Glossary of Healthcare Terms

C

Caregiver

An adult who is responsible for taking care of a member who might need extra help managing their plan information, including the ability to view, update and manage a member’s online account information.

Caregiver Access

When you’re a member, your online account offers you the ability to give a person helping you with your healthcare access to your plan information, including the ability to view, update and manage your online account information.

Case Management

A process to help you and your doctors manage and coordinate specific healthcare needs. We do this to make sure you’re getting the right care.

Centers for Medicare & Medicaid Services (CMS)

The government agency that runs the Medicare, Medicaid, Children's Health Insurance Programs, and some of the Healthcare Marketplaces.

Certificate of Coverage
 

A document that has all of the details about your coverage. It’s sometimes called your contract.

Certification
 

For some healthcare services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called precertification, authorization, or prior authorization.

Chemotherapy

Using chemicals or drugs to treat certain diseases. It’s often thought of in treating cancer.

Child Health and Disability Prevention (CHDP)

A government program that helps people under 21 years old, who have disabilities.

Chiropractic Care

A type of therapy used to help treat the spine, joint pain, and movement problems. A licensed chiropractor gives this care.

Chronic

A health condition that needs ongoing care and attention. Examples include diabetes, asthma, allergies, and hypertension.

Claim

A claim is what a doctor submits to us so they can get paid. It shows the medical services that were provided to you.

Clinic

A healthcare place or hospital department where outpatients are given treatment or advice.

Clinical Pharmacist

Licensed pharmacist who provides patient care that makes the best use of medication therapy and promotes health and disease prevention.

COBRA

If you have health coverage through your job, and you lose your job or coverage, the Consolidated Omnibus Budget Reconciliation Act (COBRA), may give you, your spouse, or kids the right to extend that health coverage.

Coinsurance

This is your share of the costs for covered healthcare services, calculated as a percentage.

Combined Maximum Out-of-Pocket

Combined maximum out-of-pocket refers to Medicare plans. It’s the most you’ll pay for covered healthcare under both Medicare Part A and Part B, for both in-network and out-of-network doctors, and includes deductibles, copayments and coinsurance. (The amounts you pay for your plan premium and for your Part D prescription drugs do not count toward it.)

Complaint

Also called a “grievance,” it’s when you tell us or write to us about something you don’t like or disagree with, regarding your coverage.

Compliance

Doing what you’ve been asked or required to do. It often refers to taking medication the way you’ve been told by your doctor. But it can also mean other ways you follow rules, guidelines or laws.

Contract

In health coverage, a contract is the agreement you make with us, that we’ll cover certain costs for your care and offer other services when you become a member.

Contract Holder

The person who signs up for the health plan. The plan may cover others, like their spouse or children, but they are called “dependents” of the contract holder. See also subscriber.

Conversion Option

The choice to move into an individual plan, if you’re leaving a health coverage plan through your job or another group.

Coordination of Benefits (COB)

This is when we ask you if you or any of your dependents also have other health coverage. It’s important because, if you do, we need to work with the other company to figure out who pays for what. If you have two health coverage plans and you accept money from both without letting them know that the other is also paying, you could be committing insurance fraud — which is a felony.

Co-payment or Co-pay

A set dollar amount you pay for a covered service, such as a doctor visit.

Cost Share

The amount you pay toward covered services, like copayments, coinsurance and/or deductibles. For most of your healthcare costs, you pay your share and we pay our share — as agreed to in your health coverage contract.

Covered Services

Care that you get from doctors and hospitals that we have agreed to pay a portion of, as part of your coverage.

Cross Brand

Brand-name drugs that have the same ingredients and are therapeutically the same but are marketed under two or more different registered trade names or trademarks.

Custodial Care

Care given to meet daily living needs of a patient, like help walking, bathing, or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care which does not require continuing services of medical-trained personnel.

D

Day Treatment Center

An outpatient facility that treats mental or behavioral health or substance abuse under the supervision of doctors. It typically offers treatment for more than two hours, but less than a full day. This treatment may also be known as "partial hospitalization."

Deductible

A set amount of money you pay at first for covered healthcare services, before your health plan begins paying.

Dental Care

Services for the health of your teeth and gums.

Dependent

Members of the subscriber's family, like a child or spouse, who are eligible for benefits under their health plan.

Diagnostic Care

Helps find the cause of a health problem through different diagnostic tests.

Diagnostic Tests

Tests and procedures ordered by a doctor to figure out what sort of health condition you have. May include radiology, ultrasound, nuclear medicine, laboratory, pathology, and others.

Disability

A physical or mental condition that limits your ability in at least one major life activity.

Disease Management

Program to help people who live with a chronic illness better understand and manage their condition. It also helps prevent future health problems.

Disenroll/Disenrollment

When a member leaves a health benefit plan. The opposite of enroll/enrollment.

Dispense as Written (DAW)

A doctor puts "DAW" on a prescription if they want it to be filled with the brand-name medication, rather than a generic version of that same drug.

Domestic Partner

Someone who lives with you for at least 12 months as if they're your spouse, but you're not married. You can include them as a dependent on your health coverage policy as long as neither of you are married to someone and you’re not related to each other in any way that prevents you from getting married by law.

Drug Formulary

A list of drugs that your health plan covers.

Drug Tiers

Prescription drugs are put into different categories based on how much they cost, whether they're brand-name or generic and sometimes other factors. Tier 1 drugs have the lowest copayment and are mostly generic versions of brand-name drugs. Tier 2 is made up of mid-priced drugs that may be brand-name but are "preferred" within their drug class. Tier 3 has mostly brand-name drugs with higher copayments.

Durable Medical Equipment (DME)

Equipment ordered by prescription from a doctor or other healthcare provider, for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, or blood testing meters for diabetics.

H

Health Assessment

An online tool that asks you questions to help you understand your overall health and offer healthy tips.

Health Benefit Plan

Health coverage may be called your health plan, health benefit plan, health coverage plan — these are all ways to describe a policy that helps you pay for your healthcare. Each plan is different. To see the ways your health benefit plan covers you log in and look over your benefits.

Healthcare Services

Anything that a doctor or other healthcare provider does for you to help you with your health. Includes checkups, treatments, care you get in a hospital and more.

Health Maintenance Organization (HMO)

A type of health plan where you only get care from a network of doctors in your area. You’ll need to choose a main doctor — also called a primary care physician or primary care doctor, from your health plan network. If you need a specialist, you’ll most likely have to go through your main doctor to get a referral.

Health Insurance Carrier

The company — like us or another health benefits company that collects your premium and helps you pay for healthcare as you need it.

Health Insurance Marketplace

Run by your state or the federal government, it’s one of the places you can shop and sign up for health coverage from us and other private health coverage companies. If you’re eligible for help from the government to pay for your health coverage, you’ll need to sign up there.

Health Reimbursement Account (HRA)

An account of money set up and funded by your employer. You can use the money to pay your healthcare costs, until your plan starts paying a bigger share — after you meet your deductible. It’s a type of consumer-driven health plan (CDHP).

Health Savings Account (HSA)

A bank account you can use to pay for health expenses. You or your employer can put tax-free money into your HSA. You’ll use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year and beyond. You can also take it with you if you change health plans.

High Deductible Health Plan

A health plan that may cost less in monthly premiums, but then you’ll need to pay for your own healthcare for a little while, up to a set dollar amount, before your health plan starts paying. Often preventive care is still covered at 100% from day one. And you have the option of opening a health savings account to help you use tax-free dollars for your care.

Health Maintenance Organization (HMO)

An HMO is a type of health plan where you only get care from a network of doctors in your area. You’ll need to choose a main doctor — also called a primary care physician or primary care doctor, from your health plan network. If you need a specialist, you’ll most likely have to go through your main doctor to get a referral.

Home Healthcare

Care given by a home health agency to you at your home. It’s most often if you’re disabled, sick or convalescent.

Home Infusion Therapy

A type of care where you get a liquid substance put into your vein, muscle or other part of your body, done at your home.

Hospice

A facility or service that gives care to terminally ill patients, as well as support to the family. The care is often for controlling pain and other symptoms, and can be provided in the home or in an inpatient setting.

Hospital

A center where you go when you need care or surgery. You may go to a hospital, get your treatment and then go home that day (outpatient). Or your condition or the care you need may require you to stay over for one or more nights (inpatient).

Health Reimbursement Account (HRA)

An HRA is an account that is set up and funded by your employer. You can use the money to pay your healthcare costs, until your plan starts paying a bigger share — after you meet your deductible. It’s a type of consumer health plan (CDHP).

Health Savings Account (HSA)

An HSA is a bank account you can use to pay for health expenses. You or your employer can put tax-free money into your HSA. You’ll use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year and beyond. You can also take it with you if you change health plans.

I

Identification Card/ID Card

The card you get from us at the beginning of your health plan year that shows that you’re a member and what kind of plan you’re on. Most doctors need to see your card before giving you care, to see how you’re covered. You can also keep your ID card on your smartphone if you download our mobile app from App Store or Google Play.

Immunizations

Shots or other medicines you get that help prevent you from getting a particular disease or condition.

Independent Physician Association (IPA)

Also called an independent practice association, it’s a company made up of doctors and other healthcare providers.

Individual Plan

A health coverage plan you buy on your own, not through your job or another type of group. It can also include your family or other qualified dependents.

In-network

Certain doctors and hospitals have agreed to accept your insurance — that’s your network. Each plan has its own network. And getting care from “in-network” doctors and hospitals just means going to those.

Infertility

A type of treatment for people who may need help to get pregnant.

Infusion Therapy

A type of care where you get a liquid substance put into your vein, muscle or other part of your body.

Inpatient

Hospital care given to someone, which requires an overnight stay.

Investigational Procedures

Healthcare procedures that are still being tested, but not yet proven to treat a condition.

Internal Revenue Service (IRS)

The US government agency that collects taxes and enforces tax law.

J

No glossary terms are currently available.

K

No glossary terms are currently available.

L

Legend Drug

A drug that, by law, can only be obtained by prescription. Legend drugs are so named because the label bears this legend: "Caution: federal law prohibits dispensing without a prescription."

Lifetime Maximum

The maximum amount of benefits your health plan carrier will pay for your lifetime, not just for a plan year.

Life-threatening Disease

A disease that may put a person's life in danger if it’s not treated.

M

Mail Service Pharmacy

A pharmacy sends your prescriptions right to you through the mail.

Maintenance Medication

A drug you take ongoing.

Managed Care

A type of care where your main doctor, also called a primary care physician (PCP) plays an active role in your care. You may be required to go through your main doctor to get a referral to other types of care, like seeing a specialist.

Marketplace

Short for health insurance marketplace. Run by your state or the federal government, it’s one of the places you can shop and sign up for health coverage from us and other private health coverage companies. If you’re eligible for help from the government to pay for your health coverage, you’ll need to sign up there.

Maternity Services

Care required for pregnancy and delivery.

Maximum Allowance or Maximum Benefit Allowance

The amount a doctor or hospital can charge for a healthcare service or item they give you.

Mediation

A process where a neutral person tries to help people resolve a dispute between them. It’s different from arbitration, which sometimes requires that the people accept whatever the neutral person decides.

Medicaid

A government program that provides health coverage to some citizens who are younger than 65 years of age who can’t afford private health insurance.

Medicare

A government program which provides health coverage to people 65 years or older.

Medical Group

A company made up of doctors and other healthcare providers who work together to care for patients.

Medical Equipment

Equipment ordered by prescription from a doctor or other healthcare provider, for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, or blood testing meters for diabetics. See also durable medical equipment.

Medical Loss Ratio (MLR)

The percentage of premiums that insurers spend on medical care, as opposed to the percentage spent on administrative expenses like customer service.

Medically Necessary/Medical Necessity

Healthcare services or supplies that are a reasonable part of your care. Sometimes we’ll ask your doctor to show that the care they’re proposing for treatment is medically necessary.

Member
 

Someone enrolled in our health coverage plans, whether they’re the main person on a policy or a qualified dependent.

Member Handbook

A document that has all of the details about your coverage. It’s sometimes called your contract, policy, evidence of coverage or certificate of coverage.

Member Representative

Someone who has been asked or appointed to speak for a member and make their care decisions.

Member Services Department

A team of people who are available to answer your questions and help you understand your plan.

Mental or Behavioral Health

The health of your mind and emotions, including substance abuse issues.

Mental Health Services

Care to address the health of the mind and emotions. May include therapy, medication, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization, treatment for substance abuse and more.

Multisource Brand Drugs

Brand name drugs which are distributed by more than one company and may have a generic version.

N

National Committee on Quality Assurance (NCQA)

A not-for-profit organization that performs quality-oriented accreditation reviews of managed care plans.

Network

Doctors and hospitals who've agreed to accept your insurance. Each plan has its own network. And getting care from your network is often a good way to get quality care at a more reasonable cost.

Network Provider

A doctor or hospital who has agreed to accept your insurance. Each plan has its own network. And getting care from your network providers is often a good way to get quality care at a more reasonable cost.

Non-formulary Drug

A drug that's not listed on your health plan's list of covered drugs. It requires authorization from the health plan in order to be covered.

Notice of Privacy Practice (NOPP)

Document that tells you how your information may be used and distributed by an organization.

O

Occupational Therapy

Treatment used to improve and maintain a patient's daily living skills because of a disability or injury.

Off-label Drug Use

Use of a drug for purposes other than those originally approved by the FDA. For example, if a drug was originally approved for use as an anti-inflammatory, using it to treat cancer would be considered an "off label" use.

Online Account

The place a member may check benefits and know how much is covered for services and prescriptions. Members can also estimate costs and change coverage with a different plan.

Open Enrollment

The time period during which you can sign up for health coverage for the following year.

Orthotic

Treatment or device used to support, align, correct, or improve the function of your bones and joints.

Out-of-area Services

Healthcare you get while away from your home area.

Out of Network

A doctor or hospital who has not necessarily agreed to accept your insurance. Some plans give you coverage when you go to out-of-network providers and some don't. But even if yours does, you'll almost always pay more for the same level of care. Also sometimes called "non-participating" or "non-par" provider — meaning they don't participate in your health plan network.

Out-of-network Provider

A doctor or hospital who has not necessarily agreed to accept your insurance. Some plans give you coverage when you go to out-of-network providers and some don't. But even if yours does, you'll almost always pay more for the same level of care. Also sometimes called "non-participating" or "non-par" provider — meaning they don’t participate in your health plan network.

Outpatient

Healthcare treatment (or the person getting that treatment) in a hospital or other healthcare facility without an overnight stay.

Outpatient Surgery

Surgical procedures done at a hospital or other healthcare facility that don't require an overnight stay.

Out-of-pocket Maximum

The maximum dollar amount you'll pay for covered services during the year. After that, your plan will pay for the rest of your covered care that year.

Over-the-counter (OTC) Drugs

Drugs that may be purchased without a prescription.

P

Partial Day Treatment

A program offered by psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. An alternative to inpatient treatment.

Participating Provider

A doctor or hospital who has agreed to participate in your health plan network and accept your insurance. Each plan has its own network. And getting care from participating providers is often a good way to get quality care at a more reasonable cost.

PCP

Short for Primary Care Physician. Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.

Pharmacy

A place to get prescribed drugs.

Pharmacy Benefit Manager (PBM)

A company that administers and manages your prescription drug benefits.

Physical Therapy

Treatment involving physical movement to relieve pain, restore function and prevent disability after a disease, injury, or loss of limb.

Physician

Another word for a medical doctor.

Point of Service (POS)

A type of health benefit plan that usually offers three different ways, or three “tiers,” to get care:

1. You pay the least for care if you choose a main doctor, also called a primary care doctor, in the network to manage your care. You go through your main doctor to see specialists.
2. You pay a bit more to see specialists or doctors in your network without a referral.
3. You pay even more to see a doctor who isn’t in the network.

Pre-Authorization/Pre-Certification/Pre-Approval

Pre-Authorization, pre-certification, and pre-approval all mean the same thing. It’s a process to determine if the proposed healthcare or service is medically necessary.

It helps determine if certain outpatient care, elective inpatient hospital stay, non-Emergency care, technology or procedure is medically necessary. It requires a healthcare doctor or facility to get pre-approval before providing specific services or procedures. Prior authorization is required for many services. Emergency or out-of-area urgent care services do not need prior authorization.

If you have questions or to check if your treatment needs pre-authorization, call the Member Services number listed on the back of your ID card.

Pre-existing Condition

A health condition that was diagnosed or treated before you enrolled in a health benefit plan.

Preferred Provider Organization (PPO)

A type of health coverage plan that covers services from almost any doctor or hospital. But you’ll almost always pay less for the same level of care when you go to one in your health plan network. You don’t usually need a referral from your main doctor, also called a primary care physician or primary care doctor, to see a specialist.

Premium

The amount you pay to us for your coverage, usually monthly. If you have health coverage through your work, your employer may share the cost of your premium.

Prescription

A doctor’s order for a drug or other item or service to help in your care.

Prescription Drug

A drug that can only be used if ordered by a doctor.

Prescription Drug Tiers

Prescription drugs are put into different categories based on how much they cost, whether they’re brand-name or generic and sometimes other factors. Tier 1 drugs have the lowest copayment and are mostly generic versions of brand-name drugs. Tier 2 is made up of mid-priced drugs that may be brand-name but are “preferred” within their drug class. Tier 3 has mostly brand-name drugs with higher copayments.

Preventive Care

Tests or treatments that may help you stay healthy or catch problems early on when they’re easier to treat.

Primary Care

A basic level of healthcare usually rendered in ambulatory settings by general doctors, family doctors, internist, obstetricians, pediatricians, and mid-level doctors. This type of care emphasizes caring for the member’s general health needs as opposed to specialists focusing on specific needs.

Primary Care Physician (PCP)

Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.

Prior Authorization

For some healthcare services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called pre-certification, authorization, certification or pre-authorization.

Prosthesis/Prosthetic Device

A device which replaces all or portion of a part of the human body.

Provider

A doctor, hospital or other person or company that provides healthcare services.

Provider Directory

A list of doctors, hospitals, and other healthcare providers.

Provider Network

Doctors and hospitals who’ve agreed to accept your insurance. Each plan has its own network. And getting care from your network is often a good way to get quality care at a more reasonable cost. See also Network and Network Provider.