Glossary Of Health Coverage And Medical Terms
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4Glossary of Health Coverage and Medical Terms
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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
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
to pay. For example, if
When a
provider
bills you for the difference between the
100%
0%
your deductible is $1000,
provider’s charge and the
allowed
amount. For example,
(See page 4 for a detailed example.)
your plan won’t pay
if the provider’s charge is $100 and the allowed amount
anything until you’ve met
is $70, the provider may bill you for the remaining $30.
not
your $1000 deductible for covered health care services
A
preferred provider
may
balance bill you for covered
subject to the deductible. The deductible may not apply
services.
to all services.
Co-insurance
Durable Medical Equipment (DME)
Your share of the costs
Equipment and supplies ordered by a health care
provider
of a covered health care
for everyday or extended use. Coverage for DME may
service, calculated as a
include: oxygen equipment, wheelchairs, crutches or
percent (for example,
blood testing strips for diabetics.
20%) of the
allowed
amount
for the service.
Jane pays
Her plan pays
Emergency Medical Condition
You pay co-insurance
20%
80%
plus
any
deductibles
An illness, injury, symptom or condition so serious that a
(See page 4 for a detailed example.)
you owe. For example,
reasonable person would seek care right away to avoid
if the
health insurance
or
plan’s
allowed amount for an
severe harm.
office visit is $100 and you’ve met your deductible, your
Emergency Medical Transportation
co-insurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.
Ambulance services for an
emergency medical
condition.
Complications of Pregnancy
Emergency Room Care
Conditions due to pregnancy, labor and delivery that
Emergency services
you get in an emergency room.
require medical care to prevent serious harm to the health
Emergency Services
of the mother or the fetus. Morning sickness and a non-
emergency caesarean section aren’t complications of
Evaluation of an
emergency medical condition
and
pregnancy.
treatment to keep the condition from getting worse.
Glossary of Health Coverage and Medical Terms
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
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