Actual Charge — The amount a doctor or other health care provider actually bills a patient. You often see the phrase, "The actual charge may be different from the allowable charge." This means your health plan may only cover a portion of what your doctor charges you. For example, your doctor bills you $35.00 for an office visit. This is the actual charge. But your health plan may only accept $32.00 for an office visit. This is the allowable charge.
Allowable Charge — The most your health plan will pay for a covered service. You may see the phrase, "The actual charge may be different from the allowable charge." This means your health plan may only cover a portion of what your doctor charges you. For example, your doctor bills you $35.00 for an office visit. This is the actual charge. But your health plan may only accept $32.00 for an office visit. This is the allowable charge.
Approval — The process of deciding whether or not a person's health plan will cover a specific service. Check your health plan carefully. You may find certain procedures, like surgery, require pre-approval. This means you need to check with your health plan to see if it will cover the service before you receive it. This simple approval process could save you money!
Approved Amount — The amount your health plan says is reasonable for a covered service. This amount may be less than the actual amount. For example, your health plan may cover $29.00 for a doctor's office visit, even though your doctor may charge you $32.00 for that visit. The $29.00 is the approved amount.
Assignment — Authorizing your health plan to pay benefits to your health care provider instead of sending payment to you.
Beneficiary — A person who will receive insurance benefits.
Benefit — Services and supplies a health plan pays for. The term also refers to the amount a health plan will pay.
Benefit Period — The period of time a health plan will pay for covered benefits. Benefit periods are usually one year. They don't always reflect a calendar year, so be sure and check your policy.
Case Management — A program that will pay for health care services your health plan usually will not cover if those services will help you get well faster or better. For example, a woman goes into premature labor and her doctor recommends a drug that will keep her from delivering the baby. Her health plan would not normally pay for this drug. But under case management, special members of the health plan's staff look at the woman's case. They realize if she were to have her baby early, the baby could risk his life and run up huge medical bills. So they authorize coverage for the drug.
Coinsurance — The dollar amount or percentage you pay. For example, if you have an "80/20 plan," your health plan would pay 80% of the covered part of the bill, and you would pay 20%. The 20% you pay is your coinsurance.
Comprehensive Coverage — A type of health insurance providing a full range of personal health services for diagnosis, treatment, follow-up and rehabilitation of patients. This type of coverage usually has deductibles, coinsurance and benefit maximums.
Copayment — A small fee you pay for each doctor's office visit, medical service or prescription. For example, your health plan may have a $10 copayment for doctor's office visits. This means every time you visit your doctor, you would pay just $10.
Cost Sharing— A method of dividing the cost of health care among consumers, insurance companies, employers and providers. For example, your employer may pay part of the premiums for your insurance. Your health plan will pay part of your health care bills, and you will pay part. If your doctor is part of your health plan's network, then he or she will cover part of the cost by negotiating a discount for his or her services. Everyone shares in the cost to help keep costs down.
Covered Service — Specific services your health plan will pay for.
Deductible — The amount of money you must pay before your health plan will pay its share. For example, if you have a health plan with a $250 deductible, you must reach that amount before your health plan begins paying.
Detoxification — A medical treatment to help a person overcome an addiction to alcohol or other substances. This treatment helps a patient with a physical or psychological dependence on alcohol or drugs to remove the addictive substances from the body. It includes 24-hour-a-day nursing care and 24-hour availability of an attending physician (MD).
Disease Management — Voluntary programs which give members the information and support needed to live well with chronic conditions. Programs help members understand their doctors' instructions and improve the way they care for themselves every day.
Emergency Medical Condition — A severe injury or illness (including pain). Your illness or injury must be so severe that if you don't get medical care right away, one of these might occur:
- Serious risk to your health. If you're pregnant, this includes your health and your unborn child's health.
- Serious damage to body functions.
- Serious damage to any organs or body parts.
Exclusions — Services or items your health plan doesn't cover.
Fee for Service — This is "traditional" insurance. You pay doctors and hospitals for each service you receive. Your health plan will pay a portion of the total cost.
Fraud — A deception that could result in your health plan paying for something it shouldn't. For example, if your doctor files a claim for a service you didn't receive, this is fraud.
HMO — Health maintenance organization. When you sign up for an HMO, you choose one doctor to coordinate all your health care. This doctor, your "primary care physician," learns your entire medical history. He or she recommends care based on knowing you from head to toe. If you should ever need care from a specialist, your primary care physician will refer you to one in your health plan's network.
Inpatient — A patient who is staying in the hospital and receiving room, board and general nursing care. For example, you need to have surgery so your doctor admits you to the hospital and you stay there for several days. You're getting inpatient care.
Intensive Outpatient (IOP) — A patient who gets treatment at a hospital, but does not stay there overnight. The patient typically attends programs at the hospital three days a week for three-hour sessions.
Managed Care — A health care process that integrates the delivery of health care services for the patient, doctor and insurance company. There are special arrangements with selected health care providers to deliver comprehensive health care services, with established fees. There are incentives for members to participate within the health care plan. Health plans also monitor the use of health care services.
Medical Management — Non-surgical treatment for any illness or disorder which may include visits with a mental health professional.
Open Access Plan — A health plan that lets you visit any doctor in the plan's network. You do not need a referral from your primary care physician.
Out-of-Pocket Maximum — Your share of medical expenses which are covered by this insurance plan is called coinsurance. Your out-of-pocket maximum is the highest total amount of coinsurance you will have to pay during a benefit period.
Outpatient — A patient who gets treatment at a hospital but doesn't stay there. For example, you go to the hospital in the morning for minor surgery. As soon as you wake up from the anesthesia, the doctor sends you home to recover. This is outpatient care because you didn't need to stay in the hospital. There may be some cases when you spend the night in a hospital, but still are considered an outpatient. It's always best to ask your doctor if you're getting outpatient or inpatient care, because your health plan may pay differently for each.
Partial Hospitalization (PHP) — A patient who gets treatment at a hospital but does not stay there overnight. The patient typically attends programs five days a week for six-hour sessions.
Pre-existing Condition — An injury or illness you had before you signed up for your current health plan for which you received a diagnosis or treatment. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before you can get benefits for them. For example, you hurt your knee playing football a couple years ago and had to have surgery. When you sign up for a new health plan, you'll have to list your knee injury as a pre-existing condition.
Primary Care Physician — A doctor who treats common illnesses and injuries. This doctor will coordinate all your medical care. You can choose a family practitioner, an internist or a pediatrician. Your doctor, your HMO and you form a team. You'll work together to find the right care to help you get healthy and stay well.
Referral — A referral is consent from your primary care physician to see a specialist for an illness or injury. You may also need a referral to have special treatments, such as x-rays or surgery. A referral saves you money by reducing unnecessary medical costs. Your primary care physician will decide if you need to see a specialist. He or she will help you choose a specialist that is right for you.
Rehabilitation — This treatment is less acute than traditional inpatient care. It helps to further improve the condition being treated. Rehabilitation may involve medical and behavioral health or substance-related treatment. This type of care includes 24-hour-a-day nursing care and 24-hour availability of an attending physician (MD).
Residential Treatment Center (RTC) — Treatment at an RTC is less acute than traditional inpatient care. It may be considered a type of long-term care. This treatment includes 24-hour-a-day nursing care and 24-hour availability of an attending physician (MD).
Specialist — A specialist is a doctor who treats certain illnesses or injuries. For example, a surgeon is a specialist. A doctor who treats allergies or heart problems is also a specialist. You may need a referral from your primary care physician to visit a specialist.
Urgent Care — Medical care for an illness or injury that is urgent but not life-threatening. You need urgent care to keep you from getting sicker or your injury from getting worse. Examples include deep cuts, severe diarrhea, ankle sprains, earaches, sore throats and fevers.