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Let's Be Clear: Insurance Speak Guide

There’s too much jargon in health insurance. Who really knows what all those acronyms and insurance-ese mean? Let’s clear it up. (pdf for download)

A | C | D | E | F | H | I | L | M | N | O | P | R |S | T

Health Insurance Speak
A

accreditation, accreditation process

certification, certification process

activate, activation date

start, start date
EG: Your health coverage will start on January 1, 2011.

adjudicate

process your claim for payment

authorize, authorization

approve, approval

EG: Your health plan will need to approve the treatment before it begins.

carry over

last year's unused funds, money left in your account from last year
EG: Your health reimbursement account pays claims using the money left over from last year, before using this year’s funds.

claimant

you

coinsurance

the amount is a percentage of the cost of the claim; your share of the cost

consumer driven health plans (CDHP)

your medical plan plus an account you can spend on health care.
EG: An account-based plan means you can pay for health care services from a health savings account (HSA) that you set up, or a health reimbursement account (HRA), which your employer has set up to help you pay for covered medical expenses.

contraindication, contraindicated

means that you can have a bad/allergic reaction to a certain drug or combination of drugs and/or food.

coordination of benefits (COB)

other insurance you may have
EG: If you have more than one medical insurance plan, coverage is coordinated.

co-pay, copayment

a pre-set amount you pay for health care
EG: You pay $10 toward a doctor’s visit and your health plan pays the rest.

deductible

what you pay before your plan begins to pay

employee assistance program (EAP)

programs offered by your employer to help you better manage work/life balance or get help with life’s challenges

explanation of benefits (EOB)

after you visit your doctor, you’ll get an explanation of benefits outlining the services you received, how much they cost, and how much your plan paid

flexible spending account (FSA)

an account your employer sets up and you contribute pre-tax dollars to, you use the money to pay for health care services

formulary

drug list
EG: Medications that can be covered/paid for under your pharmacy plan

health maintenance organization (HMO)

provides, offers or arranges for health care coverage through a network of health care professionals and facilities

health spending account

an account you can use to pay for health care services

health savings account (HSA)

a health savings account that you set up

health reimbursement account (HRA)

a health reimbursement account, which your employer sets up to help you pay for covered medical expenses

holistic

comprehensive, integrated

in-network

health care professionals and hospitals contracted with your health plan to deliver services at a negotiated rate (discount)

IVR, VRU

automated phone system

limited purpose flexible spending account

an additional health spending account that reimburses you for expenses not covered by your HSA

limited purpose health reimbursement account

an additional health spending account that reimburses you for expenses not covered by your HRA

medical management

the people and services that help you manage your health, coordinate care and navigate the health care system when you are sick or injured

member

you or a family member covered by your health plan

member liability

how much you owe

national committee for quality assurance (NCQA)

a watchdog for quality of care over managed care plans and physician organizations

network savings

discount

open access plan (OAP)

open access plans allow you to see specialists without a referral from a primary care doctor

out-of-network

health care professionals and hospitals that are not contracted with your health plan to deliver services at a negotiated rate (discount), depending on your plan, you may have to pay a higher percentage of the claim, even up to 100%

out-of-pocket (OOP)

the total of all your payments before your insurance pays at 100% (may or may not include your deductible)

outreach telephonically

call

patient liability

your financial responsibility

primary care physician (PCP)

your primary doctor

preferred provider organization (PPO)

a health plan made up of health care professionals and hospitals contracted to deliver services at a negotiated rate (discount)

periodontal disease

gum disease

provider

doctor, hospital, health care professional

roll over

last year’s unused funds, money left in your account from last year
EG: Your health reimbursement account pays claims using the money left over from last year, before using this year’s funds.

subsequent to

after

terminate

end