Glossary

An injury or illness that is evident before the effective date of the contract. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before the member can receive benefits for them. For example, you hurt your knee playing football a couple of 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.

A decision by your health insurer or plan that a healthcare 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.

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.

A network-based, managed care plan that allows the participant to choose any healthcare provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverages and lower deductibles.

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

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

Drugs and medications that by law require a prescription.

Medical and dental services aimed at early detection and intervention.

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

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 healthcare services.

The person identified on the ASO benefit description, non-group contract, insured group certificate or other coverage document.

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

The amount of money contracting healthcare providers deduct from their charge due to contracts between themselves and a health plan.

An event such as death, divorce or spouse's loss of employment that would allow enrollment in another health plan without having to wait for an open enrollment period.

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

If a primary care physician (PCP) determines a patient has a condition which requires the attention of a specialist, the PCP coordinates the transfer of care to a specialist.

Healthcare 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.

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.

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 healthcare.

A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce or marriage. See Qualifying Event.

Person who is eligible, enrolled and covered under a self-funded ASO (Administrative Services Only) group benefit plan.

An ERISA-required summary of plan eligibility, benefits and other information provided by employer groups to anyone participating in an ERISA plan.

A pre-paid fee-for-service health plan that gives members maximum freedom of choice, allowing them to seek medical care from any healthcare provider without reduction of benefits.

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.

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.

A period of time the member must wait before coverage begins. Two common types of waiting periods are company-imposed and for pre-existing conditions.

Insurance purchased by the employer to provide benefits to employees for illness or injury that arises out of or in the course of employment without regard to negligence or fault.