Glossary of terms

The highest amount a health insurance plan will pay for a service.

Medical services or items that your health insurance will pay for in full or in part.

A request for payment that you or your health care provider make to your insurance provider.

The percentage of costs you pay for a health care service after you’ve reached your deductible. For example, if your insurance company pays 80% of your claim, you will pay 20%.

A system used to figure out who pays when you have more than one health insurance plan.

A fixed dollar amount that you pay for covered services at the time of care. For example, you may have a $25 copay every time you see your primary care physician. Not all health plans have a copay.

The determination of whether you or your dependents are insured under a medical plan.

What the insurance company will pay for as defined in the policy. For example, hospital, medical and other expenses, including prescriptions and equipment.

A set of medical codes used to identify medical procedures.

The date(s) you received medical services from a health care provider.

A statement sent by insurance providers to explain how a medical service was paid. It lists the services received, costs for each and payments made. Any amounts that you’re responsible for are also explained.

A person who is licensed or certified to provide medical services.

A contract that requires a health insurer to pay some or all of your health care costs in exchange for a premium. Health insurance may apply to a limited or wide range of services. 

A health insurance plan that usually limits care to a network of doctors who work for or contract with the HMO. Care from doctors who are out of network usually isn’t covered, except in an emergency.

An employer-funded health plan that pays you back you for certain medical expenses. A fixed dollar amount is set for each year. Unused amounts may be rolled over to the next year.

A savings account that lets you set aside money on a pre-tax basis to pay for medical costs. Unused amounts can be rolled over from one year to the next. Generally, you cannot use HSA funds to pay for premiums.

An insurance plan with a high deductible. This means you will pay more health care costs yourself before the insurance company starts to pay. Once a deductible is reached, claims are paid in full by the insurance company or as specified in the policy.

The Health Insurance Portability and Accountability Act. It protects employees when they change or lose their jobs. It also focuses on the security and privacy of health care information. 

Connecticut’s public health coverage program for eligible children, adults and seniors. It pays for doctor visits, vision and dental care, prescriptions and more.

A diagnosis code that medical providers and institutions use to identify medical conditions. Also known as an ICD.

The most money you can expect to pay for covered expenses. The amount varies by plan. Once the maximum cost has been met, your health plan will pay 100% of certain expenses.

A health insurance program that provides health coverage to low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is funded by states and the federal government.

A federal health insurance program for people 65 and older and some younger people with disabilities.

A federal hospital insurance program. It generally covers inpatient hospital care, skilled nursing facility care, hospice care and some home health care.

A federal health insurance program that covers medically necessary and preventive services. It also covers other services that Part A does not cover, like physical and occupational therapy.

The doctors, hospitals and other health care providers that a health insurance plan has contracted with to provide services.

A health care provider who doesn’t have a contract with your health insurer. Also called a non-preferred provider. If you see a non-participating provider, you’ll pay more.

A provider who doesn’t have a contract with your health insurance company. Typically, you will pay more to see an OON provider than a participating provider. The insurer may deny the claim. 

A provider who has contracted with the health plan to deliver medical services to members. The provider may be a doctor, hospital, pharmacy or other facility.

A plan that will cost you less if you see doctors and other care providers who are part of your insurance plan’s network.

Your health insurance may need to preapprove certain health care services before you receive them. Typically, you or your primary care doctor contact the health plan in advance to find out if those services will be covered.

A health plan that contracts with medical care providers to create a network of providers. Normally, you will pay less to see providers who are in the network.

The amount you pay every month for health insurance. A premium does not include your deductible, copays and coinsurance.

A doctor who provides and coordinates your health care services. Typically, PCPs are adult and family medicine doctors, internists and pediatricians.

A written order from your primary care doctor for you to see a specialist or get certain medical services. 

An insurance policy or program that pays second on a claim for medical care.

A doctor who focuses on a specific area of medicine, such as heart care or cancer.

The person who pays for health insurance premiums or whose employment is the basis for membership in the insurance plan. For example, if you have health insurance through your spouse’s health insurance plan, he or she is the primary subscriber.