RESOURCES

Glossary of Terms

 
 

Allowed Amount

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing)

 

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

 

Balance Billing

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

 

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example,if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

 

Complications of Pregnancy

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.

 

Co-payment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

 

Critical Illness Insurance

Lump sum cash benefits to help cover high deductibles and pay other medical expenses for qualifying illnesses such as: cancer, heart attack, stroke, coma, paralysis, major burns, and transplants.

 

Deductible

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

 

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

 

Emergency Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

 

Emergency Medical Transportation

Ambulance services for an emergency medical condition.

 

Emergency Room Care

Emergency services you get in an emergency room.

 

Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

 

Essential Health Benefits (EHB’s)

As defined by the Affordable Care Act (ACA) regulations, qualified health plans must cover at least:

  • Ambulatory patient services such as doctors’ visits and outpatient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services including oral and vision care
 

Excluded Services

Health care services that your health insurance or plan doesn’t pay for or cover.

 

Grievance

A complaint that you communicate to your health insurer or plan.

 

Habilitation Services

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

 

Health Care Reform

On March 23, 2010, President Obama signed into law The Patient Protection and Affordable Care Act (PPACA). The law is known by many names. Most commonly it is referred to as The Affordable Care Act (ACA) and "Obamacare". The law focuses on provisions to expand coverage, control health care costs and improve the health care delivery system.

Key features:

  • A legal requirement for most U.S. citizens under age 65 to have health insurance by January 1, 2014 or pay a fine on your tax return. There has been a six week extension (until March 31, 2014) for individuals to sign up for coverage and avoid the fine.
  • More ways to get affordable health care coverage by creating state-based (run either by the state or federal government) Health Benefit Exchanges/Marketplace through which individuals can purchase coverage.
  • Expansion of benefits/coverage, especially Preventive Care which include Screenings, Wellness Exams, and Maternity.
  • Insurers cannot deny coverage to any individual plan applicant based on health status, age, gender or other defined factors. No more being denied coverage if you have a pre-existing condition, and you don’t have to pass a medical exam to qualify for coverage.
 

Health Insurance

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

 

Health Reimbursement Arrangement (HRA)

A Health Reimbursement Arrangement, or HRA, is an IRS approved, employer-funded, tax advantaged employer health benefit plan that reimburses employees for out-of-pocket medical expenses and individual health insurance premiums. A health reimbursement arrangement is not health insurance. A health reimbursement arrangement allows the employer to make contributions to an employee’s account and provide reimbursement for eligible expenses. It is often referred to (incorrectly) as a health reimbursement account.

 

Health Savings Account (HSA)

A Health Savings Account is a tax-advantaged savings account that belongs to an individual/employee and is paired with a qualified high-deductible health plan (HDHP). The 2014 HSA contribution limits are $3,300 for an individual and $6,550 for a family.

 

Home Health Care

Health care services a person receives at home.

 

Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

 

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

 

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

 

In-network Co-insurance

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

 

In-network Co-payment

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

 

Medically Necessary

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

 

Individual Mandate

Most U.S. citizens and legal residents under age 65 are required to have qualifying health coverage that includes minimum essential coverage or pay a penalty.

 

Network

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

 

Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

 

Notional Arrangement

Health reimbursements are notional arrangements; no funds are expensed until reimbursements are paid. Through health reimbursement arrangements (HRA’s), employers reimburse employees directly only after the employees incur approved medical expenses.

 

Out-of-network Co-insurance

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

 

Out-of-network Co-payment

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.

 

Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

 

Physician Services

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

 

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

 

Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

 

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

 

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

 

Prescription Drugs

Drugs and medications that by law require a prescription.

 

Preventive Care

Services covered with no cost sharing:

  • Adult Physicals
  • Well-Child Exams
  • OB/GYN Exams
  • Cancer Screenings
  • Routine prenatal maternity visits
  • Preferred preventive drugs
 

Primary Care Physician

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

 

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

 

Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

 

Qualified Health Plan (QHP)

A private health benefit plan that has been certified by Maryland Health Connection to meet requirements for certification under the Affordable Care Act (ACA) and Maryland law.

 

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

 

Rehabilitation Services

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

 

Skilled Nursing Care

Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

 

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

 

UCR (Usual, Customary and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

 

Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.