It’s important to know the most common health care terms so that you are informed when you are faced with these issues.
Appeal – The process of requesting that a provider or health plan pay for a service for which payment has been denied.
Auto-Enrollment – The automatic assignment of a person to a health insurance plan.
Broker – A salesperson who has obtained a state license to sell and service health plan and insurer contracts.
Claim – A request by an individual that his or her insurance company pay for medical services received.
Copayment – The set amount of money a health plan enrollee pays for a specific service.
Deductible – The minimum amount of out-of-pocket expenses a health care plan enrollee must pay for medical services or medication before the plan begins to cover expenses.
Employee Assistance Program (EAP) – Counseling benefits, including 24-hour access to trained counselors in-person and over the phone, which are designed for personal or family problems, including mental health, substance abuse and other problems.
Enrollee – A subscriber or dependent who is eligible for coverage under a certain health care contract.
Exclusions – Conditions or situations not covered under a certain contract or plan.
Exclusive Provider Organization (EPO) – A type of health care plan in which only services provided by doctors and hospitals in the plan's network are covered (except in cases of emergency).
Fee-For-Service (FFS) – A traditional method of payment for health care services in which users pay for services rendered.
Group Health Plan – Health coverage for employees and their families, provided by an employer or employee organization.
Health Care Provider – Provider of medical or health care.
Individual Plan – A type of insurance plan for individuals and families not eligible for health care coverage through an employer.
Lifetime Limit – A cap on the benefits available during a subscriber's lifetime under a given policy.
Managed Care – Systems and techniques used to manage health care services.
Open Enrollment Period – A period during which subscribers in a health program can revise their benefits.
Patient Assistance Programs – Programs offered by pharmaceutical companies to provide free or low-cost medications to people who could not otherwise afford them.
Point of Service (POS) – A type of health care plan in which you pay less if you use doctors, hospitals or health care providers in the plan's network.
Pre-Existing Condition – A condition or illness that you have before enrolling in a health care plan.
Preferred Provider Organization (PPO) – A type of health care plan in which a group of doctors and hospitals agrees to render particular services to a group of people for a reduced cost. This type of insurance is generally more expensive than HMOs but offers subscribers more freedom to select physicians.
Premium – The amount paid to a health care company for providing medical coverage under a contract.
Preventive Care – Health care that emphasizes prevention, early detection and early treatment.
Primary Care Physician (PCP) – A “generalist” physician who, under certain health care plans, is accountable for overall health services of enrollees.
Referral – The process of referring a patient to another doctor for specific health care services.
Waiting Period – The minimum amount of time an individual must wait before becoming eligible for specific benefits after coverage has begun.
Workers' Compensation – Insurance that covers employees who get sick or injured on the job.
