GLOSSARY OF HEALTH INSURANCE TERMS

General Terms and Definitions

Accept Assignment
When doctors agree to accept the amount Medicare approves as payment in full for their services.
Advocate/surrogate
A person you choose to make your wishes known to your doctor when you are unable to speak for yourself.
Benefits
Health care services your health plan pays for, such as visits to your doctor, approved hospital stays, and prescription drugs.
Chronic illness
An illness that can go on for an extended period of time. Cancer, heart disease, diabetes, and arthritis are examples of chronic illnesses.
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that gives certain workers and their families the right to keep their group health insurance longer if they lose it due to changes in their work or family life.
Coinsurance
The amount you pay (usually a percentage) for your health care, after you pay the deductible.
Co-payment or "Co-pay"
The set amount you pay for each medical service you get. For example, a managed care plan might charge $25 for a doctor visit.
Deductible
The amount you pay for your health care before your health plan begins to pay.
Domestic Partner
An Associate's life partner as evidenced by completing an affidavit, which attests that they are in a committed exclusive relationship.
Emergency Care
Care for severe pain, injury, sudden illness, or suddenly worsening illness that you believe can cause serious danger to your health if you do not get immediate medical care.
Enroll
To join or sign up for a health insurance plan.
Fee-for-Service
Traditional method of paying for medical care. You and/or your insurance company pay for each medical service you receive.
Formulary
A list of medications preferred or recommended by your health plan. Doctors are encouraged to prescribe medicines on this list.
Health Insurance Policy
The document that describes the health benefits an insurance company will and will not pay for.
HIPAA (Health Insurance Portability and Accountability Act)
A federal law that gives you and your family certain protections when you are changing from one group plan to another or from a group plan to an individual insurance plan.
Home Health Care
Health care that you get in your home for an illness or injury. Home health care services include skilled nursing care and physical, occupational, and speech therapy.
Hospice Care
An organization or program that provides care and comfort for people who are dying and for their family members. Its focus is to help make people as comfortable as possible at the end of their life, rather than trying to cure their illness or injury. Hospice care includes physical care, pain control, and counseling.
Health Maintenance Organization (HMO)
A managed care plan that provides health care to plan members on a pre-paid basis. In most HMOs, you must get all your care from the doctors and hospitals that are part of the plan's network. Usually a primary care doctor coordinates all of your care and refers you to specialists.
Inpatient Care
Care you get in the hospital that requires an overnight stay.
Medicaid
Medicaid is a federal and state insurance program that helps pay the health care costs of some people with low incomes.
Medicare
Federal health insurance for people who are 65 and older, for some younger people with disabilities, and for people with end stage renal disease (kidney failure).
Member Services
The department in your managed care plan that provides help and information to members of the plan and answers your questions about plan rules, costs, and health care services.
Network
A group of doctors, hospitals, and pharmacies who contract with a health plan to provide health care to plan members. To get the most benefits for the lowest cost, you generally have to use the plan's network.
Out-of-Pocket Costs
The part you pay for your health care. This may include premiums, deductibles, coinsurance, and/or copayments.
Outpatient Care
Medical or surgical care that does not include an overnight stay in a hospital.
Preferred Provider Organization (PPO)
In a PPO, you can get care from the doctors and hospitals in the plan's network or pay more to go to doctors and hospitals outside the network. Many PPOs don't require you to choose a primary care doctor or get a referral to see a specialist.
Preventive Care
Care that keeps you healthy or prevents illness, such as colorectal cancer screening, mammograms, and flu shots.
Pre-existing Condition
A health care problem that was found and/or under treatment before the start date of a new insurance policy.
Primary Care
Basic health care, such as a regular medical check-up. Primary care Care Physicians include – Clinic Multi-
Specialty, Family Practice, General Practice, Gynecology, OB-Gynecology, Internal Medicine, Obstetrics (DO), Pediatrics, Nurse Practitioners and Physician’s Assistants.
Provider
A person or facility, such as a doctor or hospital, that provides health care services.
Rehabilitative Services
Health care ordered by your doctor to help you recover from an illness or injury. These services are given by skilled nurses and physical, occupational, and speech therapists. Examples of rehabilitative services are working with a physical therapist to help you walk and with an occupational therapist to help you take a shower or get dressed.
Specialist
Doctors who focus on certain parts of the body or diseases. These doctors have many years of training in their specialty areas. Cardiologists (heart), oncologists (cancer), and rheumatologists (arthritis) are all specialists.