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Health Terms Glossary - California

Adjudication
This is when we compare your benefits to a claim you or your doctor submitted for a health care service (example: office visit). It helps us figure out if the doctor is charging the right amount, what portion we pay and what portion you pay.
Advance Directive
A signed legal document — often one that tells doctors what care decisions to make if you’re not able to speak for yourself due to an advanced health condition.
Agent
A professional whose job is to help people or companies find health coverage that’s right for them. They’re sometimes called brokers.
Allowable Charge
The amount a doctor or hospital can charge for a health care service or item they give you.
Ambulatory Services
When you get care in a clinic, emergency room, hospital or surgery center and you don’t stay the night.
Americans with Disability Act (ADA)
A law that protects people with disabilities from not being treated fairly in health care, employment, state and local government services.
Ancillary care
Health care services like lab tests, X-rays, rehab, hospice care and urgent care. They’re not necessarily performed by doctors, but help doctors diagnose or treat a health condition.
Appeals
When you ask us to take another look at a decision we’ve made. For example, if we say that a certain service isn’t covered or isn’t medically necessary — but you disagree, or your doctor disagrees, and you want us to reconsider.
Arbitration
A way of resolving a dispute by agreeing to go to a third party, often instead of taking it to court.
Authorize/Authorization
For some health care services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called precertification, authorization or prior authorization.
B
 
Balance Billing
When a doctor bills you for the difference between what they charged and the amount that’s allowed by your plan.
Benefits
These are the health care services and supplies we cover for you when you’re a member. For example, if you have health care benefits with us, we help cover the cost of the health care you get.
Benefit Period
From the start date to the end date of your coverage. During this time, if you get care, we cover the portion of the cost we’ve agreed to.
Beneficiary
The person who receives proceeds or benefits.
Brand Name Drug
When a drug company develops a new drug, they’re the only ones allowed to make it and sell it for a while under their “brand name.” At some point, other companies are allowed to make “generic” versions of it, which are often less expensive.
Broker
A professional whose job is to help people or companies find health coverage that’s right for them. They’re sometimes called agents.
California Children Services Program (CCS)
The public health program which assures the delivery of specialized diagnostic, treatment and therapy services to financially and medically eligible children under the age of 21 who have CCS eligible conditions.
California Department of Health Care Services (CDHCS)
The state agency that is responsible for the Medi-Cal program.
California Department of Managed Health Care (DMHC)
The state agency responsible for regulating health care service plans.
Case Management
A process to help you and your doctors manage and coordinate specific health care needs. We do this to make sure you’re getting the right care.
Centers for Medicare & Medicaid Services (CMS)
The government agency that runs the Medicare, Medicaid, Children's Health Insurance Programs and some of the Health Care Marketplaces.
Certificate of Coverage
A document that has all of the details about your coverage. It’s sometimes called your contract.
Certification
For some health care services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called precertification, authorization or prior authorization.
Chemotherapy
Using chemicals or drugs to treat certain diseases. It’s often thought of in treating cancer.
Child Health and Disability Prevention (CHDP)
A government program that helps people under 21 years old, who have disabilities.
Chiropractic Care
A type of therapy used to help treat the spine, joint pain and movement problems. A licensed chiropractor gives this care.
Chronic
A health condition that needs ongoing care and attention. Examples include diabetes, asthma, allergies and hypertension.
Claim
A claim is what a doctor submits to us so they can get paid. It shows the medical services that were provided to you.
Clinic
A health care place or hospital department where outpatients are given treatment or advice.
Clinical Pharmacist
Licensed pharmacist who provides patient care that makes the best use of medication therapy and promotes health and disease prevention.
COBRA
If you have health coverage through your job, and you lose your job or coverage, the Consolidated Omnibus Budget Reconciliation Act (COBRA), may give you, your spouse or kids the right to extend that health coverage.
Coinsurance
This is your share of the costs for covered health care services, calculated as a percentage.
Combined Maximum Out-of-Pocket
Combined maximum out-of-pocket refers to Medicare plans. It’s the most you’ll pay for covered health care under both Medicare Part A and Part B, for both in-network and out-of-network doctors, and includes deductibles, copayments and coinsurance. (The amounts you pay for your plan premium and for your Part D prescription drugs do not count toward it.)
Complaint
Also called a “grievance,” it’s when you tell us or write to us about something you don’t like or disagree with, regarding your coverage.
Compliance
Doing what you’ve been asked or required to do. It often refers to taking medication the way you’ve been told by your doctor. But it can also mean other ways you follow rules, guidelines or laws.
Contract
In health coverage, a contract is the agreement you make with us, that we’ll cover certain costs for your care and offer other services when you become a member.
Contract Holder
The person who signs up for the health plan. The plan may cover others, like their spouse or children, but they are called “dependents” of the contract holder. See also subscriber.
Conversion Option
The choice to move into an individual plan, if you’re leaving a health coverage plan through your job or another group.
Coordination of Benefits (COB)
This is when we ask you if you or any of your dependents also have other health coverage. It’s important because, if you do, we need to work with the other company to figure out who pays for what. If you have two health coverage plans and you accept money from both without letting them know that the other is also paying, you could be committing insurance fraud — which is a felony.
Co-payment (or co-pay)
A set dollar amount you pay for a covered service, such as a doctor visit.
Cost Share
The amount you pay toward covered services, like copayments, coinsurance and/or deductibles. For most of your health care costs, you pay your share and we pay our share — as agreed to in your health coverage contract.
Covered Services
Care that you get from doctors and hospitals that we have agreed to pay a portion of, as part of your coverage.
Cross brand
Brand-name drugs that have the same ingredients and are therapeutically the same, but are marketed under two or more different registered trade names or trademarks.
Custodial Care
Care given to meet daily living needs of a patient, like help walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care which does not require continuing services of medical-trained personnel.
Day Treatment Center
An outpatient facility that treats mental or behavioral health or substance abuse under the supervision of doctors. It typically offers treatment for more than two hours, but less than a full day. This treatment may also be known as "partial hospitalization."
Deductible
A set amount of money you pay at first for covered health care services, before your health plan begins paying.
Dental Care
Services for the health of your teeth and gums.
Dependent
Members of the subscriber’s family, like a child or spouse, who are eligible for benefits under their health plan.
Diagnostic care
Helps find the cause of a health problem through different diagnostic tests.
Diagnostic Tests
Tests and procedures ordered by a doctor to figure out what sort of health condition you have. May include radiology, ultrasound, nuclear medicine, laboratory, pathology and others.
Disability
A physical or mental condition that limits your ability in at least one major life activity.
Disease Management
Program to help people who live with a chronic illness better understand and manage their condition. It also helps prevent future health problems.
Disenroll/Disenrollment
When a member leaves a health benefit plan. The opposite of enroll/enrollment.
Dispense As Written (DAW)
A doctor puts “DAW” on a prescription if they want it to be filled with the brand-name medication, rather than a generic version of that same drug.
Domestic Partner
Someone who lives with you for at least 12 months as if they’re your spouse, but you’re not married. You can include them as a dependent on your health coverage policy as long as neither of you are married to someone, and you’re not related to each other in any way that prevents you from getting married by law.
Drug Formulary
A list of drugs that your health plan covers.
Drug Tiers
Prescription drugs are put into different categories based on how much they cost, whether they’re brand-name or generic and sometimes other factors. Tier 1 drugs have the lowest copayment and are mostly generic versions of brand-name drugs. Tier 2 is made up of mid-priced drugs that may be brand-name but are “preferred” within their drug class. Tier 3 has mostly brand-name drugs with higher copayments.
Durable Medical Equipment (DME)
Equipment ordered by prescription from a doctor or other health care provider, for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches or blood testing meters for diabetics.
Effective Date
The date your health coverage or benefits begin.
Emergency Care/Emergency Services
Immediate care or services needed when a person has such severe symptom that they reasonably believe the lack of immediate medical care could:
  • Place someone's health (or the health of an unborn child) at risk
  • Cause major harm to a body function or part
Examples of an emergency include, when someone:
  • May die
  • Has chest pains
  • Cannot breathe or is choking
  • Has passed out or is having a seizure
  • Is sick from poisoning or a drug overdose
  • Has a broken bone
  • Is bleeding a lot
  • Has been attacked
  • Is about to deliver a baby
  • Has a serious injury
  • Has a severe burn
  • Has a severe allergic reaction or has an animal bite
  • Has trouble controlling behavior and without treatment is dangerous to self or others
  • If you are experiencing an emergency, call 911 or go to the closest ER. You are covered for emergency care virtually anywhere.
If you’re not sure a health issue is an emergency, call your doctor.
Enroll/Enrollment
When you sign up for health coverage.
Enrollee
The person who is enrolling. See also Member.
Evidence of Coverage and Disclosure Form (EOC)
A document that has all of the details about your coverage. It’s sometimes called your contract.
Exclusions
Health care services that are not covered by your health plan.
Experimental/Investigational Procedures
Health care procedures that are still being tested, but not yet proven to treat a condition.
Expiration Date
The day your health coverage ends for that year.
Explanation of Benefits (EOB)
A statement you get after you go to the doctor or hospital that lists the health care treatment you got. It shows the amount the doctor charged, how much we paid and what you’ll be billed based on your benefits. An EOB is not a bill.
F
 
Federally Qualified Health Center (FQHC)
Federally funded nonprofit health centers or clinics that serve medically underserved communities. They provide primary care services on a sliding fee scale, based on your ability to pay.
Flexible Spending Account (FSA)
A special account that allows you to set aside tax-free money, to use on qualified health care or dependent care expenses.
Food and Drug Administration (FDA)
The US government agency that enforces the laws on the manufacture, testing and/or use of drugs and medical devices.
Formulary
A list of prescription drugs that have been selected and approved by our Pharmacy and Therapeutics Committee for their safety, quality, and sometimes cost. Your health plan's formulary includes drugs from every therapeutic drug class, as well as health care supplies and devices.
Generic Drug
When a drug company develops a new drug, they’re the only ones allowed to make it and sell it for a while under their “brand name.” At some point, other companies are allowed to start making “generic” versions of it. These versions have the same active ingredients and quality standards, but cost less.
Grandfathered
A health plan purchased on or before March 23, 2010, which the member has chosen to keep basically the same due to the part of the Affordable Care Act that allows you to keep your plan if you like it.
Grievance
An official complaint about your service or benefits. You can file a grievance by calling the number on the back of your ID card.
Group
An employer, association or trust that offers health coverage to its members or employees.
H
 
Health Assessment
An online tool that asks you questions to help you understand your overall health, and offer healthy tips.
Health Benefit Plan
Health coverage may be called your health plan, health benefit plan, health coverage plan — these are all ways to describe a policy that helps you pay for your health care. Each plan is different. To see the ways your health benefit plan covers you log in and look over your benefits.
Health care services
Anything that a doctor or other health care provider does for you to help you with your health. Includes checkups, treatments, care you get in a hospital and more.
Health Maintenance Organization (HMO)
A type of health plan where you only get care from a network of doctors in your area. You’ll need to choose a main doctor — also called a primary care physician or primary care doctor, from your health plan network. If you need a specialist, you’ll most likely have to go through your main doctor to get a referral.
Health Insurance carrier
The company — like us or another health benefits company that collects your premium and helps you pay for health care as you need it.
Health Insurance Marketplace
Run by your state or the federal government, it’s one of the places you can shop and sign up for health coverage from us and other private health coverage companies. If you’re eligible for help from the government to pay for your health coverage, you’ll need to sign up there.
Health Reimbursement Account (HRA)
An account of money set up and funded by your employer. You can use the money to pay your health care costs, until your plan starts paying a bigger share — after you meet your deductible. It’s a type of consumer-driven health plan (CDHP).
Health Savings Account (HSA)
A bank account you can use to pay for health expenses. You or your employer can put tax-free money into your HSA. You’ll use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year and beyond. You can also take it with you if you change health plans.
High Deductible Health Plan
A health plan that may cost less in monthly premiums, but then you’ll need to pay for your own health care for a little while, up to a set dollar amount, before your health plan starts paying. Often preventive care is still covered at 100% from day one. And you have the option of opening a health savings account to help you use tax-free dollars for your care.
HMO
Short for Health Maintenance Organization. It’s a type of health plan where you only get care from a network of doctors in your area. You’ll need to choose a main doctor — also called a primary care physician or primary care doctor, from your health plan network. If you need a specialist, you’ll most likely have to go through your main doctor to get a referral.
Home Health Care
Care given by a home health agency to you at your home. It’s most often if you’re disabled, sick or convalescent.
Home Infusion Therapy
A type of care where you get a liquid substance put into your vein, muscle or other part of your body, done at your home.
Hospice
A facility or service that gives care to terminally ill patients, as well as support to the family. The care is often for controlling pain and other symptoms, and can be provided in the home or in an inpatient setting.
Hospital
A center where you go when you need care or surgery. You may go to a hospital, get your treatment and then go home that day (outpatient). Or your condition or the care you need may require you to stay over for one or more nights (inpatient).
HRA
Short for Health Reimbursement Account. It’s set up and funded by your employer. You can use the money to pay your health care costs, until your plan starts paying a bigger share — after you meet your deductible. It’s a type of consumer-driven health plan (CDHP).
HSA
Short for Health Savings Account. It’s a bank account you can use to pay for health expenses. You or your employer can put tax-free money into your HSA. You’ll use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year and beyond. You can also take it with you if you change health plans.
ID Card/Identification Card
The card you get from us at the beginning of your health plan year that shows that you’re a member and what kind of plan you’re on. Most doctors need to see your card before giving you care, to see how you’re covered. You can also keep your ID card on your smartphone if you download our mobile app from App Store or Google Play.
Immunizations
Shots or other medicines you get that help prevent you from getting a particular disease or condition.
Independent Physician Association (IPA)
Also called an Independent Practice Association, it’s a company made up of doctors and other health care providers.
Individual plan
A health coverage plan you buy on your own, not through your job or another type of group. It can also include your family or other qualified dependents.
In-Network
Certain doctors and hospitals have agreed to accept your insurance — that’s your network. Each plan has its own network. And getting care from “in-network” doctors and hospitals just means going to those.
Infertility
A type of treatment for people who may need help to get pregnant.
Infusion Therapy
A type of care where you get a liquid substance put into your vein, muscle or other part of your body.
Inpatient
Hospital care given to someone, which requires an overnight stay.
Investigational Procedures
Health care procedures that are still being tested, but not yet proven to treat a condition.
Internal Revenue Service (IRS)
The US government agency that collects taxes and enforces tax law.
J
No glossary terms are available at this time.
K
No glossary terms are available at this time.
L
 
Legend drug
A drug that, by law, can only be obtained by prescription. Legend drugs are so named because the label bears this legend: "Caution: federal law prohibits dispensing without a prescription."
Lifetime Maximum
The maximum amount of benefits your health plan carrier will pay for your lifetime, not just for a plan year.
Life-threatening Disease
A disease that may put a person's life in danger if it is not treated.
M
 
Mail Service Pharmacy
A pharmacy sends your prescriptions right to you through the mail.
Maintenance medication
A drug you take ongoing.
Managed care
A type of care where your main doctor, also called a primary care physician (PCP) plays an active role in your care. You may be required to go through your main doctor to get a referral to other types of care, like seeing a specialist.
Marketplace
Short for Health Insurance Marketplace. Run by your state or the federal government, it’s one of the places you can shop and sign up for health coverage from us and other private health coverage companies. If you’re eligible for help from the government to pay for your health coverage, you’ll need to sign up there.
Maternity Services
Care required for pregnancy and delivery.
Maximum Allowance or Maximum Benefit Allowance
The amount a doctor or hospital can charge for a health care service or item they give you.
Medi-Cal
A California State health coverage program for low-income families. This program is funded by state and federal dollars.
Medi-Cal card
Also known as the Beneficiary Identification Card, it is the plastic card issued by the state to Medi-Cal recipients. The card is used by providers to verify Medi-Cal eligibility.
Mediation
A process where a neutral person tries to help people resolve a dispute between them. It’s different from arbitration, which sometimes requires that the people accept whatever the neutral person decides.
Medicaid
A government program that provides health coverage to some citizens who are younger than 65 years of age who can’t afford private health insurance.
Medicare
A government program which provides health coverage to people 65 years or older.
Medical group
A company made up of doctors and other health care providers who work together to care for patients.
Medical Equipment
Equipment ordered by prescription from a doctor or other health care provider, for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches or blood testing meters for diabetics. See also Durable Medical Equipment.
Medically necessary/Medical necessity
Health care services or supplies that are a reasonable part of your care. Sometimes we’ll ask your doctor to show that the care they’re proposing for treatment is medically necessary.
Member
Someone enrolled in our health coverage plans, whether they’re the main person on a policy or a qualified dependent.
Member Handbook
A document that has all of the details about your coverage. It’s sometimes called your contract, policy, Evidence of Coverage, or Certificate of Coverage.
Member Representative
Someone who has been asked or appointed to speak for a member and/or make their care decisions.
Member Services Department
A team of people who are available to answer your questions and help you understand your plan.
Mental or behavioral health
The health of your mind and emotions, including substance abuse issues.
Mental Health Services
Care to address the health of the mind and emotions. May include therapy, medication, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization, treatment for substance abuse and more.
Multisource brand drugs
Brand name drugs which are distributed by more than one company and may have a generic version.
National Committee on Quality Assurance (NCQA)
A not-for-profit organization that performs quality-oriented accreditation reviews of managed care plans.
Network
Doctors and hospitals who’ve agreed to accept your insurance. Each plan has its own network. And getting care from your network is often a good way to get quality care at a more reasonable cost.
Network Provider
A doctor or hospital who has agreed to accept your insurance. Each plan has its own network. And getting care from your network providers is often a good way to get quality care at a more reasonable cost.
Non-formulary Drug
A drug that’s not listed on your health plan's list of covered drugs. It requires authorization from the health plan in order to be covered.
Notice of Privacy Practice (NOPP)
Document that tells you how your information may be used and distributed by an organization.
O
 
Occupational therapy
Treatment used to improve and maintain a patient's daily living skills because of a disability or injury.
Off-label drug use
Use of a drug for purposes other than those originally approved by the FDA. For example, if a drug was originally approved for use as an anti-inflammatory, using it to treat cancer would be considered an "off label" use.
Open enrollment
The time period when you can sign up for health coverage for the following year.
Orthotic
Treatment or device used to support, align, correct or improve the function of your bones and joints.
Out-of-Area Services
Health care you get while away from your home area.
Out-of-network
A doctor or hospital who has not necessarily agreed to accept your insurance. Some plans give you coverage when you go to out-of-network providers and some don’t. But even if yours does, you’ll almost always pay more for the same level of care. Also sometimes called “non-participating” or “non-par” provider — meaning they don’t participate in your health plan network.
Out-of-network Provider
A doctor or hospital who has not necessarily agreed to accept your insurance. Some plans give you coverage when you go to out-of-network providers and some don’t. But even if yours does, you’ll almost always pay more for the same level of care. Also sometimes called “non-participating” or “non-par” provider — meaning they don’t participate in your health plan network.
Outpatient
Health care treatment (or the person getting that treatment) in a hospital or other health care facility without an overnight stay.
Outpatient Surgery
Surgical procedures done at a hospital or other health care facility that don’t require an overnight stay.
Out-of-Pocket Maximum
The maximum dollar amount you’ll pay for covered services during the year. After that, your plan will pay for the rest of your covered care that year.
Over-the-counter (OTC) drugs
Drugs which may be purchased without a prescription.
Partial Day Treatment
A program offered by psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. An alternative to inpatient treatment.
Participating Provider
A doctor or hospital who has agreed to participate in your health plan network, and accept your insurance. Each plan has its own network. And getting care from participating providers is often a good way to get quality care at a more reasonable cost.
PCP
Short for Primary Care Physician. Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.
Pharmacy
A place to get prescribed drugs.
Pharmacy Benefit Manager (PBM)
A company that administers and manages your prescription drug benefits.
Physical Therapy
Treatment involving physical movement to relieve pain, restore function and prevent disability after a disease, injury or loss of limb.
Physician
Another word for a medical doctor.
Point of Service (POS)
A type of health benefit plan that usually offers three different ways, or three “tiers,” to get care:
  1. You pay the least for care if you choose a main doctor, also called a primary care doctor, in the network to manage your care. You go through your main doctor to see specialists.
  2. You pay a bit more to see specialists or doctors in your network without a referral.
  3. You pay even more to see a doctor who isn’t in the network.
Pre-Authorization
For some health care services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called pre-certification, authorization, certification or prior authorization.
Pre-Certification
For some health care services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. See Pre -Authorization.
Pre-Existing Condition
A health condition that was diagnosed or treated before you enrolled in a health benefit plan.
Preferred Provider Organization (PPO)
A type of health coverage plan that covers services from almost any doctor or hospital. But you’ll almost always pay less for the same level of care when you go to one in your health plan network. You don’t usually need a referral from your main doctor, also called a primary care physician or primary care doctor, to see a specialist.
Premium
The amount you pay to us for your coverage, usually monthly. If you have health coverage through your work, your employer may share the cost of your premium.
Prescription
A doctor’s order for a drug or other item or service to help in your care.
Prescription Drug
A drug that can only be used if ordered by a doctor.
Prescription Drug Tiers
Prescription drugs are put into different categories based on how much they cost, whether they’re brand-name or generic and sometimes other factors. Tier 1 drugs have the lowest copayment and are mostly generic versions of brand-name drugs. Tier 2 is made up of mid-priced drugs that may be brand-name but are “preferred” within their drug class. Tier 3 has mostly brand-name drugs with higher copayments.
Preventive Care
Tests or treatments that may help you stay healthy or catch problems early on when they’re easier to treat.
Primary care
A basic level of health care usually rendered in ambulatory settings by general doctors, family doctors, internist, obstetricians, pediatricians and mid-level doctors. This type of care emphasizes caring for the member’s general health needs as opposed to specialists focusing on specific needs.
Primary Care Physician (PCP)
Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.
Prior Authorization
For some health care services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called pre-certification, authorization, certification or pre-authorization.
Prosthesis/Prosthetic Device
A device which replaces all or portion of a part of the human body.
Provider
A doctor, hospital or other person or company that provides health care services.
Provider directory
A list of doctors, hospitals and other health care providers.
Provider Network
Doctors and hospitals who’ve agreed to accept your insurance. Each plan has its own network. And getting care from your network is often a good way to get quality care at a more reasonable cost. See also Network and Network Provider.
Qualifying event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events include moving to a new state, certain changes in your income, and changes in your family size like getting married, divorced or having a baby. Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder can also be qualifying events.
R
 
Reasonable Charge
The amount that’s considered normal for a doctor or hospital to charge for a health care service.
Referral
A suggestion of a doctor or hospital to go to. With certain health coverage plans, especially HMO plans, you may need to get a referral from your main doctor to see a specialist or get other care.
Refill-too-soon
When you try to refill a prescription before it’s time.
Renewal
When you sign up for health coverage again with the same company or on the same health plan.
Retail pharmacies
Pharmacies located in regular shopping stores.
S
 
Second Opinion
Going to another doctor to make sure that the treatment your doctor is proposing makes sense. Sometimes we may ask you to get a second opinion to double check that the care makes sense.
Service Area
The area around where you live, where your network doctors and hospitals give you care.
Skilled Nursing Care
Rehabilitation services or care for serious health issues that are too complicated to be tended to at home or at an assisted living facility — like Alzheimer’s disease.
Skilled Nursing Facility (SNF)
Often referred to as nursing homes — licensed health care facilities that are inspected and regulated by a state’s Department of Health Services. They offer long- and short-term rehabilitation services or care for serious health issues that are too complicated to be tended to at home or at an assisted living facility — like Alzheimer’s disease.
Specialist
A doctor or other health professional who has advanced education and training in a certain area of medicine.
Speech Therapy
Treatment to correct a speech impairment which resulted from birth, or from disease, injury or prior treatment.
Standing referral
A referral by a doctor for more than one visit by a specialist.
Step therapy
Some plans require your doctor to start with one drug that's on the formulary. If that drug isn't right, your doctor can take the next step, and move you to a higher level drug.
Subscriber
The main person insured on a health plan.
Substance Abuse/Chemical Dependency
Misuse, excessive use, or improper use of alcohol or drugs to the extent that such use contributes to physical, mental or social dysfunction.
Summary of Benefits and Coverage (SBC)
A document that summarizes your health plan benefits. What’s covered, how much you’ll pay if you need care and more. You can find it by logging in to this website and going to your plan documents. View the SBC glossary terms.
T
 
TTY/TDD
A telecommunications device for the hearing-impaired.
U
 
Utilization Management
When we look at the care you’re receiving and make sure it meets certain standards. It’s often used to determine if care is medically necessary and appropriate for you.
Urgent Care
A center with doctors who treat conditions that should be looked at right away but aren’t as severe as emergencies. Can often do X-rays, lab tests and stitches.
V
No glossary terms are available at this time.
W
 
Waiting Period
A period of time a member has to wait before their health insurance can begin.
Walk-in-clinic
A doctor’s office that doesn’t require you to be an existing patient or have an appointment. Can handle routine care and common illnesses.
Well Baby/Well Child Care
Routine preventive care, testing, checkups and immunizations for a generally healthy baby or child.
Wellness Program
A health management program that incorporates disease prevention, medical self-care and health promotion.
Women, Infant and Children Program (WIC)
A State nutrition program that helps pregnant women, new mothers and young children eat well and stay healthy.
X
No glossary terms are available at this time.
Y
No glossary terms are available at this time.
Z
No glossary terms are available at this time.