Glossary of insurance terms

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.

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.

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.

Under our PriorityPOS^SM 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.

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

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.

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

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.

A bill submitted to Priority Health by a provider office for medical care or drugs.

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.

A booklet given to each person covered by a Priority Health HMO and POS 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.

Depending on your plan, you may also pay coinsurance, or a percentage of the cost of medical services, even after your deductible is paid. For example, if your plan's fee for an office visit is $100 and your coinsurance payment is 20%, your payment would be $20. Priority Health would pay the other 80%.

Your total percentage cost sharing for covered services that you pay in a contract year. Your coinsurance maximum applies toward your out-of-pocket limit.

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.

Also known as copay. The portion you pay at the time you receive a health care service. You may also have a copay when you get a prescription filled.

The part of health care costs that you have to pay based on your insurance plan. Examples include: deductibles, coinsurance, and copayments and similar charges.

Also referred to as 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.

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.

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.

The amount you pay each year before the health plan starts to pay for certain services. See your plan documents for details.

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.

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

Electronic Data Interchange is a way that businesses communicate information electronically. Examples of items that health care professionals communicate through EDI include invoices and orders. Electronic Data Interchange is used to process information faster, more accurately and more efficiently.

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Ambulance services for an emergency medical condition.

Emergency services you get in an emergency room.

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

An EOB is the summary of costs for the medical services you received over a certain amount of time. It shows you the discounts you received as a Priority Health member, what Priority Health paid toward your bill and what costs you can expect your provider to bill you.

An EOB is not a bill.

A set of health care service categories that must be covered by certain health plans.

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

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.

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.

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

A complaint that you communicate to Priority Health.

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.

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.

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

Health Care Financing Administration Common Procedural Coding System, an expansion of the AMA's CPT codes to account for additional services such as ambulance services, supplies, and equipment.

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.

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

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.

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.

Health care services a person receives at home.

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

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.

Care in a hospital that usually doesn't require an overnight stay.

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.

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.

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

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.

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

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.

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.

Maybe you've heard of the open enrollment period (OEP) for health insurance. Or maybe you haven't—but either way, there are a lot of questions and misconceptions that circulate every year when it's time to enroll in a health plan. We want to help you understand what the Open Enrollment Period is, what it means for you and how you can find the best health plan for you during this time.

What does open enrollment mean?
The Open Enrollment Period, also known as OEP, is the annual period of time when individuals can enroll in Qualified Health Plan either through the federal Marketplace or a private insurer like Priority Health.

How long is the Open Enrollment Period? When does it start?
The Open Enrollment Period runs from Nov. 1 through Jan. 15 every year. During this time, you can enroll in an Individual or family health plan.
How does the Open Enrollment Period work?
During OEP, you can enroll yourself and/or your family in a health plan for the following year. You can purchase a plan from a trusted health coverage company or through the Marketplace. Be aware that not all insurers' plans are available on the Marketplace, as individual insurers may offer more choices if you shop with them directly. You can also consult with a licensed insurance agent if you would like more assistance choosing a plan.

Can I sign up for health coverage after the Open Enrollment Period?
You will need to enroll or renew your health plan before Jan. 15 to have health coverage for the year. If you miss the deadline, you won't be eligible for coverage unless you experience a qualifying life event (QLE). This can include life events like getting married, having a baby or moving to a new location. A QLE gives you the opportunity to enroll during a special enrollment period (SEP). Otherwise, you'll need to wait until the next OEP and pay a penalty when you file your federal tax return.

Can I buy health coverage at any time?
You can only purchase health insurance during the Open Enrollment Period or if you qualify for a Special Enrollment Period. Open Enrollment Period occurs Nov. 1 through Jan. 15.

Special enrollment is the exception to open enrollment.
If you've experienced a qualifying life event you may be eligible for a Special Enrollment Period. Qualifying life events include:

• Loss of essential coverage
• Loss of COBRA benefits
• Marriage
• Birth
• Permanent relocation
• Divorce
• Adoption
• Death of previous policy holder
• Named legal guardian
• New foster child
• Change in citizenship
• Newly eligible for government assistance

An unexpected medical event or injury does not qualify you to enroll in health coverage during a Special Enrollment Period. In all cases, you'll need to provide proof of your life event, such as a marriage or birth certificate, so make sure to have those documents handy when applying.

Depending on your specific circumstance, you're only allowed 60 days from the day of your qualifying life event to change or enroll in health coverage. If you don't take action by the deadline, you could find yourself without coverage until the next Open Enrollment Period.

Shopping for a new health plan during the Open Enrollment Period can be confusing, but with research, helpful tools and consideration, choosing a new plan doesn't have to be difficult. See plans and prices or visit our Learning Center to view helpful articles about how to save money and compare plans.

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.

The maximum amount of deductibles, copayments and coinsurance you will pay for covered services in a contract year. Once you reach this maximum, covered services will be covered at 100% with no additional cost to you.

The most a plan member will pay for covered services each year, including the deductible and coinsurance.

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.

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.

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

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.

A type of managed-care coverage that allows members to choose to receive services either from participating providers or from providers outside the PriorityPOS^SM 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 PriorityPOS 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.

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.

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.

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.

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."

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.

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.

The amount you pay for your health insurance.

Health insurance or plan that helps pay for prescription drugs and medications.

Drugs and medications that by law require a prescription.

Preventive care includes specific health care services that help you avoid potential health problems or find them early when they are most treatable, before you feel sick or have symptoms. Examples of preventive care include flu shots, physical exams, lab tests and some prescriptions.

You pay $0 for preventive care services listed in your plan documents when received from an in-network provider.

We pay for preventive care services in full when you receive them from an in-network provider.

Looking for our preventive health care guidelines?

Our preventive health care guidelines explain what we cover as part of preventive care benefits.

• Download now

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.

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.

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

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.

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.

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

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.

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.

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

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.

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

Some medications require step therapy. This means you must first try taking an alternative medication—usually a generic—in the same drug family to see if you can effectively manage your condition before you can continue to take a non-preferred, more expensive drug. Rest assured, these alternatives are proven to be equally as safe and effective but are lower-cost drugs.

Your current prescription may be covered if the alternatives suggested aren't effective or your doctor deems it medically necessary. If you've completed step therapy requirements in the past, your provider can send us the information for review.

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.

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.