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.