Health Care Terms

Appeal – The process of requesting that a provider or health plan pay for a service for which payment has been denied.

Auto-Enrollment – The automatic assignment of a person to a health insurance plan.

Broker – A salesperson who has obtained a state license to sell and service health plan and insurer contracts.

Claim – A request by an individual that his or her insurance company pay for medical services received.

Consolidated Omnibus Budget Reconciliation Act (COBRA) – Federally supported health care benefits for people whose employment has been terminated or who have experienced other circumstances that lead to loss of coverage.

Copayment – The set amount of money a health plan enrollee pays for a specific service.

Deductible – The minimum amount of out-of-pocket expenses a health care plan enrollee must pay for medical services or medication before the plan begins to cover expenses.

Employee Assistance Program (EAP) – Counseling benefits, including 24-hour access to trained counselors in-person and over the phone, which are designed for personal or family problems, including mental health, substance abuse and other problems.

Enrollee – A subscriber or dependent who is eligible for coverage under a certain health care contract.

Exclusions – Conditions or situations not covered under a certain contract or plan.

Exclusive Provider Organization (EPO) – A type of health care plan in which only services provided by doctors and hospitals in the plan's network are covered (except in cases of emergency).

Fee-For-Service (FFS) – A traditional method of payment for health care services in which users pay for services rendered.

Flexible Spending Account (FSA) – A plan that provides employees with the opportunity to set aside funds pre-tax for certain medical expenses.

Group Health Plan – Health coverage for employees and their families, provided by an employer or employee organization.

Health Maintenance Organization (HMO) – A type of U.S. health care coverage in which subscribers are only covered for health care from a provider within a given network.

Health and Human Services (HHS) – U.S. department that oversees health-related programs and issues.

Health Care Provider – Provider of medical or health care.

Health Savings Account (HSA) – A way for those with health insurance to set aside money that is pre-taxed to pay for their health care costs, known as "qualified expenses," which include (but are not limited to) deductibles, copayments, coinsurance, monthly prescriptions and more.

High Deductible Health Plan (HDHP) – This is a health plan with tax advantages that combines a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) with traditional medical coverage.

Individual Plan – A type of insurance plan for individuals and families not eligible for health care coverage through an employer.

Lifetime Limit – A cap on the benefits available during a subscriber's lifetime under a given policy.

Managed Care – Systems and techniques used to manage health care services.

Medicaid – A federal and state program that helps with medical costs for some low-income individuals and families.

Medicare – A federal program that helps cover the medical costs of elderly and disabled individuals.

Open Enrollment Period – A period during which subscribers in a health program can revise their benefits.

Patient Assistance Programs – Programs offered by pharmaceutical companies to provide free or low-cost medications to people who could not otherwise afford them.

Point of Service (POS) – A type of health care plan in which you pay less if you use doctors, hospitals or health care providers in the plan's network.

Pre-Existing Condition – A condition or illness that you have before enrolling in a health care plan.

Preferred Provider Organization (PPO) – A type of health care plan in which a group of doctors and hospitals agrees to render particular services to a group of people for a reduced cost. This type of insurance is generally more expensive than HMOs but offers subscribers more freedom to select physicians.

Premium – The amount paid to a health care company for providing medical coverage under a contract.

Preventive Care – Health care that emphasizes prevention, early detection and early treatment.

Primary Care Physician (PCP) – A “generalist” physician who, under certain health care plans, is accountable for overall health services of enrollees.

Referral – The process of referring a patient to another doctor for specific health care services.

State Health Insurance Assistance Program (SHIP) – A state-run, federally funded program that provides free local health insurance counseling to Medicare subscribers.

Waiting Period – The minimum amount of time an individual must wait before becoming eligible for specific benefits after coverage has begun.

Workers' Compensation – Insurance that covers employees who get sick or injured on the job.