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Words That Matter

A Patient’s Healthcare Glossary

Illustrated in recent survey data, Patient Advocate Foundation has documented that for some of the most commonly used terms surrounding healthcare and health insurance, as little as 59% of patients felt that they were confident in the meaning of the words.

Critical vocabulary used during enrollment and the usage of health insurance, including deductible, co-payment, network, covered services and excluded services are too frequently confused by patients. In addition, our survey data has shown a distinct correlation between the understanding of these words and the ease of enrollment process and also a patient’s ultimate satisfaction of the plan they selected.

To reduce this confusion and help patients better understand the jargon they will likely encounter in healthcare, the below glossary is a resource to help patients understand these words with plain language definitions.

Affordable Care Act (ACA, ObamaCare)

noun, əˈfôrdəb(ə)l ker akt: A comprehensive healthcare reform law enacted in 2010 and that included many provisions that impact today's current healthcare plans.

Allowed Amount (Negotiated Rate)

noun, əˈlou əˈmount: The contracted payment amount agreed between a provider in your network and the insurer as compensation for a particular service. If you owe any co-insurance or cost-sharing, this is the amount used to define your costs.

Benefits (Covered Benefits)

noun, ˈbenɪfɪt z: The entire package of defined medical procedures, therapies, prescriptions and services listed within your insurance plan documents in which the insurer agrees to provide compensation on your behalf.

Co-insurance

noun, kO-in-'shu'r-ins: The percentage amount you pay towards a covered healthcare service. The amount is calculated based on the allowed amount for that service, and is only relevant after you have paid your full deductible amount.

Commercial Health Insurance ( Private Insurance)

noun, kəˈmərSHəl helTH inˈSHo͝orəns: Health insurance offered by private for-profit companies in exchange for a premium paid by enrollees. Commercial insurance plans can be structured in many different ways and are frequently offered with numerous plan types. Also known as private health insurance.

Co-payment (Co-pay)

noun, koh-pey-muh: The fixed amount you are responsible to pay for a covered health service, usually due at the time you receive the care. If your plan is subject to co-pays, the amounts are defined within your plan language.

Coverage

noun, ˈkəv(ə)rij: An agreement between you and your insurer where they cover some of your health care costs in exchange for a premium. If you have coverage in place, you have agreed to the terms of the agreement.

Coverage Details

noun, ˈkəv(ə)rij dee-teyls: The provisions and conditions applicable to the agreement between you and your insurer to pay for your health care costs.

Covered Services

noun, kuhv-er ‘d ˈsər-vəs ez: The medical services, procedures or treatments that are listed within your coverage details that the insurer has agreed to provide payment on your behalf.

Deductible

noun, dəˈdəktəb(ə)l: The amount you pay for covered healthcare services before your insurer begins to pay. Typically, you must reach your full deductible amount before your insurance will cover any of the costs associated with covered services. (excluding preventive services)

Effective Date

noun, əˈfektiv dāt: The first date you become covered for health insurance under your plan.

Emergency Room (ER)

noun, i-ˈmər-jənt-sē ˈrüm: The site where you can be treated for acute illness, trauma or life-threatening situations, in which emergency-certified providers are prepared to provide prompt treatment. Frequently co-located with a hospital, but may also be a stand-alone facility.

Employer-Based Health Plan

noun, əmˈploiər bās helTH ˈplan: Health insurance sponsored and coordinated by your employer and available to you as an employee. Many employer-based health plan premiums are covered in part by the employer, lowering the amount you owe in premiums. Also referred to as job-based health plans.

Enrollment Date

noun, inˈrōlmənt dāt: The date when you signed up for health insurance and officially submitted your application and enrollment paperwork.

Excluded Services (Uncovered Services)

noun, ikˈsklo͞od ˈsərvəs: Healthcare your insurer has stated that it does not pay for, as defined in your plan language.

Health Insurance Card

noun, helTH inˈSHo͝orəns ˈkärd: A wallet-sized card issued by your insurer when enrollment is complete and coverage begins. The card serves as proof of insurance and contains basic information regarding the insured member, the plan structure, co-payments and co-insurance and has contact information to reach the insurer.

Health Maintenance Organization (HMO)

noun, helTH ˈmānt(ə)nəns ôrɡənəˈzāSH(ə)n: A plan where you pay a higher premium in exchange for defined co-payments and co-insurance amounts associated with care due at the time of service. Most HMO's do not have a deductible, and are structured to reduce the exposure to large out-of-pocket costs. HMOs may also require your care to be provided by members of its network in order to be covered, with limited or no benefits for care received by a provider outside of this network.

High Deductible Health Plans (HDHP)

noun, ˈhī dəˈdəktəb(ə)l helTH ˈplan: A plan that typically has lower premiums but higher deductibles that must be met before the insurer begins to pay toward your care.

In-Network (Preferred)

adjective, in ˈnetˌwərk: The set of doctors, hospitals, laboratory, pharmacy and other providers that have agreed to provide healthcare services to your plan's members at set rates is called the insurer's network. In-network is a description that refers to a provider who is a member of this network. Preferred provider is another term used for in-network provider.

Insurance (Health Insurance)

noun, inˈSHo͝orəns: A type of contract in which you agree to pay a premium to a company in exchange for help paying for the cost of medical services should you require them during the time period of coverage. You must pay the premium even if you do not receive any care during that period.

Marketplace (Health Insurance Marketplace)

noun, ˈmärkətˌplās: A shopping resource where people can compare, research and purchase insurance plans for the next plan year. Marketplaces are available in each state and are the only places where you can qualify and receive premium tax credits to help offset the cost of your monthly premium for the plan you select.

Navigator

noun ,ˈna-və-ˌgā-tər: An individual or organization that is trained to help you when shopping for insurance, and can assist in completing enrollment forms or evaluating plan options. Navigators are required to be unbiased and work to help you find the best health plan for your needs, all at no cost to you.

Network

noun, ˈnetˌwərk: Medical providers that have contracted with your plan to provide your care at a reduced negotiated rate. This group of providers is referred to as your network or your insurer's network.

Non-Covered Services (Excluded Services, or Un-Covered Services)

noun, nän kəvər ˈsərvəs: Healthcare services your insurer does not pay for as part of your plan agreement.

Open Enrollment

noun, ōpən inˈrōlmənt: A defined period of time each year during where an individual may select or change his or her health insurance plan for the following plan year. Open enrollment periods and time of year vary based on the whether seeking Commercial insurance, employer-based insurance or Medicare insurance. Medicaid does not have an open enrollment period.

Out-of-Network

noun, out əv ˈnetˌwərk: The description given to doctors, hospitals, laboratory, pharmacy and other providers that do not have a current agreement in place with your insurer to provide you discounted rates. Out-of-network providers may charge you any amount they want in exchange for their services, and are typically higher than the negotiated rate of in-network providers. Non-Preferred provider is another term used for an out-of-network provider. Your plan may have stated that it will not cover any portion of care provided by a out-of-network doctor; check your plan documents to be certain.

Out-of-Pocket Maximum

noun, out əv ˈpäkət ˈmaksəməm: The most you'll have to pay for covered services in a policy period before your insurer will pay 100% of the cost toward covered services. Typically includes your deductible and additional patient responsibility elements like copayments and coinsurance. Premiums and un-covered services do not count towards your out-of-pocket maximum.

Preferred Provider Organization (PPO)

noun, pri-ˈfər prə-ˈvī-dər ȯr-gə-nə-ˈzā-shən : A type of health plan provided to you in exchange for your premium, that allows you access to a network of medical providers, such as hospitals and doctors who agree to provide you care at a discounted rate. This plan type may allow care outside of these providers, but typically will do so at a higher cost to you.

Premium

noun, ˈprēmēəm: When you decide to enroll in a health plan, this is the amount you agree to pay in exchange for having an insurer issue you insurance coverage. This amount is typically due on a monthly basis, but can be charged in other frequency. You must pay the premium amount regardless if you receive any care by medical providers during your plan term. If you do not pay your premium, you are canceling the contract and the insurer does not have to pay towards your care.

Premium Tax Credit (Tax Subsidy)

noun, ˈprēmēəm taks ˈkredət: A tax credit that can help you afford health coverage through the Health Insurance Marketplace by providing instant savings on premium payments. In order to receive the Premium Tax Credit you must meet and maintain eligibility criteria throughout your plan year.

Preventive Services

noun, prəˈven(t)iv ˈsərvəs: Routine care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. The Affordable Care Act mandates that preventive care is included in coverage with no out-of-pocket charges connected to these services. (Grandfathered plans may be excluded from the Affordable Care Act provisions)

Primary Care Physician (PCP)

noun, ˈprī-ˌmer-ē ˈker fə-ˈzi-shən: A doctor skilled in family medicine and general internal medicine that serves as a central point of coordination for your care. This doctor is equipped to treat many common care needs and can refer you to a specialist or another doctor when needed. If you have a HMO plan type, the primary care physician is your main doctor on record with the insurance company.

Provider

noun, prəˈvīdər: Any medical professional who provides health services to patients. Frequently thought of as a doctor or physician, but also includes pharmacists, laboratory professionals, physical therapists, nurses, radiologists, clinical social workers, or medical facilities.

Special Enrollment Period

noun, ˈspeSHəl inˈrōlmənt ˈpirēəd: A time when you can enroll in insurance outside of open enrollment due to a special circumstance.

Summary of Benefits & Coverage (SBC)

noun,ˈsə-mə-rē ˈäv ˈbe-nə-ˌfitz ən(d) ˈkəv-rij: A short, plain-language overview of your insurance plan, including an outline of your coverage benefits, out-of-pocket expenses and exclusions. The Affordable Care Act standardized this document to ensure that within all commercial and employer-based health plans, you can easily compare and contrast various plans. This is not a substitute for the full-length document which defines your complete coverage benefits, provided to you by your insurer.

Tax Penalty (Fee)

noun, taks ˈpen(ə)ltē: A charge that must be paid if you don't have insurance or your insurance doesn't meet the minimum essential coverage in a given calendar year. The penalty amount varies based on how long you are without coverage and your annual income. The penalty is due at the same time you file your income taxes for the previous tax year.

Urgent Care Facility

noun, ˈər-jənt ˈker fə-ˈsi-lə-tē: A site where you can be treated for non-life threatening illness without an appointment and be seen by medical providers who are prepared to provide prompt treatment for common conditions. Urgent care facilities typically are open longer than a provider's office each day and see patients on weekends. Urgent care facilities are frequently stand-alone facility not connected to a hospital or doctor's office.

This “Words that Matter” glossary and “Chatter that Matters” materials are part of a branded project supported by Patient Advocate Foundation and the Patient Action Council. Survey data referenced above was analyzed within with the “Health Insurance Marketplace Experience Survey” project which collected responses from a random sample of healthcare consumers from November 2014 to January 2015.