A Glossary of Important Terms
Allowed Amount
This is the amount that in-network Providers have contractually agreed to accept as payment in full for a covered service. For non-network Providers, this is the amount that Regence has determined to be reasonable charges for the covered service. Amounts in excess of the “Allowed Amount” are not considered a covered service and do not count toward your Out-of-Pocket Maximum. While the plan does not consider charges in excess of the Allowed Amount to be covered services, a non-network Provider can bill you directly for these charges. This is called “Balance Billing.”
Appeal
A request for your health insurer or plan to review a decision or a grievance again.
Balance Billing
When a Provider bills you for the difference between the Provider’s charge and the Allowed Amount. For example, if the Provider’s charge is $100 and the allowed amount is $70, the Provider may bill you for the remaining $30. A preferred Provider may not Balance Bill you for covered services.
Co-insurance
Once you have satisfied any applicable Deductible, the plan pays a percentage of the allowed amount. If the plan pays 80% after Deductible, that means you pay the other 20%, until you hit your Out-of-Pocket Maximum.
Complications of Pregnancy
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t Complications of Pregnancy.
Co-payment/Copay
Copays are fixed dollar amounts that you pay directly to the provider. For example, Office Visits, Emergency Room, and Prescription Drug Copays.
Deductible
The Deductible is the amount you pay upfront for covered health services before your insurance plan starts to pay. The Deductible resets every January.
Not all services are subject to the Deductible. Please refer to the plan benefit grid to see which services are subject to the Deductible and which are not.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a healthcare provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
Emergency Medical Condition
An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Medical Transportation
Ambulance services for an Emergency Medical Condition.
Emergency Room Care
Emergency services you get in an emergency room.
Emergency Services
Evaluation of an Emergency Medical Condition and treatment to keep the condition from getting worse.
Excluded Services
Healthcare services that your health insurance or plan doesn’t pay for or cover.
Grievance
A complaint that you communicate to your health insurer or plan.
Habilitation Services
Healthcare Services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Health Insurance
A contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium.
Home Healthcare
Healthcare services a person receives at home.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
In-network Coinsurance
The percentage (for example, 20%) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
In-network Copayment
A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.
Medically Necessary
Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Network
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide healthcare services.
Non-Preferred Provider
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Out-of-Network Coinsurance
The percentage (for example, 40%) you pay of the allowed amount for covered healthcare services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
Out-of-Network Copayment
A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
Out-of-Pocket Limit
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or healthcare your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.
Out-of-Pocket Maximum
This is the most you can spend out-of-pocket in a plan year for covered services. Once you’ve reached your plan’s Out-of-Pocket Maximum, the plan pays 100% of covered services for the remainder of the plan year. The Out-of-Pocket Maximum resets every January.
Included in the Out-of-Pocket Maximum: Deductible, Copays (including Rx Copays), and Coinsurance.
Note: Balance Billed charges from non-network providers are not considered covered services and do not count toward the Out-of-Pocket Maximum.
Physician Services
Healthcare services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Plan
A benefit your employer, union, or other group sponsor provides to you to pay for your healthcare services.
Preauthorization
A decision by your health insurer or plan that a healthcare service, treatment plan, Prescription Drug, or Durable Medical Equipment is medically necessary. 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.
Preferred Provider
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all Preferred Providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have Preferred Providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Prescription Drugs
Drugs and medications that by law require a prescription.
Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of healthcare services.
Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), healthcare professional or healthcare facility licensed, certified, or accredited as required by state law.
Reconstructive Surgery
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.
Rehabilitation Services
Healthcare services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of healthcare.
Usual, Customary and Reasonable (UCR)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the Allowed Amount.
Urgent Care
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Room Services.