Accident rider: Accident coverage is an extra feature, or "rider," that will cover the costs of an accident or injury. It is available for an extra cost on some Priority Health individual health insurance plans.

Agent: An independent insurance agent can explain health insurance terms to you and suggest what plan would work best for your needs, your health and your budget. You don't pay more when you use an agent to buy your policy.

Allowed amount: The maximum amount Priority Health will pay for each health care service covered by your plan. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. See Balance billing.

Alternate benefits: Under our PriorityPOSSM plan, this refers to covered services received from providers who do not participate in the PriorityPOS network. This is sometimes referred to as "out-of-network benefits." Members pay more for alternate benefits than for preferred (in-network) benefits.

Appeal: A request for Priority Health to review a decision or a grievance again.

Balance billing: When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Benefits: The health care items or services covered by your plan. Covered benefits and excluded services are defined in your plan's coverage documents.

CPT: Current Procedural Terminology, the medical service coding system managed by the American Medical Association. Most services patients receive can be identified by CPT code, from office visits to complex surgeries.

Care management: Coordinated health care for plan members who are at risk for or have suffered a catastrophic health episode or who have a condition that could lead to an increased use of services.

Claim: A request for payment that you or your health care provider submits to Priority Health when you get items or services you think are covered.

Clinical Practice Guidelines: See Practice Guidelines.

Certificate of coverage (COC): A booklet given to each person covered by a PriorityHMOSM plan describing what is covered and what is not, subject to changes stated in any rider that might add to or delete some covered benefits.

Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if your plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. Priority Health would pay the rest of the allowed amount, 80%.

Complication of pregnancy: Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency Caesarean section aren't complications of pregnancy.

Copayment: A fixed amount (for example, $25) you pay for a covered health care service, usually when you receive the service, usually after you have met your deductible. The amount can vary by the type of covered health care service.

Cost sharing: The share of costs covered by your plan that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges. It doesn't usually include premiumsbalance billing amounts for non-network providers, or the cost of non-covered services.

Covered, coverage: Refers to what your plan contract is set up to pay for. If a service or drug is not covered by your plan, you will have to pay 100% of the cost yourself.

Coverage documents: Documents that explain exactly what your plan contract includes and what it does not include, how to access health care, what services require preauthorization from Priority Health, and much more. Depending on what plan they have, members of Priority Health plans may receive an insurance policy, a Certificate of Coverage, an Explanation of Coverage, or a Summary Plan Description. If you don't receive one of these documents after you've been enrolled, contact your Human Resources staff or call our Customer Service number.

Deductible: An amount you have to pay each year for the health care services your plan covers before your plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've spent $1,000 for covered health care services that apply to the deductible. Not all health care costs will count towards your deductible.

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.

Emergency medical transportation: Ambulance services for an emergency medical condition.

Emergency room care: Emergency services you get in an emergency room.

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

Essential health benefits: A set of health care service categories that must be covered by certain health plans starting in 2014.

Excluded services: Services that your health insurance or plan doesn't pay for or cover.

Fee-for-service: The traditional method of paying for medical services. A provider charges a fee for each service provided, and the insurer pays all or part of that fee. Sometimes the patient pays a copayment for each visit to the doctor or other provider.

Flexible spending account (FSA): A special account that allows individuals to set aside tax-free dollars to pay for dependent care and certain health expenses that are not paid for by a health insurance plan.

Formulary: A list of the prescription drugs your plan will cover. Also called a drug list.

Generic drugs: A drug that has only a chemical name, as opposed to a brand name. Every drug is given a generic name to describe its chemical makeup. A generic equivalent drug is a chemical copy of the original brand-name drug. There are also generic alternative drugs, which are not chemically identical but which treat the same disease or condition.

Grievance: A complaint that you communicate to Priority Health.

Guaranteed issue: In certain situations, such as losing your employer-sponsored retiree health insurance, a health insurance company cannot deny you from enrolling in its Medigap policies or increase your Medigap premium because of your health conditions. This period is called your "guaranteed issue" period. During this period, you have a "guaranteed issue right" to enroll.

HCPCS: HCFA (see below) Common Procedural Coding System, an expansion of the AMA's CPT codes to account for additional services such as ambulance services, supplies, and equipment.

HCFA: Health Care Financing Administration, the agency that administers the Medicare, Medicaid, and Child Health Insurance programs.

Habilitative services: See rehabilitation services.

Health insurance: A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Health maintenance organization (HMO): An organization that provides health care in return for pre-set monthly payments. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that their members must use in order to be covered for that care.

Health reimbursement account (HRA): Employers may set up health reimbursement accounts to reimburse their employees tax-free for qualified medical expenses up to a fixed dollar amount per year. Employers own the funds in the account; usually, the funds don't roll over from year to year.

Health savings account (HSA): A special type of savings account. You can only use the money if you're a member of a high-deductible health plan and only to pay for qualified medical expenses. You and your employer can contribute funds to your HSA. The funds contributed to the account aren't subject to federal income tax at the time of deposit. Like a retirement account, you own the funds, no matter where you go or work in the future.

High-deductible health plan (HDHP): A plan that features higher deductibles than traditional health plans. High-deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement account to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

HMO: A health maintenance organization (HMO) is a type of health plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Home health care: Health care services a person receives at home.

Hospice services: Services to provide comfort and support to people in the last stages of a terminal illness.

Hospitalization: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital outpatient care: Care in a hospital that usually doesn't require an overnight stay.

Leased network/partner network:network Priority Health has contracted with to provide services to members who live or travel outside of our standard coverage area.

Managed care organization: A general term for HMOs and all health plans that provide health care in return for pre-set monthly payments and that coordinate care through a specific network of primary care physicians and hospitals.

Medically necessary: 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.

Network: The providers (doctors, hospitals, pharmacies etc.) and suppliers your Priority Health plan has contracted with to provide health care services to plan members. Providers may be in one Priority Health plan network, such as our PPO plan network, but not in others, such as our HMO plan network.

Non-preferred provider: A provider who is not in your plan's network. If your plan allows you to go to non-preferred/out-of-network providers, you'll pay more in copayments and coinsurance.

Out-of-pocket limit/maximum: The most you pay during your plan year or policy period before your plan begins to pay 100% of the allowed amount for your health care. This limit does not have to count premiumsbalance billing amounts for non-network providers, other out-of-network cost-sharing, or spending for non-essential health benefits.

Open Enrollment Period: The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events..

Out-of-network: Not in the health plan's network of selected and approved doctors and hospitals. Members who get care out-of-network (sometimes called out-of-area) without getting permission from their health plan to do so may have to pay for all or most of that care themselves. Exceptions are usually made for extreme emergencies or urgent care needed when traveling away from home.

Out-of-pocket maximum: The most a plan member will pay for covered services each year, including the deductible and coinsurance.

Patient-centered medical home (PCMH): A model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.

Physician services: Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates. 

Plan: A contract defining the services/benefits, provider network and cost-sharing amounts that Priority Health offers/accepts to provide health care to you for a monthly premium. The details of your plan are defined in legal documents called summaries of benefits, policies, coverage documents, riders, and other names.

Point-of-service (POS) plan: A type of managed-care coverage that allows members to choose to receive services either from participating providers or from providers outside the PriorityPOS plan's network. In-network care from participating health care providers is more fully covered; for out-of-network care, members pay deductibles and coinsurance, much like traditional health insurance coverage.

There are two slightly different versions of the PriorityPOSSM health plan.

  • POS A refers to the network used by the traditional fully funded point-of-service (POS) plan, where for a set premium per member, Priority Health covers both the administrative and the medical costs of all members.
  • POS B refers to the network used by the self-funded and shared funded versions of the POS plan, where the members' employer covers all or part of the medical costs.

Practice guidelines (also called Clinical Practice Guidelines): Carefully developed guidelines on how best to diagnose and treat specific medical conditions. Practice guidelines are usually based on clinical literature showing effectiveness and on the opinions of experts. They are designed to help physicians and patients make decisions, and to help a health plan evaluate appropriateness and medical necessity of care.

Preauthorization: Some health care services, treatment plans, prescription drugs and durable medical equipment require a formal approval from Priority Health in advance before your plan will pay for them. Sometimes called prior authorization, prior approval or precertification, preauthorization isn’t a promise Priority Health will cover the cost. The preauthorization requirement doesn't usually apply in emergencies.

Preferred benefits: Under our PriorityPOS plan, this refers to covered services received from health care providers who participate in the PriorityPOS network. This is sometimes referred to as "in-network benefits."

Preferred provider: A provider who has a contract with Priority Health to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.

Preferred provider organization (PPO): A network of doctors and hospitals that provides care at a lower cost than through traditional insurance. PPO members get better benefits (more coverage) when they use the PPO's network of health care providers. They pay higher out-of-pocket costs when they choose to get care outside the PPO network.

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

Prescription drug coverage: Health insurance or plan that helps pay for prescription drugs and medications.

Prescription drugs: Drugs and medications that by law require a prescription.

Preventive care: Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples include immunization shots, screenings like Pap smears, mammograms and colonoscopies, and cholesterol checks.

Primary care: Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, pediatrics, or family practice, or by a nurse, nurse practitioner or physician's assistant.

Primary care provider (PCP): A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), 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.

Product: A health plan, such as HMO, POS, or PPO.

Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Qualified health plan: A health plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.

Reconstructive surgery: Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Referral: A formal request to get care from a specialist or hospital. Some specialists require a referral from a patient's primary care doctor before they will see a patient.

Rehabilitation services: 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. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Rider: An addition to a member's coverage documents that describes any changes to their basic plan. For example, a contraceptive rider may add or delete contraceptive coverage.

Skilled nursing care: Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

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

Specialty drug: A drug that requires special handling. It is generally self-administered and used for a chronic illness.

Specialty pharmacy: A pharmacy that specializes in the handling, distribution, and patient management of specialty drugs.

State Medicaid carve out: A group of drugs that the State of Michigan, not Priority Health, determines to be covered or not for Medicaid plan members.

Tier: Classification for drugs listed in our formulary or approved drug list. Generally, the lower the tier (1 = lowest), the lower your cost.

UCR (usual, customary and reasonable): 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. The UCR amount sometimes is used to determine the allowed amount.

Urgent care: 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 room care.

Health insurance and managed care are complicated topics. We hope these definitions help you make sense of your coverage. Many of these definitions were taken from the National Committee for Quality Assurance (, United States Department of Labor (, and websites.

Last modified: 8/6/2015
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