Glossary

A - B - C - D - E - F - G - H - I - L - M - N - O - P - Q - R - S - T - U - V - W - Y

Note: clicking links below to the “ACA Uniform Glossary” will open a new browser window to a document on the Center for Medicare & Medicaid Services (CMS) website. The Affordable Care Act requires insurance carriers to use this glossary for common health insurance terms.

A

Affordable Care Act (ACA): The healthcare reform law enacted in 2010. This term is short for PPACA, or the Patient Protection and Affordable Care Act, and is sometimes referred to as “Obamacare.”

Adjudication: Processing a healthcare claim through a series of edits to determine proper payment.

Allowed amount: Please see ACA Uniform Glossary.

Alternative care: (1.) Medical care received in lieu of inpatient hospitalization. Examples include outpatient surgery, home healthcare, and skilled nursing facility care. (2.) Nontraditional care delivered by providers such as midwives, acupuncturists, naturopaths, massage therapists, and chiropractors.

AMA: American Medical Association

Ambulatory care: Often called “outpatient care,” this is healthcare that takes place without being admitted to a hospital. For example, health services rendered in a physician’s office, a clinic, a hospital’s outpatient facility, or home setting.

Ancillary medical services: Covered services that supplement the care furnished by providers. Examples of ancillary services include ambulance service,  durable medical equipment, imaging services such as x-rays, laboratory services, prescription drugs, and physical or occupational therapy.

Appeal: Please see ACA Uniform Glossary.

ARRA: The American Recovery and Reinvestment Act is also referred to as an economic stimulus bill. On February 17, 2009, President Obama signed the Act, which includes several provisions related to healthcare. In part, the Act creates new opportunities for individuals to qualify for continuation coverage provided by a group health plan. The Act also provides for a subsidy for that continuation coverage for some individuals and their family members.

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B

Balance billing: Please see ACA Uniform Glossary.

Behavioral healthcare: Treatment of mental health, chemical dependency, and substance abuse disorders.

Benefit Year: The annual cycle in which a health insurance plan operates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall. Deductibles and other benefit year limits typically reset at the beginning of each new benefit year.

Board certified: A physician who has passed an examination given by a medical specialty board.

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C

Carrier: Another name for the insurer; insurance company, or underwriter of risk.

Case management: Case management is typically used for members who have a catastrophic illness or injury or are receiving long-term or specialized care. Case managers help members navigate their plan’s benefits, get the services they need, and help to provide continuity of care and transition planning.

Certificate of Creditable Coverage (COC): A document that provides proof of a person’s insurance coverage. Under HIPAA laws, health insurers must issue this certificate to individuals when their coverage ends under an employer-provided group health plan, or under certain individual policies.

Chemical Dependency Services: Services (inpatient or outpatient) related to the treatment of addiction and/or substance abuse disorders.

Claim: A bill submitted by a provider (or a member) to an insurance company to establish that medical services were provided.

Clinic: Healthcare facility that provides preventive, diagnostic, and treatment services to patients in an outpatient setting.

COBRA: Acronym for Consolidated Omnibus Budget Reconciliation Act, a federal law that requires employers to offer continued health insurance coverage to employees whose health and dental insurance coverage terminates. COBRA applies only to groups of 20 or more employees; groups with fewer than 20 employees are subject to state continuation laws.

COB: See Coordination of Benefits.

COC: See Certificate of Creditable Coverage.

Co-insurance: Please see ACA Uniform Glossary.

Complaint: An expression of dissatisfaction about a specific problem encountered by a member, or about a decision by the insurer (or agent acting on behalf of the insurer). A complaint must include a request for action to resolve the problem or change the decision.

Complications of pregnancy: Please see ACA Uniform Glossary.

Coordination of Benefits (COB): When people have more than one health insurance policy, this coordination indicates which insurance plan will pay the claim, or pay the claim first. There are different types of COB provisions. Some types of COB mean that both plans contribute to paying covered expensesand there may be little or no out-of-pocket cost to the member. Other COB provisions only compare the benefits of the two plans and ensure that they benefit is paid at the best of the two possible benefits. When benefits are coordinated, one plan pays benefits first (the “primary coverage”) and the other pays based on the remaining balance (the “secondary coverage”).

Co-payment: Please see ACA Uniform Glossary.

Cost sharing: When a member is responsible for paying a portion of the cost of care via deductibles, copayments, or coinsurance.

Coverage: Services or benefits provided through a health insurance plan.

CPT: Current Procedural Terminology. Codes used by healthcare professional to identify the specific medical services provided to a member. CPT codes are usually listed on a member’s Explanation of Benefits (EOB) statement.

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D

DAW: Dispense As Written. These are instructions a doctor writes on a prescription to indicate to a pharmacist that generic or other drugs should not be substituted for the specific (usually brand-name) drug that the doctor has prescribed. (Please note, your health plan may only cover generic or preferred brand-name drugs, even if your doctor has indicated DAW on your prescription. Check your plan’s benefits and discuss this with your doctor. Together, you may be able to find a drug that meets your needs and will be covered by your plan.)

Date of Service: The date on which a person received a healthcare service.

Deductible: Please see ACA Uniform Glossary.

Dependents: Family members of the subscriber who are eligible for coverage on the subscriber’s plan.

Diagnosis: The identification of a disease or condition through examination.

DME: See Durable Medical Equipment.

Durable Medical Equipment (DME): Please see ACA Uniform Glossary.

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E

EFT: See Electronic Funds Transfer

Effective Date: The date on which health insurance becomes effective. 

Electronic Funds Transfer (EFT): The ability to make electronic payments directly to a bank account. For example, individuals may choose to pay their monthly premiums via EFT instead of mailing a check. Insurance carriers may choose to pay providers via EFT.

Eligibility Requirements: The age, service, and other requirements specified by a plan document or employer as pre-conditions to enrolling in a health plan.

Emergency medical condition: Please see ACA Uniform Glossary.

Emergency medical transportation: Please see ACA Uniform Glossary.

Emergency room care: Please see ACA Uniform Glossary.

Emergency services: Please see ACA Uniform Glossary.

Enrollee: Person eligible for services as either a subscriber or covered dependent in a health plan. May also be referred to as a “Member.”

Enrollment: Process by which an individual becomes covered under a health or dental plan.

ER: Emergency Room

Essential Health Benefits (EHB): A set of health care service categories that must be covered by certain plans, starting in 2014 as part of the Affordable Care Act. EHB’s include hospitalization, maternity care, emergency care, preventive care and other services. See Healthcare.gov for more information.

Evidence of Coverage: See Certificate of Creditable Coverage (COCC)

Exchange: An online marketplace where individuals and small employers can purchase health insurance for coverage that begins in 2014. Buying health insurance in an exchange is optional; however, most federal assistance to help individuals and families pay for health insurance is only available through an exchange.

Excluded services: Please see ACA Uniform Glossary.

Experimental procedures: Services, supplies, treatments, or drug therapies that the health plan has determined are not generally accepted as proven and effective in treating the illness for which their use is proposed. Also called “investigational” or “unproven” procedures.

Explanation of Benefits (EOB): Every time you use your health insurance benefits, your insurance company will send you a statement that shows the service you had (like an office visit) and how they applied your benefits to it. This statement is called an Explanation of Benefits. If you need help reading or understanding your PacificSource EOB, please see our “About your EOB” page.

Extended care facility: A nursing home type of setting that offers skilled, intermediate, or custodial care.

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F

Flexible Spending Account (FSA): An employee benefit offered by many companies that allows employees to have pretax dollars withheld from their salaries to pay for unreimbursed medical expenses and dependent-care expenses, such as babysitting or eldercare.

Formulary: Health insurers generally maintain a list, called a formulary, of “preferred” generic and name brand medications. The medications listed on the formulary are usually covered at a higher level than those medications not listed. (The medications not included on the formulary are often referred to as the “non-preferred” brands.) A formulary can also be called a drug list.

FSA: See Flexible Spending Account.

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G

Generic Drug: A prescription drug that has the same active ingredients as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs as safe and effective as brand-name drugs.

Global: All-inclusive. For example, a bill for “global surgery” includes the surgery plus all pre-op and post-op care, or a “global billing” may include all charges for a series of treatments.

Grievance: Please see ACA Uniform Glossary.

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H

Habilitation services: Please see ACA Uniform Glossary.

Health insurance: Please see ACA Uniform Glossary.

Health Insurance Portability and Accountability Act (HIPAA): Federal legislation designed to improve the portability of health coverage, reduce healthcare costs by standardizing the processing of healthcare transactions, increase the security and privacy of healthcare information, and to make other changes to the healthcare delivery system.

Health Reimbursement Arrangement (HRA): An IRS-approved, tax-favored benefit that reimburses employees, up to a maximum dollar amount, for qualified medical care expenses not reimbursed by an employer's health plan. HRAs are paid for solely by the employer. Any unused portion of the maximum dollar amount at the end of a coverage period may be carried forward to increase the maximum reimbursement amount in subsequent coverage periods.

Health Savings Account (HSA): A tax-sheltered savings account that may be used by beneficiaries covered by qualified high deductible health plans to pay for healthcare expenses not covered by their health plan. Money remaining in the account at the end of the year may be used in the following year. Contributions to an individual’s HSA can be made by anyone, including the employer, up to an annual maximum.

Home health care: Please see ACA Uniform Glossary.

Hospice services: Please see ACA Uniform Glossary.

Hospitalization: Please see ACA Uniform Glossary.

Hospital outpatient care: Please see ACA Uniform Glossary.

HRA: See Health Reimbursement Arrangement.

HSA: See Health Savings Account.

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I

ICD or ICD-9-CM: International Classification of Diseases, 9th Edition (Clinical Modification); book of narrative/numeric codes used by healthcare providers to classify medical diagnoses.

Individual Insurance Market: The market for health insurance coverage offered to individuals who do not have access to a group health plan, for example, through their employer. In some states, a group or employer health plan that has fewer than two participants may also be considered part of the individual insurance market.

In-network co-insurance: Please see ACA Uniform Glossary.

In-network co-payment: Please see ACA Uniform Glossary.

Inpatient care: Care provided in a licensed bed in a hospital, nursing home, or other medical or psychiatric institution, usually for at least 24 hours.

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L

Lifetime Limit or Lifetime Maximum: A limit, or “cap” on the total amount of benefits that may be paid for a specific service. For example, your plan might have limits on the dollar amounts of benefits it will provide (such as a plan that will only pay $300 for foot orthotics over the lifetime of your plan.) Or your plan may have limits on the number of times it will pay for a certain service (for example, the plan may only pay for one liver transplant per lifetime).

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M

Medically necessary: Please see ACA Uniform Glossary.

Medicare: The federal health insurance program for older U.S. citizens and the disabled.

Member: Often used in place of “the enrolled” or “the insured” person, the member is anyone covered by the health plan, whether they are the subscriber or dependent on their policy.

Mental Health and Chemical Dependency Parity: Oregon’s mental health parity law, which became effective January 1, 2007. It requires group health insurance policies to cover treatment of chemical dependency and mental or nervous conditions at the same level and with no more restrictions than those imposed for other medical conditions.

MRI: Magnetic Resonance Imaging

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N

Network: Please see ACA Uniform Glossary.  

Noncovered services: Those services excluded from coverage by your health plan.

Nonemergent condition: Meaning “not a life-threatening emergency,” this is defined as routine examinations, diagnostic work-ups for chronic conditions, routine prenatal care, elective surgery, and scheduled follow up visits for prior emergency conditions. Receiving nonemergent care in an emergency room setting is usually not covered by health plans.

Nonformulary covered prescriptions: Drugs that are not specifically listed on an insurer’s formulary are considered non-formulary drugs and typically have a higher cost for the member. (Occasionally an insurer make may a list of prescription drugs that are nonformulary, to make it easier for members to compare.)

Nonpreferred/Nonparticipating provider: Please see ACA Uniform Glossary.

Nurse practitioner: A registered nurse who has advanced skills in the assessment of physical and psychosocial health status of individuals, families, and groups.

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O

Obamacare: See ACA.

Open Enrollment: An annual period, usually occurring shortly before the beginning of a new plan year, during which eligible people can enroll for health insurance benefits and/or change their elections from the previous year. Unless you have a qualifying special event, this is typically the only time of year that you can enroll in a health insurance plan.

OTC: See Over-the-Counter Drug or Medicine.

Out-of-area: That area that is outside your insurer’s service area.

Out-of-network co-insurance: Please see ACA Uniform Glossary.

Out-of-network co-payment: Please see ACA Uniform Glossary.

Out-of-panel provider: Usually called a “nonparticipating” or “non-network” provider, this is a  provider who is not a part of the panel of doctors and other providers selected for your healthplan’s provider network.

Out-of-pocket limit (OOP): Please see ACA Uniform Glossary.

Outpatient: A person who visits a clinic, emergency room, or health facility and receives healthcare without being admitted as an overnight patient.

Outpatient care: Care given to a person that does not require an overnight stay in a bed in a licensed hospital, nursing home, or other facility.

Over-the-Counter (OTC) drug or medicine: A drug or medicine that is sold lawfully without a prescription.

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P

Participating provider panel: A listing of the providers and facilities that have contracted with your health insurer to provide services at a discount to members.

PBM: Pharmacy Benefit Manager

PCP: See Primary Care Provider.

PDL: See Preferred Drug List.

PHI: See Protected Health Information.

Physician: A person duly licensed and qualified to practice medicine in the state where his/her practice is located.

Physician services: Please see ACA Uniform Glossary.

Plan: Please see ACA Uniform Glossary.

Plan administration: Management of a health plan, including accounting, billing, personnel, marketing, and legal services.

Plan Year: The 12-month period on which a plan operates. Note: the plan year may or may not be the same as the benefit year. Your policy or plan description/handbook should indicate which month is the start of each plan year.

Point of Service (POS): A type of health plan in which you may pay less (or have a higher level of benefits) if you use doctors, hospitals, and other healthcare providers that belong to a plan’s network.

Policyholder: The employer or individual to which the health insurance contract is issued and in whose name the policy is written. In a plan contracting directly with the individual or family, the policyholder is the individual to whom the contract is issued.

Portability: Access to continuous health coverage so that the insured does not lose insurance coverage due to any change in health or personal status (such as employment, marriage, or divorce).

POS: See Point of Service.

PPACA: Patient Protection and Affordable Care Act, federal legislation enacted in 2010. This is also referred to as ACA or Obamacare.

Preauthorization: Please see ACA Uniform Glossary.

Pre-existing condition: Physical or mental condition of an insured person that existed before enrollment in a health plan. Pre-existing conditions may result in a limitation  of coverage or benefits. Pregnancy is not considered a pre-existing condition.

Preferred Drug List (PDL): A list of brand name prescription medicines that is more limited than a standard drug formulary. Drugs on the list are selected based on clinical results and economic value.

Preferred provider: Please see ACA Uniform Glossary.

Premium: Please see ACA Uniform Glossary.

Premium Tax Credit: Please see ACA Uniform Glossary.

Prescription drug coverage: Please see ACA Uniform Glossary.

Prescription drugs: Please see ACA Uniform Glossary.

Preventive care: Healthcare focused on preventive measures such as routine physical exams, check-ups, immunizations, etc., and not a specific medical complaint. This type of care is also sometimes referred to as “routine,” “screening,” or “pre-care.”

Primary care: Routine medical care, normally provided in a doctor’s office. Professional and related services are administered by an internist, family practitioner, obstetrician-gynecologist, pediatrician, or nurse practitioner in an ambulatory setting, with referral to secondary care specialists as necessary.

Primary care physician (PCP): Please see ACA Uniform Glossary.

Primary care provider (PCP): Please see ACA Uniform Glossary.

Provider: A person licensed, certified, or otherwise authorized  to administer healthcare services. Examples of providers include physicians, dentists, nurses, pharmacists, and other healthcare facilities or entities.

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Q

Qualifying Event: Usually you cannot make changes to your health insurance enrollment except during an annual open enrollment period. However, there are special life events, called qualifying events, that may allow you to change your coverage, drop your coverage, or enroll in coverage, even if it's not open enrollment time. There are qualifying events for COBRA and qualifying events for a special enrollment period.

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R

Reconstructive surgery: Please see ACA Uniform Glossary.

Referral: A specific process by which the member’s primary care practitioner (PCP) directs the member to  other providers, usually specialists, for further care. Some health plans require you to get a formal referral from your PCP before you see a specialist or other type of provider. (Please note, a doctor suggesting the names of other providers is not the same thing as a formal (usually written) referral.)

Referral authorization: The processes an insurance company uses for reviewing and authorizing referrals to specialist physicians or other types of providers by primary care practitioners.

Rehabilitation services: Please see ACA Uniform Glossary.

Rider: A rider is an amendment to an insurance policy. Some riders will add coverage (such as adding a dental rider to a medical policy), while some riders exclude coverage for a certain service or condition.

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S

SBC: See Summary of Benefits and Coverage

Service Area: The geographic area in which a health insurance plan’s benefits are available. Some health insurance plans will not provide coverage outside of the plan’s service area. 

Skilled nursing care: Please see ACA Uniform Glossary.

Skilled Nursing Facility (SNF): A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and/or medical care that is of a lesser intensity than that received in a hospital.

SNF: See Skilled Nursing Facility.

Special Enrollment: A time outside of the open enrollment period during which you and your family have a right to sign up for health insurance if you experienced certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage.  

Specialist: Please see ACA Uniform Glossary.

Subrogation: When healthcare costs of enrollees are the responsibility of an entity other than the insurer, such as workers’ compensation, automobile  coverage, or a third party.

Subscriber: The person who is responsible for payment of premiums to the insurance company, or whose employment or other status, except for family dependency, makes them eligible for enrollment in a health plan..

Summary of Benefits and Coverage (SBC): A summary of the costs and coverage of a health plan. The SBC must be used by all insurance companies to make it easier for people to compare plans based on price, benefits, or other features.

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T

Tertiary care: Healthcare services which are not available through a community hospital setting. This may include complex cancer procedures, transplants, and neonatal intensive care.

Third party liability: The circumstance under which a company other than the insurer is responsible for paying a member's claim.

Triggering Event: One of several specific events listed in the COBRA Link to term statute that will result in a qualifying event if it also causes a loss of coverage under a group health plan.

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U

Usual, customary, and reasonable (UCR): Please see ACA Uniform Glossary.

Urgent care: Please see ACA Uniform Glossary.

Utilization review: A formal process used by an insurer, or delegated by the insurer, to monitor a patient’s use of healthcare services and  evaluate the medical necessity, appropriateness, efficacy, or efficiency of those services, procedures, or settings.

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V

Vision Coverage: Vision coverage is a health benefit that at least partially covers vision care, like eye exams and glasses.

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W

Waiting Period: A period that must pass before an employee or dependent is eligible to enroll under the terms of a group health plan.

Well-baby and Well-child Visits: Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

Well-woman care: Routine preventive care services provided to adult women, which may include pap smears, mammograms and other services.

Wellness Program: A program of health promotion and/or disease prevention.

WHCRA or Women’s Health and Cancer Rights Act: A federal law that requires group health plans that provide mastectomy benefits to provide coverage for reconstructive surgery and certain other related benefits.

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Y

YTD: Year-To-Date

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Last updated 9/26/2014