Glossary of Health Care Terms

Appeal - The process of requesting 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 that 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.

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 their plan begins to cover expenses.

Employee Assistance Program (EAP) - Benefits that are designed for personal or family problems, including mental health, substance abuse and other problems.

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

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

Fee-For-Service (FFS) - A traditional method of payment for health care services where 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 to employees and their families, provided by an employer or employee organization.

Health Maintenance Organization (HMO) - A type of U.S. health care coverage where subscribers are required to receive all of their health care from a provider within a given network.

Health and Human Services (HHS) - The U.S. department that is responsible for health-related programs and issues.

Health Care Provider - Providers of medical or health care.

Individual Plans - 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.

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 where 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 the total 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.