U.S. Health Insurance Vocabulary

The maximum amount on which payment is based for covered health care services. If your provider charges more, you may have to pay the difference.

A

A request for your health insurer or plan to review a decision or a grievance again.

A

Billing from the provider for the difference between their charge and the amount allowed by your health plan.

B

Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.

C

A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

C

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.

D

Equipment and supplies (e.g., crutches, blood glucose testing strips, oxygen) ordered by a health care provider for a patient’s everyday or extended use.

D

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

E

Health care services that your health insurance or plan does not pay for or cover.

E

A formal complaint you communicate to your health insurer or plan.

G

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

H

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

M

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

N

The maximum you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover.

O

A provider who has contracted with your health insurer or plan, but whose discount may not be as deep as other preferred providers.

P

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. This decision does not guarantee payment.

P

A provider who has a contract with your health insurer or plan to provide services to you at a discount.

P

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

P

A physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

P

A physician, health care professional or health care facility licensed, certified or accredited as required by state law.

P

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.

R

Services from licensed nurses in your own home or in a nursing home.

S

A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions; or a non-physician provider who has more training in a specific area of health care.

S

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency care.

U

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. Sometimes used to determine the allowed amount.

U