– The amount you owe for certain covered services before your health plan begins to pay
for them. There are per-person (individual) deductible amounts and family deductible amounts. For
example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000
deductible for covered health care services subject to the deductible. The deductible may not apply to
– A person who receives health coverage through a spouse, parent or other family
member who is the contract holder or policyholder.
Durable Medical Equipment (DME)
– Equipment and supplies ordered by a health care provider for
everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches or
blood testing strips for diabetics.
Emergency Medical Condition
– An illness, injury, symptom or condition so serious that a
reasonable person would seek care right away to avoid severe harm.
– Evaluation of an emergency medical condition and treatment to keep the
condition from getting worse.
– Health care services that your plan doesn’t pay for or cover.
– A generic drug has the same active ingredients as the original brand-name drug.
It might use different inactive ingredients, like fillers that may affect the color or shape of the drug.
In other respects, the drug is clinically identical. Generic drugs usually cost 30-60 percent less than
brand-name drugs. They are rated by the Food and Drug Administration (FDA) to be as safe and
effective as brand-name drugs.
– A complaint that you communicate to your plan.
Health Maintenance Organization (HMO)
– A form of health coverage that emphasizes preventive
care. With an HMO, members prepay a premium for health services, which generally includes inpatient
and outpatient care. For the member, it means reduced out-of-pocket costs and no paperwork.
– Prevents you from being billed for charges for covered services from an affiliated
provider due to events beyond your control.
Hospital Outpatient Care
– Care in a hospital that usually doesn’t need an overnight stay.
– Care in a hospital that requires admission as an inpatient and usually needs an
overnight stay. An overnight stay for observation could be outpatient care.
Independent Review Organization
– An outside medical review organization hired by health care
providers and facilities to provide objective, unbiased, medical opinions that support effective decision
making based on medical evidence.
– A place with many doctors under one roof. This can mean PCPs and
specialists. It can also mean services, like lab, X-ray and optical.
– Health care services or supplies that are needed to prevent, diagnose or
treat an illness, injury, disease or its symptoms and that meet accepted standards of medicine.
– The facilities, providers and suppliers your health plan has contracted with to provide
health care services.
– A medical partnership or individual doctor who does not have a contract
with your health plan. Services received from non-affiliated providers are not covered, unless the care
is an emergency.
– The most you will pay for the combined total of all copays, coinsurance and
deductibles for covered services in a benefit period (usually a calendar year). Once you meet your
out-of-pocket limit, your health plan pays all of the allowed amount for covered services.
Personal Care Physician (PCP)
– A doctor who directly provides or coordinates a range of health
care services for you.
– An employer that sets up a healthcare plan for the benefit of its employees. The
responsibilities of the plan sponsor include determining plan design and funding covered claims.
– A decision by your plan that a health care service, treatment plan, prescription
drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior
approval or precertification. Your plan may require preauthorization for certain services before you
receive them, except in an emergency. Preauthorization is not a promise that your plan will cover the
– The amount that must be paid for your plan. You and/or your employer usually pay it
monthly, quarterly or yearly.
Prescription Drug Coverage
– Plan that helps pay for prescription drugs and medications.
– Drugs and medications that by law require a prescription.
– Health care that stresses finding out early about problems and early care of
conditions, including routine doctor’s exams, vaccines and well-person care.
– To be sure certain medications or medical services are used correctly and only
when truly necessary, some plans may use a system where doctors or members need to get approval
from the plan before a medication or service is covered.