Health Insurance Terminology

Healthcare insurance is on the minds of a lot of people right now as the December 15th open enrollment deadline to sign up for health insurance through the Market Place is fast approaching. And in case you hadn’t noticed, this year’s open enrollment period is much shorter than in prior years.


“We are fundamentally changing the nature of the health-care marketplace.” ~President Trump

With all the various terms a person will see while combing through the available plans, it can be a bit confusing, so Blue Chip Benefits would like to take this opportunity to share with you what we feel are the 30 definitions you are most likely to come across.

Allowable Charge – An allowable charge is an approved dollar amount that a health insurance company will reimburse a provider for a certain medical expense. Also referred to as allowed amount.

Balance-Billed – The difference in amount between the provider’s charge and the allowed amount (a “preferred” provider may not balance bill you for a covered service).

Co-insurance – The percentage of cost that is your responsibility after having a covered health care service. (This percentage will be due in addition to any applicable deductible.)

Co-pay – A fixed amount that you will pay for a specific service, such as an office visit.

Deductible – A deductible is a specific dollar amount your health insurance plan may require you to pay out-of-pocket toward covered medical care each year, before your health plan begins to pay for covered medical expenses.

Diagnostic Test – A diagnostic test is a procedure performed to confirm, or determine the suspected presence of a disease in an individual, usually following the report of symptoms, or based on the results of other medical tests.

Durable Medical Equipment – Equipment and/or supplies ordered by a health care provider for every day or extended use that provides therapeutic benefits to the patient in need because of certain medical condition and/or illness.

Emergency Room – A medical treatment facility specializing in emergency medicine and the acute care of patients who arrive at the facility without prior appointment.

Habilitation – Refers to a process aimed at helping disabled people attain, keep or improve skills and functioning for daily living.

Home Health Care – Health care services a person receives at home.

Hospice Services – Services that provide comfort and support to persons in the last stages of a terminal illness, and their families.

Hospitalization – Care received in a hospital that requires admission as an inpatient and an overnight stay.

Imaging – Medical imaging is the technique and process of creating visual representations of the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues. Medical imaging seeks to reveal internal structures hidden by the skin and bones, as well as to diagnose and treat disease.

Inpatient Care – A term used to describe a person admitted to a hospital for at least 24 hours.
Network Provider – The providers, facilities and suppliers your health insurer has contracted with to provide health care services.

Out-of-Pocket Limit – The dollar amount you will have to pay before your insurer begins to pay for services. This limit does not include premiums, balance-billed charges nor services your insurer does not cover.

Outpatient Care – Care received in a hospital that usually does not require an overnight stay.

Non-Preferred Provider – A provider who does not have a contract with your health insurer to provider services.

Participating Provider – A provider who has contracted with your health insurer to provider services, but at a higher rate than your preferred provider. You will usually pay more for services, than if you were to see a preferred provider.

Pre-authorization – Also knows as prior authorization, prior approval or pre-certification, this is a decision made by your health insurer that allows you to receive treatment, prescriptions or durable medical equipment, according to your policy.

Pre-existing Condition – A health problem that existed or was treated before the effective date of your health insurance coverage. Most health insurance contracts have a pre-existing condition clause that describes conditions under which the health insurance company will cover medical expenses related to a pre-existing condition.

Preferred Provider – A provider who has contracted with your health insurer to provide services at a discounted rate.

Preventative Services – Medical care focused on prevention and early-detection of disease. This type of care is best exemplified by routine examinations and immunizations.

Premium – The amount you pay to be covered by health insurance. Usually billed monthly, but can be billed quarterly or annually.

Primary Care Physician (PCP) – A physician/doctor {Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.)} who provides or coordinates a range of health care services for patients.

Provider – A doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or a clinical social worker who is authorized to practice by the State and who provides preventive, curative, promotional or rehabilitative health care services in a systematic way to people, families or communities.

Rehabilitation – Services that aim to restore some or all of the patient’s physical, sensory or mental capabilities that were lost due to injury, illness, or disease.

Skilled Nursing Care – Services received from a licensed nurse, in your own home or nursing home.

Specialist – A physician/doctor who focuses on a specific area of medicine to diagnose manage, prevent or treat certain types of symptoms and conditions—such as a cardiologist.

Urgent Care – Care received for an illness, injury or condition that was serious, but not so severe that it requires an emergency room visit.

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