Glossary of Health Coverage and Medical Terms

Excluded Services 

Health care services that your health insurance or plan doesn’t pay for or cover. 

Grievance 

A complaint that you communicate to your health insurer or plan. 

Habilitation Services 

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. 

Health Insurance 

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home Health Care 

Health care services a person receives at home. 

Hospice Services 

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization 

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care 

Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance 

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. 

In-network Co-payment 

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. 

Medically Necessary 

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. 

Network 

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. 

Non-Preferred Provider 

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. 

Out-of-network Co-insurance 

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than in network co-insurance. 

Out-of-network Co-payment 

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments. 

Out-of-Pocket Limit 

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. 

Physician Services 

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.