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Connecticut Health and Medical Insurance Glossary of Terms

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    This glossary and definitions are provided to give you a general understanding of how words are used sometimes by health insurance plans. Each State and every health insurance plan has a complete list of definitions within the health insurance policy agreement, or the certificate of coverage. Please refer to your health plan documents for specific definitions and understanding of your coverage and medical benefits. If you have specific legal question or problem, please call a legal authority.  
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Accidental – sudden and not intended

Accidental health policy – is a type of health insurance policy that pays for medical expenses for accidental medical care only.

Allowable expense(s) - A medical health expense that is approved by the insurance company and part or all of which is covered under a health insurance plan. Health plan documents will show examples of expenses or services that are or are not considered allowable medical expenses.

Adjudication – Legal process used by health plans to determine the availability of coverage and benefits for a medical claim.

Ambulatory Surgery - Surgical procedures that do not require an overnight hospital stay. These can be done inside a hospital or medical office. This is also referred to as outpatient surgery.

Appeals - The process used by a member of a health plan to request the health plan re-consider the denial of a previous authorization or a decision to deny a claim.

Approved Insurance plans - are those plans that are approved by the State Insurance Department and carry many coverage’s required by law. These plans are generally better than non approved insurance plans.

Authorization – is the approval of a medical procedure prior to such procedure. This also called preauthorization or precertification. This is a good thing for a member to do.

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Benefit – term used to indicate that there is coverage or protection under the terms of the health insurance plan for payment for medical services.

Benefit period - The maximum length of time for which medical benefits will be paid.

Brand name drug - A prescription which is patented and protected by trademark registration.


Capitation – A prepaid amount paid by the insurance company to a medical provider for services render to a member of a health insurance plan.

Case management - The process of identifying members at high risk for problems associated with physical or mental health care needs and assessing opportunities to coordinate care to optimize the outcome and reduce expenses.

Certification – approval of medical procedure and or coverage.

Chemotherapy – Medical treatment of malignant disease by chemical or biological drugs.

Chiropractic care - Alternative medical care administered by a licensed chiropractor. A chiropractor adjusts the spine and joints to treat physical pain and to improve general health.

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Claim payment - for payment of benefits for medical care services provided to a member by a medical provider.

Coinsurance – is the portion of a medical expense that is shared by the member and the insurance company. Coinsurance is usually expressed as a percentage. The insurance company pays 80% and the member pays 20% of the medical bill. There is usually a limitation as to the maximum a member will pay per year. Then the health plan will pay 100% thereafter per year.

Company Insurance Agents – are employees of the health insurance company and whose job is to sell their employers health plan only.

Connecticut health insurance specialist - is an Independent agent in Connecticut who represents the employer or individual in purchasing health insurance. Such agents are experts on all health plans in Connecticut.

Contract - A legal written agreement between 2 parties or an employer and insurance company. The health plan contract describes the coverage’s and limitations of the health plan.

Coordination of benefits – a contract provision within a health insurance plan that explains how claims are to be paid in the event of there being 2 or more health plans covering a medical procedure. Coordination of benefits is a systematic insurance procedure to avoid delays in paying claims, and to avoid paying more than 100% of the medical claim.

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Copayment - The dollar amount required to be paid by the member in connection with medical care or prescription drugs.Covered benefits – medical care which is covered in whole or in part under a health insurance plan. These coverage’s and limitations are stated within the insurance policy.

Custodial Care - Any type of care where the care provided is to attend to the member's activities of daily living. This care does not require the attention of a licensed or trained medical provider. Some examples of this are: assistance in walking, getting in and out of bed, bathing oneself, dressing oneself, feeding oneself, using the toilet, and medicating oneself.

Credentialing providers – Many health insurance companies publish a network of approved medical providers to their members in health plans. Medical plans are expected by the public and the legal system to assess a provider's qualifications and record on issues relating to professional competence and conduct prior to including the physician in a list of approved providers.

Customary and Reasonable - the amount charged for medical services by other providers in the same geographic area is called customary and reasonable. This is also called “reasonable and customary” and also “usual, customary and reasonable (UCR)ry, and Reasonable"(UCR).

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Deductible – the amount a you must pay for a medical service. The deductible can be stated per person, per family, per year, per admission, and per service or per procedure. You also can have a combination of these conditions. For example, you can have a deductible for medical and a deductible for prescriptions.

Dependent - a person who is eligible to be enrolled for medical coverage as determined by the laws of the State and agreed upon with the health insurance plan. Some examples would be a spouse, a child, or a domestic partner.

Diagnostic tests – are medical procedures to determine how a patients health is. Some examples are x-rays, blood tests, urine tests, ultrasound, and other laboratory and pathology tests.

Drug Formulary - a list of prescription drugs created by the health insurance plan which includes generic drugs and brand name drugs. Drugs not on these lists are called Non-formulary drugs and have larger Copays. All health plans vary on copays and some health plans require you to pay the difference between a generic and name brand drug. Always refer to a Independent Health Insurance Specialist for answers to this.


Emergency medical condition - is when a member experiences acute symptoms of great severity or severe pain, and that a normal person, would expect that immediate medical attention is needed to prevent death or disability. Each State and health insurance plans uses different wording in this area.

Enrollee – is someone who has been added to a health plan. This procedure is called enrolling a member and thus the term enrollee is also used for members who have been added to a plan. Also called member and possibly dependent

Exclusions are specific limitations that are placed on specific health conditions and specific circumstance where the health plan provides no coverage or benefits. These exclusions are specified with the health insurance policy.

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Experimental procedures – are medical procedures that are not generally recognized by the medical community to be effective or appropriate for the diagnosis and treatment of a specific condition. Each state and health plan has different wording that is approved by the state the health plan is sold. It is always good to get approval from the health plan before any unusual procedures.

Explanation of Benefits – is a form that is mailed to a health plan member explaining how a claim is being handled and explains amount paid by the company and the amount to be paid by the member.


Formulary - a list of prescription drugs created by the health insurance plan which includes generic drugs and brand name drugs. Drugs not on these lists are called Non-formulary drugs and have larger copays. All health plans vary on copays and some health insurance plans require you to pay the difference between a generic and name brand drug. Always refer to a Independent Health Insurance Specialist for answers to this

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Generic Drug – is a prescription drug which is not protected by trademark registration, and is sold as an equal to a Name Brand drug.


Health Insurance Agents - There are many types of insurance agents selling health insurance in Connecticut. Here are some prominent examples:
1. Employee health insurance agents - are required to sell their companies health plans only. Anthem Blue Cross uses employee and non employee agents.
2. Multi State insurance agents – are usually found on the internet and are located outside of Connecticut. They sell in many states and offer prices for many companies. 3. Property Casualty Insurance Agents – are local agents that handle auto ins., homeowner ins., commercial ins., workers compensation ins. , boat insurance. , life ins., health ins etc.
4. Financial planners are those agents that offer investment products such as Mutual Funds. There are over 12,000 Mutual Funds in America.
5. Health Insurance Specialists - this is a small group of agents. These agents spend the majority of their time, helping people and businesses with their health insurance. They are aware of most of the health plans offered in Connecticut.

Health Plan - health insurance is referred to as HMOs, PPOs, PFFS, POS plans etc. which are all health plans. Each health plan defines the coverage’s or benefits offered and then takes away coverages through exclusions, limitations and conditions.

Health Insurance Portability and Accountability Act (HIPAA) - HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:
1. Limiting exclusions for pre-existing conditions;
2. Providing credit for prior health coverage;
3. Allowing transmittal of the coverage information to a new insurer;
4. Providing rights to allow individuals to enroll for health coverage when they lose their health coverage or have a new dependent;
5. Prohibiting discrimination in enrollment/premiums
6. Guaranteeing availability of health insurance coverage for small employers.

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Health Maintenance Organization (HMO) – is a type of health insurance plan where the members of the health plans are able to go to the medical providers within the HMO network. The medical providers have contracts to provide services at set fees for all members within the HMO network of providers.

Home health care – is a coverage or benefit that pays for skilled nursing and other services provided in a home setting. This is an alternative to confinement in a hospital or skilled nursing facility which is very expensive. .

Hospice Care - this is non-medical care, given to a terminally ill person as an inpatient or at home care. This care is to allow terminally ill patients to remain, for as long as they can, in the familiar surroundings of their home, before they die.

Hospital – is a business that offers inpatient and outpatient services. A hospital may be a general hospital, an acute care hospital, or a rehabilitation or specialty care hospital.

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Indemnity Plan – an indemnity plan allows members flexibility in their choice of health care providers for covered medical expenses. Members are very active and are responsible for seeking precertification, paying for services rendered, and submitting claims for reimbursement by the health plan. These plans usually have deductibles and coinsurances which the member must pay before any expenses are paid under the health insurance plan.

Independent Insurance Agents and Brokers – are an insurance agent that understands many health insurance plans and represents the member or employer when purchasing health insurance. They are independent in that they are not employed by by health plan and have the independence to sell many different companies and their health plans.

In-Network – is sometimes called an HMO and refers to the use of providers who participate in health plan's provider network.

Inpatient Care – is when service is provided after the patient is admitted to the hospital and has a bed for the night. Inpatient care must last for 24 hours or more.


Limitations – are restrictions within a health insurance plan that places a limit on the amount of coverage or benefits it will pay.

Loss – is a term used to describe an event, such as an injury or illness, that causes a person to incur medical coverage or benefits.

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Managed Care – is when a health plan forms a network of providers at set fees and procedures and requires certification and pre authorization for certain services. This care also identifies members at high risk for problems associated with physical or mental health care needs and assesses opportunities to coordinate care and to optimize the outcome and reduce expenses.

Maximum Out of Pocket - is the maximum out of pocket amount that a member or enrollee will have to pay for expenses covered under the health plan. The maximum can be a coinsurance maximum or a copayment maximum. Once a member reaches the out of pocket maximum, the health plan pays 100% of covered medical care

Medical Emergency - is when a member experiences acute symptoms of great severity or severe pain, and that a normal person, would expect that immediate medical attention is needed to prevent death or disability.

Medically necessary – is a term use by health plans when determining whether coverage and benefits for medical care that is appropriate.

Member – is the person and their dependents who are enrolled in and covered by a health insurance plan. Some companies refer to members as called enrollees or subscribers.

Mental disorder – is a medical condition for which coverage and benefits for medical care and treatment by a mental health professional such as a psychiatrist, a psychologist or a psychiatric social worker.

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Network - Physicians, hospitals and other health care providers who agree to participate and provide medical services at reduced fees in a health insurance plan. Networks are also called a provider network.

Non-Participating Provider - is a term generally used to refer to medical providers who have not contracted with a health plan to provide services at reduced fees. POS plans would act as an indemnity plan and cover some of the expenses for out of network claims. Non-Participating provider are covered as Network providers when use was for a emergency situation.


Occupational Therapy – is medical treatment to restore a person’s ability to perform activities of daily living such as bathing, dressing, walking, eating, and drinking.

Office Visits – coverage or benefits for costs incurred as a result of a vist to a doctors office.

Out of Network – is when members use health care providers who have not contracted with the health plan to provide services.

Out of Pocket Maximum – is the maximum out of pocket amount that a member or enrollee will have to pay for expenses covered under the health plan. The maximum can be a coinsurance maximum or a copayment maximum. Once a member reaches the out of pocket maximum, the health plan pays 100% of covered medical care.

Outpatient Prescriptions – any prescription prescribed by a physician and dispensed by a pharmacist outside of a hospitalization.

Outpatient Surgery – is surgery that is performed on a member who is able to leave the hospital without an overnight stay in the hospital. This is also called ambulatory surgery.

Outpatient X-ray and Lab Tests – are medical services incurred for x-ray and lab tests that are not part of inpatient hospital fees.

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Participating Provider – is a physician, a hospital, a skilled nursing facility, or other medical provider, who contracts with a health insurance plan, to provide medical services to members/enrollees for a negotiated fee. They are sometimes called a Network provider.

PCP – is a shortened slang for Primary Care Physician.

Physical Therapy – is medical treatment which uses physical movement to relieve pain, restore function and prevent disability following disease, an injury, or a loss of limb.

Plan documents - includes the health insurance policy, the group agreement, group policy, and/or a certificate of insurance.

Point of Service Plan (POS plan) – is a health insurance plan that provides coverage and benefits for medical care received from both participating and non-participating providers.

Preauthorization / precertification – is when a health insurance plan requires specific medical procedures, such as hospitalization or outpatient surgery to be approved by the health insurance plan. When it is anticipated that a member is to obtain medical care that requires precertification, the participating provider should precertify or preauthorize those services prior to treatment. This is good because there are no surprises, such as a $80,000 medical bill to the member.

Preexisting condition – is a health problem or condition that existed prior to the date your health insurance plan became effective.

Preexisting Condition Exclusion – is when a health insurance plan adds or uses a clause or rider that specifies it will not cover a preexisting condition. Sometimes the clause may limit the benefit payable for treatment of a preexisting condition until a certain period of time has passed. This varies by State and health insurance plan.

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Preferred Provider Organization (PPO) – is a type of health insurance plan that allows members to manage their care and can self-refer to medical providers either in or out-of-network. Members do not need to select a primary care physician.

Prescription – is a written order from a licensed provider for medical treatment. Medical treatment can be the usual prescription drug, or it could be for other medical care such as physical therapy.

Preventative Care – is medical care usually provided by a physician and is not medically necessary to address a medical problem or condition. What is included under preventative care varies greatly from each health plan and each State. Typical coverage is annual exams, routine physicals, OBGYN exams Mammograms, and pap smears. Yet some health plans cover flu shots, colonoscopy’s, prostate exams and blood tests. It is best to consult a local health insurance expert for accurate answers here.

Primary Care Physician (PCP) – is usually your first contact for a medical problem. They are the local physicians such as a family care practitioner, an internist or a pediatrician. Primary Care Physicians monitors your health, and diagnoses and treats minor health problems, and refers you to specialists if needed.

Prosthetic Devices – are a device which replaces all or a portion of a part of the human body. These devices are medically necessary because a part of the body is permanently damaged, is absent, or is malfunctioning.

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Q - R

Radiation Therapy – is the medical treatment of a disease by radium, cobalt, x-ray, or high-energy particle sources.

Reasonable and Customary Charge – is the maximum amount a plan or health insurance plan will consider for a covered expense. Medical charges are “reasonable and customary” if they are similar to charges made by most physicians or providers for similar medical care in the same locality.

Referral – some health plans requires a member to get a recommendation from their primary care physician before they see a specialist physician. A member who fails to get a referral could find the health plan will not pay for those medical services. The better plans do not require referrals. Members usually have to pay for 2 doctor visits.


Second Opinion – this is usually a voluntary option, or a mandatory requirement to visit another physician or surgeon for an opinion regarding a diagnosis, a course of treatment or having a specific surgery.

Short Term Health Insurance- is a temporary health insurance intended for people who need coverage for less than 1 year. Generally, these plans do not cover preexisting conditions and are more of a catastrophic plan. The pricing is generally half the price of a regular health insurance plan. They were developed for people in between jobs, just graduating school, or for temporary losses of health plans.

Skilled Nursing Facility – is a medical institution that is licensed and approved under state law. These medical providers are providing skilled nursing care and related services.

Subscriber – is usually the employee covered under an employer's group insurance plan. The subscriber can enroll or remove dependents on the policy. Subscribers are sometimes referred to as members or enrollees.

Specialist - A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty.

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T- U

Urgent Care – is medical care for an unexpected illness or injury that is not life threatening, but requires medical care now to avoid complications and to stop unnecessary pain and suffering, such as a cut requiring stitches or a high fever. Urgent care is great for evening and weekends, but the copay is generally higher than a doctor visit but less than a hospital emergency room visit.


Well Baby and Well Child Care is medical care for routine care such as exams, testing, checkups, and standard immunizations for a healthy child.

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  JA May 19, 2016          
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