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Health Care 101

Understand health insurance from A to Z.


A | B | C | D | E | F | G | H | I | M | N | O | P | Q | S | U





A


Affordable Care Act (ACA)
A new law that was passed in 2010. This law puts into place health reform, or improvements, over the span of four years and beyond. In general, the law is intended to make health care more accessible and affordable for more people.

Allowed Amount
This is the limit a health plan will pay for a service. If a provider charges more than the allowed amount, you may have to pay the difference.

Approved Amount
The amount a health plan agrees to pay a provider for services you receive.

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B


Benefit
A service, medical supply or drug that health insurance helps pay for. Some examples are doctor visits, tests and X-rays.

Billed Amount
The total dollar amount billed to a health plan (or submitted for payment) by a provider for services given.

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C


Claim
This is a request by a provider to be paid by a health plan for services given. For example, a doctor submits a claim to a health plan for an office visit.

Claim Number
This is the control number assigned to a claim by the insurer. Please reference this number when calling a member service representative to discuss a claim.

Coinsurance
The part of the medical bill you pay after meeting your annual deductible. For example, if you have an X-ray after you have paid your deductible for the year, your health insurance company will pay most of the bill, and you will pay a certain percentage of it. Your percentage of the X-ray bill is coinsurance.

Copay (or Copayment)
A set cost you pay when you receive a service. Most plans have a copay for doctor visits.

Coventry® Mobile
This is a free mobile app you can use on your smartphone or tablet. You can access your health plan and benefits information on the app at anytime, anywhere. For example, you can use Coventry Mobile to access your member ID card.

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D


Deductible
The amount you pay before your health insurance starts paying toward your costs.

Dependent
This is a person who is covered by another person’s plan. It can be a child, spouse or domestic partner.

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E


Effective Date
This is the date your coverage starts.

Essential Health Benefits
Beginning in 2014, every health insurance plan will include certain benefits. Whether you buy on the exchange or go direct to the insurance company of your choice, health insurance plans will include essential health benefits. These benefits are intended to cover basic health concerns.

Exchange
The Health Insurance Marketplace (or “exchange”) is a new way to shop for health insurance beginning October 1, 2013. Online stores help you find a plan that fits your needs and your budget.

Explanation of Benefits (EOB)
This is a statement a health plan sends to a health plan member. It shows charges, payments and any balances owed.

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F


Flexible Spending Account (FSA)
This is a way a worker can set aside money to help pay for health care. It is used with a health benefits plan. The worker asks for money to be taken from his or her pay each pay period. This money is not taxed in most states. The money goes into a fund the worker can use to pay for different health expenses. All money must be used by the end of the stated year or it will be lost. This money cannot be transferred to another job or account.

Formulary (also “Preferred Drug List”)
This is a list of prescription drugs the health plan covers. It includes the most common generic and brand-name drugs covered by a prescription drug plan. Most drugs are covered on one of three tiers. These tiers represent copay (or coinsurance) levels.

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G


Grandfathered Health Plan
A health plan that was in place before the health care law was passed in 2010. A grandfathered plan is exempt from some requirements of the new law. The grandfather rule enables businesses and families to keep the plan they have, if they wish to.

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H


Health Insurance
Health insurance helps you and your family stay healthy. It also helps to protect against high costs when there is illness or injury. A contract requires a health plan (health insurer) to pay some or all of your health care costs in exchange for a premium.

Health Insurance Carrier
Also known as a “health care insurer” or an “insurer.” The company that provides health insurance coverage.

Health Maintenance Organization (HMO)
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers.

Health Reimbursement Arrangement (HRA)
Owners of a qualified high-deductible health plan (QHDHP) who are not qualified for a health savings account (HSA) can use an HRA.

Health Savings Account (HSA)
An account that allows you to contribute pre-tax money to be used for qualified medical expenses. HSAs, which are portable, must be linked to a qualified high-deductible health plan (QHDHP).

High-Deductible Health Plan (HDHP)
This health plan has to meet federal rules. This is so members can put money into a health savings account (HSA) or health reimbursement arrangement (HRA). These funds can help pay for health care. The plan deductible is higher than a standard health plan. Premiums are lower.

High-Performance Network (HPN)
A high-performance network is made up of select hospitals, doctors and specialists who work together with your insurance carrier to connect you with the right care at the right time. It’s your personal health care team that coordinates your health care for all stages of wellness, health and illness to give you the best in personalized health care.

HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA). This law protects health insurance coverage for workers and their families when they changes or lose their jobs. It also requires standards for electronic health care transactions. This law was most recently amended to add privacy rules that became effective April 14, 2003.


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I


In-Network Coinsurance
The percent you pay of the allowed amount for covered health care services to providers who are contracted with a health plan. The in-network coinsurance is lower than out-of-network coinsurance.

In-Network Copay (or Copayment)
A fixed amount you pay when you go to a network provider for a service. For example, a provider’s office charges a $15 copay at the time services are given. In-network copays are usually lower than out-of-network copays.

Insured
The person who holds the policy with the insurer. This person can also be referred to as a “member” or “enrollee.”

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M


Marketplace
The Health Insurance Marketplace (or “exchange”) is a new way to shop for health insurance beginning October 1, 2013. Online stores help you find a plan that fits your needs and your budget.

Member
A person who belongs to a health plan. This person can also be referred to as an “insured” or “enrollee.”

Member Responsibility
This is the amount a member may be responsible to pay a provider. This amount is not payable to the health plan. If payment is made at the time of service, this may not be applicable. A copay, deductible and coinsurance amounts are considered a member’s responsibility.

My Online ServicesSM
This is the free website you can use to manage your health and benefits information. It’s your go-to source for everything related to your policy, benefits and health. For example, you can use My Online Services to access your claims information. You can also estimate health care costs before going to a doctor and much more.

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N


Network
A group of health care providers. It includes doctors, hospitals and urgent care centers. Providers who participate in a network sign a contract with a health plan to provide services. Generally, the network provides services at a special rate. With some health plans, people get more coverage when they get care in the network.

Nonpreferred Provider
A provider who does not have a contract with a health plan to provide services to you. This provider is not part of the network. You will pay more to see a nonpreferred provider.

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O


Out-of-Network Coinsurance
The percent you pay of the allowed amount for covered health care services to providers not contracted with a health plan. The out-of-network coinsurance is usually higher than in-network coinsurance.

Out-of-Network Copay (or Copayment)
A fixed amount you pay when you go to a non-network (or out-of-network, nonpreferred) provider for a service. For example, a provider’s office charges a $30 copay at the time services are given. This copay is usually more than in-network copays.

Out-of-Pocket
The costs you pay—including copays, deductibles and coinsurance.

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P


Patient
The person who received medical services.

Point-of-Service (POS)
A health plan that allows you to choose between in-network and out-of-network care each time medical treatment is needed.

Policy
This is a legal agreement. It is between a customer (an individual, “member” or “enrollee”) and a health plan. The policy lists all details of the plan’s coverage. A policy may also be referred to as a “contract” or “Certificate of Insurance.”

Preferred Provider
A provider who has a contract with a health plan to provide services. The services are usually given at a discounted rate.

Preferred Provider Organization (PPO)
A health plan that provides covered services at a discounted cost for an insured (or “enrollee”) who uses network health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network. In this scenario, the insured generally pays a higher portion of the cost for services received.

Premium
The set amount you pay for health insurance. Premium is usually paid on the same day of each month.

Preventive Care
This type of care is often covered in a health plan. It includes programs or services that can help people prevent disease. It may include yearly exams, shots and tests for some diseases. The tests are sometimes called screenings.

Primary Care Physician (PCP)
This is a doctor who is part of a network. He or she is a patient’s main contact for care. They coordinate care their patients get from specialists and other care facilities.

Prior Authorization
Also known as “precertification” or “preauthorization.” This is an approval you get for care before receiving the care. This helps you to know if the care is covered by a health plan. This is not a promise your health plan will cover the cost.

Provider
This term refers to a licensed person or place that delivers health care services. Some examples are doctors and hospitals.

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Q


Qualified High Deductible Health Plan (QHDHP)
A health plan with lower premiums that covers health care expenses after you pay out of pocket or from another source. To qualify as a health plan that can be coupled with a health savings account (HSA), the Internal Revenue Code requires the deductible to be at least $1,000 for an individual and $2,000 for a family. High-deductible plans are also known as catastrophic plans.

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S


Specialist
A doctor who focuses on a specific area of medicine. He or she is trained to give care for a particular disease, part of the body or age group.

Step Therapy
This is a way a health plan controls drug costs. It means you must try certain drugs before a particular brand-name drug will be paid for by the health plan. The first drugs are often generic and cost less.

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U


Urgent Care
This is for a sudden illness or injury that is not life threatening. Care still needs to be given quickly so you do not develop more serious pain or problems. Urgent care is not as severe as to require emergency room care.

Utilization Management

Health insurance company services that help you get the right care from the right doctor at the right time.

Your Health Care. Simplified.

My Online Services is your go-to source for everything related to your policy, benefits and health.

  • Estimate health care costs before going to a doctor
  • Find health and wellness information for babies, kids, teens and parents
  • Access personalized wellness tools to get or stay healthy
  • Track appointments and schedule reminders for flu shots and other important services
  • Create and maintain a record of your personal health history
  • Get timely health news updates
  • View recent medical and pharmacy claims
  • Search for a doctor or pharmacy in your network
  • Request, display or print your member ID card

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Please note that legal definitions vary by state and the above definitions are general in nature. All members should read and understand their full benefit documents, including their Evidence of Coverage and Certificate of Coverage.