Navigating the world of health insurance can be difficult, especially after a brain injury. These basic terms can help you get started.
This glossary has many commonly used terms, but isn't a full list. 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 minght not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.
Maximum amount on which payment is based for coered health care services. This may be called "eligible expense," "payment allowance," or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
A request for your heal insurer or plan to review a decision or a grievance again.
When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan plays the rest of the allowed amount.
Complications of Pregnancy
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarian section aren't complications of pregnancy.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive a service. The amount can vary by the type of covered health insurance.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won't pay anything until you've met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetes.
Emergency Medical Condition
An illness, in jury, symptoms, or conditions so serious that a reasonable person would seek care right away to avoide severe harm.
Emergency Medical Transportation
Ambulance services you get in an emergency medical condition.
Emergency Room Care
Emergency services you get in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Health care services that your health insurance or plan doesn't pay for or cover.
A complaint that you communicate to your health insurer or plan.
Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn't require an overnight stay.
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
A fixed amount (for example, 15%) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
The facilities, providers, and suppliers of health insurer or plan has contracted with to provide health care services.
A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll play more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.
The percent (for example, 40%) you pay for the allowed amount for covered health care servcies to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
A fixed amount (for example, $30) you pay for covered health care servcies from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your co-payments, deductibles, co-insurance payments, out-of-network payments, or other expenses toward this limit.
Health care services a licensed medical physician (MD - Medical Doctor or DO - Doctor of Osteopathic Medicine) provides or coordinates.
A benefit your employer, union, or other group sponsor provides to you to pay for your health care services.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn't a promise your health insurance or plan will cover the cost.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also "participating" providers. Participating providers also contract with your health insurance or plan, bu the discount may not be as great, and you may have to pay more.
The amount that you must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, yearly.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Drugs and medications that by law require a prescription.
Primary Care Physician
A physician (MD - Medical Doctor or DO - Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A physician (MD - Medical Doctor or DO - Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of health care services.
A physician (MD - Medical Doctor or DO - Doctor of Osteopathic Medicine), health care professional, or health care facility licensed, certified, or accredited as required by state law.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt , or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Social Security Disability Insurance (SSD or SSDI)
Social Security Disability Insurance (SSD or SSDI) is a payroll tax-funded, federal insurance program of the United States government.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
UCR (Usual, Customary, and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Care for an illness, injury, or condition serious enough that a reasonable person would seek care righ away, but not so severe as to require emergency room care.
Worker's Compensation (Work Comp)
An insurance plan that employers are required to have to cover employees who get sick or injured on the job.