Health Insurance – Glossary

Chemical Dependency – Inpatient

Many insurance plans cover treatment for substance abuse detoxification and treatment. Most plans, however, place limits or exclusions on treatment, such as limiting the number of days a patient may stay at a treatment facility or the number of times a patient may go in for treatment, or requiring care to be either on an inpatient or outpatient basis.

Chemical Dependency – Outpatient

Many insurance plans cover treatment for substance abuse detoxification and treatment. Most plans, however, place limits or exclusions on treatment, such as limiting the number of times a patient may go in for treatment or requiring care to be either on an inpatient or outpatient basis.


COBRA requires organizations with twenty or more employees to offer the continuation of group health benefits (Medical, Dental, Vision, and Medical Reimbursement Account) to employees (and covered dependents) upon experiencing a “Qualifying Event.”

Employers are required to provide initial COBRA notification to covered employees and dependents. A letter detailing an individual’s rights upon experiencing a “qualifying event” and an explanation of the conversion privilege. The legislation defines the following six situations as “Qualifying Events” that require COBRA continuation:

  • Termination of Employment
  • Reduction of Work Hours
  • Employee’s Death
  • Employee’s Divorce
  • Medicare Entitlement
  • Change in Dependent Status (i.e. dependent turns 18 and not a full time student)


Coinsurance is the amount that you are obligated to pay for medical services after you have satisfied your co-payment or deductible required by your health insurance plan. Coinsurance is usually a percentage of the charge for a service rendered by a healthcare provider. For example, if your health insurance plan covers 80% of the allowable charge for a specific service, you may be required to pay the remaining 20% as coinsurance.


The fee you pay for certain medical services or for each prescription. For example, you may pay $20 for an office visit or $10 to fill a prescription and the health plan covers the balance of the charges.(1) A fee that many insurance plans require an insured to pay for certain medical services (such as a physician’s office visit). (2) An amount that the insured must pay toward the cost of each prescription under a prescription drug plan.


A specific dollar amount that you may be required to pay out-of-pocket each year before your health insurance plan starts to make payments for your claims. Not all plans have a deductible. In general, most Indemnity and PPO plans have a deductible, while HMO plans do not typically require one. Copays typically do not count towards a plan’s deductible.

Effective Date

This is the date that you would like coverage to become effective. Effective date must be in the future. The date you choose may effect the quote you recieve. For the most accurate quote, please choose a date within the next 30 days for coverage to begin.

Emergency care

Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan’s network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.

Exclusion and limitations

Conditions, situations and services not covered by the health plan.

Formulary drugs

Formulary drugs generally have a lower copay. A formulary drug is one that has been thoroughly reviewed by a team of expert pharmacists and physicians; these drugs have been identified as safe, effective and beneficial to members for treating medical conditions. When deciding between drugs which are equally safe and effective, the formulary team also considers the relative costs of medications. These savings are then passed on to you through lower premiums.

Generic drugs

When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug “delivers the same amount of active ingredient in the same time frame as the original product.”

Inpatient surgery

Medical procedures which require the patient to spend at least one night at the hospital. Most plans limit the amount of time an inpatient may stay at the hospital following surgery.

Maternity care (optional)

Maternity care coverage typically includes OBGYN visits and hospitalization and physician fees associated with the birth of a child. Optional maternity care covered benefits vary by insurer.


A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.

Non-formulary drugs

Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan’s formulary list.

OB-GYN exam

An OB-GYN Exam usually includes screening for certain diseases including cancers of the breasts, cervix, uterus, vagina and surrounding area. The OB-GYN is a specialist who is responsible for helping women have healthy pregnancies and healthy newborns.


Health care services received outside the PPO network that usually result in higher costs except in emergencies.

Out-of-Pocket Maximum

A dollar amount set by the plan which puts a cap on the amount of money the insured must pay out of his or her own pocket for covered expenses over the course of a calendar year.

Outpatient surgery

Surgery that does not involve an overnight stay in a hospital. Common outpatient surgeries include tonsillectomies, colonoscopies, biopsies and cataract removal.

Pre-existing conditions

Any health condition or illness that you had before your insurance coverage begins can be considered a pre-existing condition.

PPO (Preferred Provider Organization)

An organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.

Routine annual exam

A yearly medical “checkup,” during which your doctor will perform simple medical care such as checking your height, weight, vision and blood pressure, as well as screening for problems like colon cancer, cervical cancer, prostate cancer and high cholesterol. Routine annual exams are typically covered by most, but not all, health plans.

Short Term Medical

Short-Term Medical plans provide individual and family coverage for a limited time frame, typically 30 days up to 12 months. These plans are major medical plans designed to protect you in the event of an illness or injury; they are not meant to cover routine exams, preventive care, dental or eye care, or immunizations. Keep in mind that you can only apply for one additional benefit period, typically of up to six months, IF no claims were incurred under a previous plan and IF there has been no significant change in your health. If you are looking for a choice of plan types, a plan that covers routine medical expenses or the ability to renew your plan beyond one year, an Individual Medical plan, while typically more expensive, may be a better fit for your health insurance needs.


The process of identifying and classifying the degree of risk represented by a proposed insured.

Urgent care

Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.

X-ray and laboratory procedures

If the medical plan covers these, typically the insurance company will pay for any x-ray or diagnostic lab test done in support of basic health services. For example, basic health services for x-rays include basic skeletal plain film x-rays, outpatient ultrasounds, MRI, and CT scans. Dental x-rays are typically not covered. Basic health services for laboratory procedures include blood panels and urinalysis.