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- A provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan. You’ll pay less if you see a provider in the network. Also called “preferred provider” or “participating provider.”
www.cms.gov/medical-bill-rights/help/guides/health-insurance-terms
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What is a health insurance glossary?
What is social participation as consumer participation?
What is a health insurance policy?
What is a health plan & how does it work?
This glossary is an aid to help you understand some common insurance terms and some WPA specific terms. A customer should always refer to their specific Policy or Scheme documentation to check their level of cover, benefits, terms and conditions and Policy or Scheme definitions.
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Administrative services only
An employer-sponsored health insurance plan where the employer pays for the employee’s health benefits and relies on the insurance company to administer the plan only. The insurance company may process claims on behalf of the employees, but the employer typically pays the claims themselves.
Affordable Care Act
A health care law, also called Obamacare, established in 2010, that expanded affordable health insuranceaccess to individuals and families in the U.S. The ACA health insurance marketplace was launched in conjunction with the ACA, which allows eligible Americans to shop for and purchase health insurance. The health law also expanded Medicaid eligibility, allowed parents to keep their children on their health insurance until 26, prohibits lifetime monetary caps on coverage, sets annual in-netwo...
Allowed amount
The maximum amount of money a health insuranceplan pays for qualifying medical services. Alternative terms for allowed amount are “eligible expense” and “payment allowance.”
Emergency medical condition
A critical condition, including an illness, symptom or injury, that needs immediate medical treatment.
Emergency medical transportation
Transportation to a hospital or medical facility, usually via ambulance, when an individual is experiencing a medical emergency.
Emergency room care
Medical treatment received in a hospital’s emergency department when an individual needs immediate treatment for a sickness, symptom or injury they are experiencing.
Indemnity insurance
A supplemental health insurance plan that covers some of the cost of hospital stays. Most hospital indemnity insuranceplans cover hospitalizations with or without surgery, as well as intensive care and critical care hospital stays. This type of plan pays out based on the number of days you stay in the hospital.
In-network coinsurance
The percentage of the cost of a medical bill you pay when you receive treatment from a medical provider that contracts with your plan’s network. You only pay in-network coinsurance once you’ve met your deductible.
In-network copayment
The amount of money that an insured person pays for a medical service when you visit a provider that contracts with your health plan’s network. In-network copayments are generally less expensive than out-of-network copayments.
Medicaid
A federal- and state-funded health insurance program that provides benefits to low-income individuals and families, and those with disabilities. Medicaid eligibility and costs are based on income.
Medicare
Medicare is a federal health insurance program for individuals who are over age 65 and younger people with qualifying disabilities. People who are eligible can choose between Original Medicare and Medicare Advantage. Original Medicare includes Part A (hospital coverage), Part B (medical coverage) and Part D (prescription coverage). Medicare Advantage, also called Part C, includes Part A and Part B and often has prescription drug benefits integrated in the plans. Private health insurance compa...
Medical debt
Medical debtis the amount of money you owe in unpaid medical bills.
Physician services
Any service that is provided by a licensed Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.).
Physician-hospital organization
A group comprised of hospitals and physicians that work together to manage and coordinate patient care. The entities in a PHO may also provide covered services to the subscribers of a health insurance plan.
Point-of-service (POS) plan
A point of service (POS) is a type of health insurance plan that is a hybrid of an HMO and PPO. POS plans allow individuals to receive care in-network or out-of-network, but members are required to work with a primary care provider to get referrals for specialists. POS plans aren’t nearly as common as PPO, HMO and EPO plans.
Short-term health insurance
A health insurance plan that provides coverage for a limited time period for up to a year with the chance to extend for another two years in most states. Short-term health insuranceisn’t regulated by the ACA, so the plans aren’t required to cover essential medical benefits. Short-term plans can be cheap, but beware of limited coverage, high out-of-pocket costs when you need care. Some states don’t allow short-term health plans or limit the length of time.
Skilled nursing care
Medical services provided by a licensed nurse, sometimes under the supervision of a medical doctor. Skilled nursing care is often provided in facilities such as nursing homes, hospitals and assisted living communities, but also can be provided in your home.
Special enrollment period
A time period in which an individual is eligible to enroll in or modify a health insurance plan outside of open enrollment. To qualify for a special enrollment period(SEP), you typically must experience a qualifying life event, such as giving birth or adopting a child, switching jobs, getting married or divorced, or moving to a new state.
- Elizabeth Rivelli
Jun 22, 2023 · Health insurance terms you should know. Health care terms, medical bills, and forms can be hard to understand. Here are some common health care terms, and what they mean. Download this page as a PDF.
Here are some common health care terms, and what they mean: Allowed Amount – This is the maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” For example, if you get services during an office visit from an in-network provider and your ...
Mar 1, 2024 · From understanding the role of agents to grasping different cost structures like copayments, coinsurance, and deductibles, this glossary provides knowledge to help you make informed decisions when searching for health coverage. 28 Common Terms You’ll Likely See in Health Insurance.
Aug 29, 2013 · Definitions for social participation differ from each other and are not sufficiently distinct from the ICF definition of participation. The ICF definition of participation itself does not adequately capture the objective state and subjective experience of involvement with others in society.
Sep 5, 2018 · The terms surrounding health insurance and private medical insurance can be confusing. Read our A-Z guide to demystify health insurance policies.
