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Brand Name Drug - a drug under patent by a pharmaceutical company
Claim - a request for a payment due to medical services rendered
COBRA - The Consolidated Omnibus Budget Reconciliation Act - provides certain
former employees, retirees, spouses, former spouses, and dependent
children the right to temporary continuation of health coverage at group
rates. This coverage, however, is only available when coverage is lost
due to certain specific events. Group health coverage for COBRA
participants is usually more expensive than health coverage for active
employees, since usually the employer pays a part of the premium for
active employees while COBRA participants generally pay the entire
premium themselves. It is ordinarily less expensive, though, than
individual health coverage.
Co-insurance - the medical expense paid by the member after the deductible is
satisfied, this amount is a percentage of a fixed dollar amount
Co-pay - the contracted amount paid by the member for services rendered
Deductible - the dollar amount the member pays prior to receiving the benefits
from the insurance company
DHMO - Direct HMO - a HMO (health maintenance organization) plan offering the
additional benefit of no referral required to see a specialist
DME - Durable Medical Equipment
Durable Medical Equipment - equipment that can withstand repeated use and is
primarily and usually used to serve a medical purpose, is generally not
useful to a person in the absence of illness or injury, and is appropriate
for use in the home
Formulary Drugs - brand name drugs under patent, the list varies from insurance
carrier to carrier
Gatekeeper - primary care physician, who needs to refer the member to another
doctor
Generic Drugs - a prescription drug that has the same active-ingredient formula
as a brand-name drug no longer under patent
Home Health Care - medical services rendered to a covered individual in their
place of residence
In Network - a provider of medical services accepting your insurance carriers
plan benefits
In Patient - an admitted hospital or facility stay which requires an overnight visit
Maximum Out of Pocket - the maximum amount of money which would be required
by a member to pay under the benefit summary of the
insurance plan
Non Formulary Drugs - brand name drugs under patent, the list varies from
insurance carrier to carrier
Non Gatekeeper - a medical plan which requires no referral
Open Access Plan - O/A Plan - a medical plan which requires no referral
Out of Network - a provider of medical services not accepting your insurance
carriers plan benefits, if your plan offers out of network benefits,
these benefits become effective once the out of network
deductible and co-insurance are met
Out of Pocket - a medical expense paid by the covered individual before the plan
benefits are applied
Out Patient - a hospital or facility visit where the covered individual is in and out
the same day (out patient surgery)
Pre certification - approval needed by the insurance company for certain covered
benefits offered through the insurance coverage
Preexisting Condition - a health condition which was diagnosed prior to obtaining
health insurance coverage
Primary Care Physician - PCP - the doctor you generally go to for all your medical
needs, annual physical, opinion...
Referral - the permission needed by your primary care physician to see a specialist
Usual, Customary or Reasonable - UCR - the percentage that your insurance
company is willing to pay for services rendered by an out of network provider,
assuming your plan offers out of network benefits; these amounts are also
impacted by the location of the services rendered (zip code)
