Glossary Of Health Coverage And Medical Terms Page 2
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4Excluded Services
Medically Necessary
Health care services that your
health insurance
or
plan
Health care services or supplies needed to prevent,
doesn’t 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
Network
or plan.
The facilities,
providers
and suppliers your health insurer
Habilitation Services
or
plan
has contracted with to provide health care
services.
Health care services that help a person keep, learn or
improve skills and functioning for daily living. Examples
Non-Preferred Provider
include therapy for a child who isn’t walking or talking at
the expected age. These services may include physical and
A
provider
who doesn’t have a contract with your health
occupational therapy, speech-language pathology and
insurer or
plan
to provide services to you. You’ll pay
other services for people with disabilities in a variety of
more to see a non-preferred provider. Check your policy
to see if you can go to all providers who have contracted
inpatient and/or outpatient settings.
with your
health insurance
or plan, or if your health
Health Insurance
insurance or plan has a “tiered”
network
and you must
pay extra to see some providers.
A contract that requires your health insurer to pay some
or all of your health care costs in exchange for a
Out-of-network Co-insurance
premium.
The percent (for example, 40%) you pay of the
allowed
Home Health Care
amount
for covered health care services to providers who
not
do
contract with your
health insurance
or plan. Out-
Health care services a person receives at home.
of-network co-insurance usually costs you more than
in-
network
co-insurance.
Hospice Services
Services to provide comfort and support for persons in
Out-of-network Co-payment
the last stages of a terminal illness and their families.
A fixed amount (for example, $30) you pay for covered
not
health care services from providers who do
contract
Hospitalization
with your
health insurance
or plan. Out-of-network co-
Care in a hospital that requires admission as an inpatient
payments usually are more than
in-network
co-payments.
and usually requires an overnight stay. An overnight stay
for observation could be outpatient care.
Out-of-Pocket Limit
The most you pay during a
Hospital Outpatient Care
policy period (usually a
Care in a hospital that usually doesn’t require an
year) before your
health
overnight stay.
insurance
or
plan
begins to
pay 100% of the
allowed
In-network Co-insurance
amount. This limit never
The percent (for example, 20%) you pay of the
allowed
Jane pays
Her plan pays
includes your premium,
amount
for covered health care services to
providers
who
0%
100%
balance-billed
charges or
contract with your
health insurance
or plan. In-network
(See page 4 for a detailed example.)
health care your health
co-insurance usually costs you less than
out-of-network
insurance or plan doesn’t cover. Some health insurance
co-insurance.
or plans don’t count all of your co-payments, deductibles,
co-insurance
payments, out-of-network payments or
In-network Co-payment
other expenses toward this limit.
A fixed amount (for example, $15) you pay for covered
health care services to
providers
who contract with your
Physician Services
health insurance
or plan. In-network co-payments usually
Health care services a licensed medical physician (M.D. –
are less than
out-of-network co-payments.
Medical Doctor or D.O. – Doctor of Osteopathic
Medicine) provides or coordinates.
Glossary of Health Coverage and Medical Terms
Page 2 of 4
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