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This glossary has many commonly used terms, but isnt 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
might not have exactly 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.)
Bold blue text indicates a term defined in this Glossary.
See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real
life situation.
Allowed Amount Co-payment
Maximum amount on which payment is based for A fixed amount (for example, $15) you pay for a covered
covered health care services. This may be called eligible health care service, usually when you receive the service.
expense, payment allowance" or "negotiated rate." If The amount can vary by the type of covered health care
your provider charges more than the allowed amount, you service.
may have to pay the difference. (See Balance Billing.)
Deductible
Appeal The amount you owe for
A request for your health insurer or plan to review a health care services your
decision or a grievance again. health insurance or plan
covers before your health
Balance Billing insurance or plan begins
Jane pays Her plan pays
When a provider bills you for the difference between the to pay. For example, if
100% 0%
providers charge and the allowed amount. For example, your deductible is $1000,
if the providers charge is $100 and the allowed amount your plan wont pay (See page 4 for a detailed example.)
is $70, the provider may bill you for the remaining $30. anything until youve met
A preferred provider may not balance bill you for covered your $1000 deductible for covered health care services
services. subject to the deductible. The deductible may not apply
to all services.
Co-insurance
Your share of the costs Durable Medical Equipment (DME)
of a covered health care Equipment and supplies ordered by a health care provider
service, calculated as a for everyday or extended use. Coverage for DME may
percent (for example, include: oxygen equipment, wheelchairs, crutches or
20%) of the allowed blood testing strips for diabetics.
amount for the service. Jane pays Her plan pays
You pay co-insurance 20% 80% Emergency Medical Condition
plus any deductibles (See page 4 for a detailed example.) An illness, injury, symptom or condition so serious that a
you owe. For example, reasonable person would seek care right away to avoid
if the health insurance or plans allowed amount for an severe harm.
office visit is $100 and youve met your deductible, your
co-insurance payment of 20% would be $20. The health Emergency Medical Transportation
insurance or plan pays the rest of the allowed amount. Ambulance services for an emergency medical condition.
Glossary of Health Coverage and Medical Terms OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Page 1 of 4
Excluded Services Medically Necessary
Health care services that your health insurance or plan Health care services or supplies needed to prevent,
doesnt pay for or cover. diagnose or treat an illness, injury, condition, disease or
its symptoms and that meet accepted standards of
Grievance medicine.
A complaint that you communicate to your health insurer
or plan. Network
The facilities, providers and suppliers your health insurer
Habilitation Services or plan has contracted with to provide health care
Health care services that help a person keep, learn or services.
improve skills and functioning for daily living. Examples
include therapy for a child who isnt walking or talking at Non-Preferred Provider
the expected age. These services may include physical and A provider who doesnt have a contract with your health
occupational therapy, speech-language pathology and insurer or plan to provide services to you. Youll 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 health insurance or plan, or if your health
Health Insurance insurance or plan has a tiered network and you must
A contract that requires your health insurer to pay some pay extra to see some providers.
or all of your health care costs in exchange for a
premium. Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed
Home Health Care amount for covered health care services to providers who
Health care services a person receives at home. do not contract with your health insurance or plan. Out-
of-network co-insurance usually costs you more than in-
Hospice Services network 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-payment
A fixed amount (for example, $30) you pay for covered
Hospitalization health care services from providers who do not contract
Care in a hospital that requires admission as an inpatient with your health insurance or plan. Out-of-network co-
and usually requires an overnight stay. An overnight stay payments usually are more than in-network co-payments.
for observation could be outpatient care.
Out-of-Pocket Limit
Hospital Outpatient Care The most you pay during a
Care in a hospital that usually doesnt require an policy period (usually a
overnight stay. year) before your health
insurance or plan begins to
In-network Co-insurance pay 100% of the allowed
The percent (for example, 20%) you pay of the allowed amount. This limit never Jane pays Her plan pays
amount for covered health care services to providers who includes your premium, 0% 100%
contract with your health insurance or plan. In-network balance-billed charges or
(See page 4 for a detailed example.)
co-insurance usually costs you less than out-of-network health care your health
co-insurance. insurance or plan doesnt cover. Some health insurance
or plans dont count all of your co-payments, deductibles,
In-network Co-payment co-insurance payments, out-of-network payments or
A fixed amount (for example, $15) you pay for covered other expenses toward this limit.
health care services to providers who contract with your
health insurance or plan. In-network co-payments usually Physician Services
are less than out-of-network co-payments. Health care services a licensed medical physician (M.D.
Medical Doctor or D.O. Doctor of Osteopathic
Medicine) provides or coordinates.
st st
January 1 December 31
Beginning of Coverage End of Coverage Period
Period
more more
costs costs
Jane pays Her plan pays Jane pays Her plan pays Jane pays Her plan pays
100% 0% 20% 80% 0% 100%
Jane hasnt reached her Jane reaches her $1,500 Jane reaches her $5,000
$1,500 deductible yet deductible, co-insurance begins out-of-pocket limit
Her plan doesnt pay any of the costs. Jane has seen a doctor several times and Jane has seen the doctor often and paid
Office visit costs: $125 paid $1,500 in total. Her plan pays some $5,000 in total. Her plan pays the full
Jane pays: $125 of the costs for her next visit. cost of her covered health care services
Her plan pays: $0 Office visit costs: $75 for the rest of the year.
Jane pays: 20% of $75 = $15 Office visit costs: $200
Her plan pays: 80% of $75 = $60 Jane pays: $0
Her plan pays: $200