Glossary

Find easy-to-understand definitions for common health care terms.

Accreditation: Accreditation is a process medical organizations go through to be recognized for meeting certain standards.
Allowed Amount / Allowable Amount / Allowable Charge: The allowed/allowable amount/charge is the maximum amount your health plan allows for covered health services. If you choose to go to an out-of-network provider and are charged over the allowed amount, you may have to pay the difference. See also: Balanced Billing.
Annual Physical: Your annual physical is a physical examination you are entitled to receive once per year.
Annual Wellness Visit: An Annual Wellness Visit is a yearly visit with your primary care provider meant to help you improve your health and stay well.
Appeal: An appeal is a request that your health plan company review or change a claim decision.

Balanced Billing: Balanced Billing refers to the difference between the provider's charge and the allowed amount. Doctors and hospitals may bill patients to make up this difference.
Benefit: Medical services, drugs or other items covered by your health plan are considered benefits.
Benefit Period: The amount of time that your health plan will pay for certain covered medical services is known as the benefit period.

Claim: A claim is a payment request that your health care provider submits to your health plan when you receive covered health care items and services.
Coinsurance: Coinsurance is the percentage of the allowed amount for the covered health services you may be required to pay, usually once the plan deductible has been met.
Copay / Copayment: The copay or copayment is a set dollar amount you pay toward a doctor visit and other services. This amount can vary based on the health plan coverage terms.
Coverage Gap / Medicare Donut Hole: The period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage is known as a coverage gap or Medicare Donut Hole.

Deductible/Annual Deductible/Calendar Year Deductible: The deductible, annual deductible or calendar-year deductible is the amount you pay for covered health care services before your plan begins to pay. After you have paid your deductible, you usually pay only a copayment or coinsurance for covered services.
Dependent: An eligible dependent is someone covered by another person's health coverage plan; specific to our plans, it can be a spouse and/or a child up to age 26.
Drug Tiers: Drug tiers are groupings of different drugs requiring different copays.

Effective Date: The date on which your health plan coverage becomes active is known as the effective date.
Enrollment Period: The time during which people can sign up for a health plan or Medicare plan is known as the enrollment period.
Excess Charge: The difference between what your health care provider charges and the Medicare-approved amount is known as an excess charge, and you are typically billed for it.
Explanation of Benefits (EOB): An EOB is a statement sent by the health plan to you that explains charges, payments and any balances for medical services.

Formulary: A list of prescription drugs covered by the health plan is known as a formulary.

Grievance: A grievance is a complaint about the way your Medicare health plan is providing care. If you have a grievance about a plan's refusal to cover a medical service, supply or prescription, you must file a claim.
Guaranteed Renewable Policy: Medicare Supplement Plans are considered guaranteed, renewable policies and therefore cannot be terminated by the health plan unless premiums are unpaid.

Health Savings Account (HSA): An HSA is a tax-advantaged savings account you can use to pay for qualified health care costs. To be eligible for an HSA, you must have a High Deductible Health Plan (HDHP).
High-Deductible Health Plan (HDHP): A type of health plan with higher deductibles and lower premiums than most other health plans, HDHPs can be combined with HSAs, though you usually will be required to pay higher health care costs before the health plan starts to pay its share.

Initial Enrollment Period (for Medicare): The period in which you qualify to enroll for Medicare is the initial enrollment period. It lasts from three months prior to your 65th birthday until three months after.
In-Network: Doctors, hospitals, pharmacies and other health care providers that have agreed to provide members of a certain health plan with services and supplies at a discounted price are considered in-network. For some plans, your medical care is only covered if you get it from an in-network provider.

Lifetime Maximum: The maximum dollar amount a plan will pay over the lifetime of your coverage is your lifetime maximum.

Medicare: Medicare is a federal health plan program for people 65 and older (and certain younger people who have permanent kidney failure or end-stage renal disease). Eligible people can enroll in Medicare Parts A, B, C or D.
Medicare Part A, Hospital Services: Part A pays for hospital stays, skilled nursing facility care, nursing home care, hospice care and home health services.
Medicare Part B, Medical Services: Part B helps pay for doctors and outpatient care.
Medicare Part C (AKA Medicare Advantage or MA Plans): Another Medicare option you may have, part C plans provide Medicare A, B and D coverage, in addition to other possible services.
Medicare Part D: Part D is an optional Medicare plan that provides some coverage for prescription drugs.
Medicare Supplement Plan/Medigap Policy: Supplemental or Medigap policies are offered through private companies and help you pay for some benefits not covered by Medicare Parts A and B.

Open Enrollment: Open enrollment is a period when people make choices about their health plan coverage.
Original Medicare: Original Medicare is also known as Medicare Part A and/or Medicare Part B.
Out-of-Pocket Costs: An out-of-pocket cost is a medical cost you are responsible for paying, such as copays, coinsurance, deductibles and other fees.
Out-of-Pocket Maximum: The most you have to pay for covered medical services in a plan year is your out-of-pocket maximum. After you spend this amount, your health plan pays 100% of the costs of covered benefits.

Pre-Existing Condition: A health condition that was diagnosed or treated before the date that a health plan's coverage began is known as a pre-existing condition.
Premium: The amount you pay each month for your health plan is your premium.
Preventative Care: Routine health care services, including screenings, annual physicals and check-ups are all a part of preventative care.

Skilled Nursing Facility (SNF): An SNF is a licensed organization that provides nursing care and rehabilitation for people who do not need to be in a hospital. It doesn't include nursing homes or care for those who need help with daily living.
Summary of Benefits and Coverage (SBC): An SBC is a document that tells you what a health plan covers and what your share of the costs will be

Underwriting/Medical Underwriting: The process used to decide who is eligible for coverage and sets related rates and premiums is known as underwriting or medical underwriting.

Waiting Period: A period of time that must pass before your health plan will cover certain services is called a waiting period.

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