Health Care Glossary

The following glossary is to help you understand important terms used in health insurance.

Contract or benefit plan year

The 12-month period that begins on the effective date of your health insurance plan.

Open enrollment

A certain period each year when you can enroll in a health insurance plan, add family members or make other changes to your coverage. The choices you make will be in effect until open enrollment of the following year.

Qualifying event

A change in your life that can make you eligible to enroll in or change your health coverage outside of the open enrollment period. Examples include the birth of a child, marriage, divorce or becoming eligible for Medicare. There are others, too.

Claim

A request to have health insurance pay for health care services. The request can come from you, your doctor or another health care provider.

Claim summary

Explains the services you received, how much the doctor (or other health care provider) billed your health insurance, how much health insurance paid and how much, if any, that you are responsible for paying.

Coinsurance

A sharing of health care costs in which you and your insurance company each pays a percentage.

Copayment or copay

A fixed amount that you pay for a certain health care service.

Deductible

A specific dollar amount that you have to pay each year for your health care expenses before your insurance company starts to pay.

Health savings account (HSA)

A tax-free savings account that you may use with a high-deductible health plan. The HSA allows you to set aside pre-tax money to pay for qualified health care expenses not covered by the health plan.

In network

Doctors and other health care providers who participate in a health insurance plan’s provider network and agree to accept the plan’s negotiated payment for services. You typically pay less out of your pocket, if anything, when you use in-network providers.

Maximum allowable amount

The most that the health insurance plan will agree to pay an out-of-network doctor for a certain service. You may be responsible for paying any balance of the doctor’s charges.

Out of network

Doctors and other health care providers who do not participate in a health insurance plan’s provider network. You may be required to pay more out of your pocket when you use out-of-network providers.

Out-of-pocket maximum

Limits the total amount you have to pay each calendar year for health care expenses, including deductibles, copayments and coinsurance. Monthly health insurance premiums do not count toward the out-of-pocket maximum.

Premium

The monthly fee charged by an insurance company to provide your health coverage.

Health maintenance organization (HMO)

A type of health insurance plan that allows you to see any doctor or other health care provider who participates in the plan’s network.

High-deductible health plan (HDHP)

A type of health insurance plan that requires you to pay a higher dollar amount for your care before the plan starts to pay. In exchange, you generally pay a lower monthly premium than you would for other types of plans.

Point-of-service (POS) plan

A health insurance plan that gives the choice to see any health care provider, in- or out-of-network. Members generally pay less out-of-pocket, when they use in-network providers.

Affordable Care Act

A federal law that requires most U.S. citizens and residents to have health insurance. The law also created health insurance marketplaces (or exchanges). In Connecticut, the exchange is called Access Health CT, where you can buy health insurance and possibly receive help paying for it, depending on your income.

Access Health CT

An insurance exchange in Connecticut to help people purchase health insurance. ConnectiCare offers a number of insurance plan options on Connecticut’s public exchange.

Ambulatory services

Health services that do not require you to stay overnight in a hospital. You might receive these services in a hospital setting or at a freestanding facility, such as a walk-in clinic.

Health assessment

An online questionnaire that provides information about your current health. By answering a series of questions, you receive a personal health score, a comparison with others of your age and gender, and recommendations for healthier living.

Outpatient services

Health care services that do not require you to be admitted to the hospital.

Preventive care

Care that your doctor provides to prevent illness or injury, as opposed to treating or diagnosing it. Examples include routine checkups, immunizations and screenings, such as mammograms and colonoscopies. Your ConnectiCare health plan covers most preventive care services for free.

Primary care provider (PCP)

A primary care provider is a physician, physician’s assistant or advanced practice registered nurse (APRN) who is your main contact for health care. Your PCP can do everything from writing prescriptions to referring you to a specialist when necessary. This is the person who knows the most about your health history and helps you navigate the health care system.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. This is also sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Provider

A health care professional or facility that provides you with health care services. There are many types of providers, from hospitals and nursing homes to doctors and mental health counselors.

Pharmacy benefit

The part of a health insurance plan that covers prescription drugs.

Prescription drug list

A list of prescription drugs that are covered by your health insurance plan. It’s also called a “formulary.” A drug list is usually divided into sections called “tiers.” A tier includes medicines within a similar price range.