GLOSSARY OF HEALTH TERMS

Additional Insured:  Anyone covered under your health plan that is not named as “insured” or “main applicant” from the insurance company.

Benefit:  The dollar amount your health insurance carrier will pay when you file a claim for a covered loss.

Benefit Period:  The period during which you will be eligible for benefits.  Generally, your benefit period will begin with the first medical service you received for a specific illness and end after you have not been treated for that condition for 60 days.

Carrier:  The insurance company you receive your health insurance plan from.

Certificate of Insurance:  This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier.  It specifically explains what will and what will not be covered and the maximum amount you will be responsible for and the maximum amount the insurance company will be responsible for.

Claim:  This refers to any request to your health insurance company for benefits to be paid.

Coinsurance:  This is a percentage of the total medical bill you will be required to pay, generally after your deductible has been met.

Co-payment:  This is a fixed fee required by a health insurance company to be paid by the patient at the time of each office visit, outpatient service, inpatient service or filling of a prescription.

Covered Expenses:  This refers to the various medical procedures and benefits your insurance company has agreed to provide coverage for.

Deductible:  The amount you have to pay out-of-pocket for medical expenses before the insurance company will begin to pay.     

Exclusion:  A specific condition or procedure that is not covered by your policy.

Effective Date:  This refers to the date on which your insurance coverage will actually begin to cover you.

In-network:  Healthcare facilities or providers who are contracted through your health plan.

Lifetime Limit:  This is the cap or maximum amount of money your insurance company is responsible for.

LOS or Length of Stay:  This refers to the length of time any individual spends in a hospital or an in-patient care facility.

Maximum Out-of-Pocket Expenses:  The most you will have to pay during any one year, in the form of deductibles and coinsurance fees, for medical care.

Managed Care:  A healthcare plan that seeks to control medical costs by contracting with a network of providers.  These plans require preauthorization for visits to specialists.  HMO’s, PPO’s and POS’s are all forms of managed care policies.

Medicaid:  This is a joint federal and state program that provides health coverage for low-income individuals or families.  Although largely funded by the federal government, Medicaid is run by the state where coverage may vary from state to state.

Medicare:  This is a U.S. federal healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65.  It also offers benefits to disabled individuals and individual who is undergoing dialysis for kidney failure or who is in need of a kidney transplant.

Network:  This refers to the groups of doctors, hospitals, medical professionals, and facilities who have been contracted by an insurance company to provide healthcare services to their customers.  They usually have pre-negotiated fees for procedures or services.

Out-of-Network:  This usually refers to doctors, hospitals or other healthcare providers that are non-participants of the contracted network used by your health insurance plan.  Services provided by out-of-network providers are usually at higher costs.

Preventative Care:  Health services that focus solely on preventative care measures such as physical exams, immunizations, diagnostic tests and mammograms.

Premium:  The dollar amount you will pay on a monthly basis in exchange for your insurance coverage.

Primary Care Physician:  This is family physician, pediatrician, or internist chosen to monitor your health, treat most of your health problems, and refer you to specialists when necessary.

Provider:  This refers to any individual or facility that provides you with care.

Rider:  This refers to any policy attachment that makes additions or changes to your original insurance plan.

Stop Loss:  The most you will have to pay during any one year, in the form of deductibles and coinsurance fees, for medical care.

Waiting Period:  This refers to a specified time period during which you will not be covered by your insurance for a specific condition or benefit.

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