital services include lab tests, physical therapy, minor surgery, and x-rays. Outpatient services generally cost less than inpatient services because they do not require the patient to stay in a health care facility for a continuous period of time.

  • medical services

    Health care services that a licensed physician (m.d. – physician or d.o. – doctor of osteopathic medicine) provides or coordinates. The ultimate goal of medical services is to improve or maintain the health of patients.

  • point of service (pos) contract

    If you use a medical provider outside of your health plan’s network, you can work with your insurance company to create a managed care or point-of-service contract. if you choose to do so, you will be subject to higher copays, deductibles, or coinsurance.

  • premium = invoice

    A premium is the amount you pay for health insurance. it is essentially your health insurance bill, which may be due monthly, quarterly, or annually. it’s a bill that you may or may not see, depending on the type of health insurance you have.

    Example: If you have health insurance through your employer, money may be deducted from your paycheck each month for health insurance. this is your insurance premium.

  • prescription drug coverage

    This is the part of your health plan that helps pay for your prescription drugs.

  • prior authorization

    Sometimes your health insurance plan requires certain medical services to be approved before you receive them. this is called prior authorization or prior authorization, prior approval, or precertification. It allows your health insurance company to make sure that the care you are receiving is medically appropriate and is provided in the appropriate setting.

  • reconstructive surgery

    surgery and follow-up treatment necessary to correct or improve a body part due to birth defects, accidents, injuries, or medical conditions.

  • rehabilitation services

    health care services to help regain skills and function. If you have been ill, injured, or disabled and have lost skills or functions as a result, you may be able to use rehabilitation services. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services.

  • riders

    Optional benefits or benefits package not included in your standard health plan coverage that can be purchased for an additional premium. this would be considered an amendment to your insurance policy.

    Example: You can purchase a dental rider to add dental coverage to your health insurance policy.

  • routine/preventive visit

    Wellness or preventive visits are usually scheduled appointments that include a checkup, screenings and counseling. they do not include tests or services to monitor or manage a condition or disease once it has been diagnosed. Depending on your plan type, care provided during these visits is often covered with no out-of-pocket costs. watch the video ►

  • skilled nursing care

    Health care services provided by registered nurses (RNs) and/or specialized therapists (physical, speech, or occupational therapists). Skilled nursing care can meet short-term needs, like a broken bone, or long-term needs, like cancer or asthma.

  • specialist

    A specialist is a doctor who focuses on a specific area of ​​health care. Some examples of specialists include cardiologists (heart), dermatologists (skin), pulmonologists (lungs), and ophthalmologists (eyes).

  • telemedicine

    Telemedicine is a different way of receiving care from a medical expert. Instead of seeing a doctor in person, you can talk to them on the phone, computer, or tablet. use telemedicine as an alternative to urgent care or when you can’t get to the doctor’s office. watch the video ►

  • timely presentation

    A timely filing is basically the deadline by which a doctor must file a claim with an insurance company.

  • ucr rates (usual, customary and reasonable)

    To control expenses, insurance companies develop UCR rates. These are the determined amounts paid by your insurance company for a medical service. rates are based on what providers in a geographic area typically charge for the same or similar medical services. The amount of the UCR is sometimes used to determine the amount allowed.

    glossary was developed by cdphp. This resource is intended as an overview of commonly used healthcare terms; it is not intended to supplement or modify a member’s policy. members should review their contract for definitions specific to their own plan.

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