Glossary of insurance terms

A

Accident rider

Agent

Allowed amount

Alternate benefits

Appeal

B

Balance billing

Benefits

C

CPT

Care management

Claim

Clinical Practice Guidelines

Certificate of coverage (COC)

Coinsurance

Complication of pregnancy

Copayment

Cost sharing

Covered, coverage

Coverage documents

D

Deductible

Drug tier

Durable medical equipment (DME)

E

Emergency medical condition

Emergency medical transportation

Emergency room care

Emergency services

Essential health benefits

Excluded services

F

Fee-for-service

Flexible spending account (FSA)

Formulary

G

Grievance

Guaranteed issue

H

HCPCS codes

HCFA

Habilitative services

Health insurance

Health maintenance organization (HMO)

Health reimbursement account (HRA)

Health savings account (HSA)

High-deductible health plan (HDHP)

HMO plan

Home health care

Hospice services

Hospitalization

Hospital outpatient care

L

Leased network/partner network

M

Managed care organization

Medicaid carve out

Medically necessary

N

Network

Non-preferred provider

O

Open Enrollment Period

Out-of-network

Out-of-pocket limit/maximum

P

Physician services

Patient-centered medical home (PCMH)

Plan

Point-of-service (POS) plan

Practice guidelines

Preauthorization

Preferred benefits

Preferred provider

Preferred provider organization (PPO)

Premium

Prescription drug coverage

Prescription drugs

Preventive care

Primary care

Primary care provider (PCP)

Product

Provider

Q

Qualified Health plan

R

Reconstructive surgery

Referral

Rehabilitation services

Rider

S

Skilled nursing care

Specialist

Specialty drug

Specialty pharmacy

U

UCR (usual, customary and reasonable)

Urgent 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 (www.ncqa.org) and United States Department of Labor (www.dol.gov) websites.