Glossary

Accreditation – This is proof that a health plan or hospital meets certain standards. An outside group decides this through an official review.

Adjudication – This is the way health plans decide how much they will pay for certain expenses.

Allowable expenses – This is part of a bill that is eligible to be paid under your health plan.

Annual Election Period (AEP) – This is the time of the year when you can make changes to your Medicare plan.

Beneficiary – This is the person you choose to receive your assets if you die. It can be the person you choose to receive payment from a life insurance policy after your death.

Beneficiary (Medicare) – This is someone who has a health plan under Medicare or Medicaid.

Benefit – This refers to medical services covered by your health plan. This word is also used to describe your health plan in general. It can also mean payment received under a plan.

Benefit period – This is a maximum length of time during which benefits will be paid.

Centers for Medicare and Medicaid Services (CMS) – This is a federal agency. It runs the Medicare program. It also works with states to run the Medicaid program.

Certificate of coverage – This details the benefits provided by your health plan. It lists what is covered and what is not covered. You will receive this document after you are approved for a plan.

Claim – This is a request to be paid by a health plan for health services given.

Coinsurance – This is the percentage of health care expenses you pay after your deductible. Your health plan pays the rest up to any benefit or lifetime maximum.

Copay – This is the dollar amount you pay for health care expenses. In most plans, you pay this after you meet your deductible limit.

Coverage gap – This is also called the “donut hole.” It is the part of the Medicare plan where the member pays for what the plan does not pay.

Death benefit (also known as Face amount) – This applies to life insurance. It is the money that an insurance company pays when an insured dies.

Deductible – The amount you pay for covered services before your health plan begins to pay.

Effective date – This is the date your health plan becomes active. Your coverage starts on this day.

Eligibility – This includes terms that decide who can get coverage. The requirements vary. They could include health conditions.

Emergency care – Immediate medical care needed because of an injury or an illness of sudden and unexpected onset.

Enrollment period (Medicare) – This is when people can sign up for Medicare. At this time, the plan accepts those new to Medicare. The plan must also allow all eligible people with a different Medicare plan to join.

Exclusions – These are conditions or services that the health plan does not cover.

Explanation of Benefits (EOB) – This is a statement a health plan sends to a health plan member. It shows charges, payments, and any balances owed. It may be sent via mail or email.

Fee for service – This is a process used by some health plans. It lets plans pay doctors and other providers a fee for each service they provide.

Health insurance carrier/provider – This is a company that provides health insurance plans.

Health Insurance Portability and Accountability Act (HIPAA) – This is a federal law. The law helps protect private health information. It sets national standards for handling private health records.

Home health care – It means health care services given in a patient’s home. It is often offered after a hospital stay. Coverage depends on the patient’s needs and health plan.

Hospice care – A program of care and support for someone who is terminally ill; helps them live out the time they have remaining to the fullest extent possible.

ID card – This is the card that you get when you join a health plan. It helps doctors and other health care providers know what coverage a patient has.

Indemnity plan – This is a type of health plan. Members can get care from any licensed doctor or hospital. They get the same level of benefits no matter who they see. There are no networks. The plan pays a percentage of each covered health care service. These plans often have deductibles, coinsurance and certain benefit maximums. This is also called a “Traditional plan”.

Initial enrollment period (IEP) – This period lasts seven months. It runs around the event that qualifies you for Medicare, for example, your 65th birthday. It lasts the three months before, the month of, and three months after the event.

Lapse (or lapse in coverage) – Anyone who buys an insurance plan pays premiums. You pay this amount every month. If you miss a payment, the insurance company can cancel your coverage. It means you have let your insurance coverage lapse. You have let it end.

Length of stay – This is the number of days a patient stays in the hospital for treatment. Days are counted in a row.

Lifetime maximum – This is the total dollar amount of benefits you can receive. It can also be the total number of services you can receive. These totals are limits for a lifetime, not just for a plan year.

Limitations -- These are restrictions that health plans place on coverage. They say what your plan does not cover.

Medicaid – Medicaid is a state government program. It provides health care coverage. It is meant for people with low incomes. This includes families and children.

Medical condition – This is a disease, illness or health problem for which you seek treatment.

Medicare – This is a program of the federal government. It provides health care coverage. It is for people: age 65 or older, with certain disabilities, who have permanent kidney failure, with dialysis/transplant.

Medicare-approved amount – In original Medicare, the amount that a physician who accepts assignment can be paid, including what Medicare pays and any other deductibles, coinsurance, or copayments.

Medicare prescription drug plan (PDP) – This is an optional Medicare plan. It is separate from a Medicare health plan. It provides coverage for some prescription drugs. It is offered through a private company. Sometimes, it is called a “PDP.”

Medicare supplement – This is an insurance policy. It is offered through private companies. It helps pay for some benefits not covered by Medicare Part A and Medicare Part B. It is also known as “ Medigap”.

Member – A member is someone who belongs to a health plan. Sometimes, a member is known as an “enrollee” or “policyholder”.

Monthly plan premium – This is the payment you make every month to a health plan. You are paying for the health insurance coverage the health plan provides.

Out-of-pocket costs – These are medical costs that a member must pay. Copays and deductibles are examples.

Plan exclusions and limitations – These are legal conditions. They apply to health plans. They list specifically what is and what is not covered by the plan.

Pre-existing condition – This is a health condition. It was diagnosed or treated before the date a health plan’s coverage began.

Premium – This is the amount paid to a health plan company for coverage. A person can pay it directly. Sometimes a person has a health plan with an employer. Then this cost might be shared between the person and the employer.

Provider – This term is used often by health plans. It means a licensed person or place that delivers health care services. Some examples are doctors, dentists, hospitals, and more.

Rider – This is a policy that is separate from the main policy. It has changes in it that affect the main policy.

Skilled nursing facility (SNF) – This is a place that gives nursing care to people who do not need to be in a hospital. It is licensed. It gives rehabilitation and other care, too. It does not include nursing homes or care for those who need help with daily living.

Special election period (SEP) – This is for people with a Medicare plan. It is a time when they can change their benefits because something in their life changes. Examples are moving out of a plan service area, or being able to get Medicaid. If nothing in their life changed, they must wait for an enrollment period.

State insurance department – This is an agency that makes state insurance laws. It also makes sure insurance companies follow the laws in their state.

Underwriting – This process helps assess the costs of insuring potential members. It is used to decide who is eligible for coverage. Medical questions may be asked. A health exam may be required. Rate level and premiums are based on results.

Wellness programs – These programs try and help people stay healthy. They may include ways to prevent disease, stay fit and care for one’s own health. They show people how to take up healthy lifestyle behaviors.