Glossary

Healthcare words, translated into everyday English.

78 terms you’ll see on bills, insurance letters, and forms. Educational information only, not medical, legal, or financial advice.

78 terms

A

Affordable Care Act (ACA): A federal law that sets rules for health insurance to protect patients. It requires plans to cover basic health needs and stops them from denying you for past illnesses. Always verify your plan rules with your insurer or an official government source.
Allowable Charge: The highest amount your health plan will pay a doctor for a service. If the doctor charges more, you might have to pay the difference. Always verify costs with your insurer or provider.
Appeal: A formal request asking your health plan to look again at a denied claim. You can ask them to change their mind if you think they should pay for your care. Always verify the appeal steps with your insurer or an official government source.
Assignment of Benefits: An agreement you sign that lets your doctor get paid directly by your health plan. This saves you from having to receive the check and pay the doctor yourself. Always verify payment details with your insurer or provider.
Authorization: A rule saying you must get approval from your health plan before you get certain medical care. If you do not get this first, the plan might not pay. Always verify if you need approval with your insurer or provider.

B

Balance Billing: When a doctor bills you for the difference between their total charge and what your insurance paid. The No Surprises Act makes this illegal in many emergency and out-of-network cases. Always verify your rights with your insurer or an official government source.
Beneficiary: A person who gets health care coverage through an insurance plan. This means you or your family members are the ones protected by the policy. Always verify covered family members with your insurer or an official government source.
Benefit Period: The exact block of time your health plan covers your medical care. This often starts the day you go to the hospital or use a service. Always verify dates and rules with your insurer or an official government source.
Billed Amount: The total price a doctor or hospital asks for before insurance pays any of it. This is usually higher than what you will actually owe. Always verify the final amount you owe with your insurer or provider.

C

Centers for Medicare & Medicaid Services (CMS): The federal agency that runs major healthcare programs like Medicare and Medicaid. They also help manage the ACA marketplace. Always verify program details with an official government source.
Charity Care: A program under IRS rule 501(r) that requires nonprofit hospitals to offer free or lower-cost care to people who cannot afford to pay. You have to apply for it and show proof of your income. Always verify your hospital's charity care policy with the provider.
Claim: A bill sent to your health plan by you or your doctor asking them to pay for your medical care. The plan reviews it to decide how much they will cover. Always verify claim status with your insurer or provider.
COBRA: A federal law that lets you keep your job-based health plan for a short time after you lose your job. You will usually have to pay the full cost of the monthly bill yourself. Always verify COBRA rules with your insurer or an official government source.
Coinsurance: The share of the costs you must pay for a medical service after you pay your deductible. For example, your plan might pay 80% while you pay 20%. Always verify your cost share with your insurer or provider.
Copayment: A flat fee you pay for a medical service, like $20 for a doctor visit or prescription. You normally pay this at the time you get the care. Always verify the exact fee with your insurer or provider.
Cost-Sharing: The amount of money you pay out of your own pocket for healthcare. This includes deductibles, copayments, and coinsurance. Always verify your total expected costs with your insurer or provider.
Covered Service: A medical treatment or test that your health plan agrees to pay for, at least in part. If it is not covered, you might have to pay the whole bill. Always verify what is covered with your insurer before getting care.
CPT Code: A five-digit number used by doctors to tell your insurance exactly what test or treatment you received. Insurance uses this code to decide how much to pay. Always verify these codes with your provider or insurer if you have billing questions.

D

Deductible: The amount of money you must pay for your own health care each year before your insurance starts to pay. For example, if it is $1,000, you pay the first $1,000. Always verify your yearly total with your insurer or provider.
Denial: When your health plan decides they will not pay for a medical service or prescription. You have the right to challenge this decision. Always verify the reason for denial with your insurer or an official government source.
Dependent: A child, spouse, or family member who gets health coverage through your insurance plan. They get the same benefits you do under that policy. Always verify who can be added to your plan with your insurer or an official government source.
Diagnosis Code: A set of letters and numbers a doctor uses to tell your insurance what illness or injury you have. This proves to the plan why you needed the medical care. Always verify these codes on your bill with your provider or insurer.
Dual Eligible: A person who qualifies for both Medicare and Medicaid at the same time. These two programs work together to cover most of the person's health care costs. Always verify your benefits with an official government source.

E

Emergency Medical Condition: A sudden illness or injury that is so serious your health is in great danger without fast medical help. Health plans must cover these visits even if the hospital is out of network. Always verify coverage rules with your insurer or an official government source.
Emergency Room: The part of a hospital that treats severe, life-threatening injuries or illnesses right away. Care here costs more than going to a regular doctor or urgent care. Always verify coverage details with your insurer or an official government source.
ERISA External Review: A legal right that lets an outside group check your denied claim if you get insurance through a private employer. This group decides if your health plan must pay for the care. Always verify your appeal rights with your insurer or an official government source.
Essential Health Benefits: Ten basic medical services that all ACA marketplace plans must cover, like emergency care and prescriptions. These rules make sure your insurance actually protects you when you get sick. Always verify your plan's benefits with your insurer or an official government source.
Explanation of Benefits (EOB): A paper or digital letter from your health plan showing what they paid for your doctor visit. It is not a bill, but it shows what you might owe. Always verify the math on this letter with your insurer or provider.

F

Facility Fee: An extra charge hospitals or clinics add to your bill just for using their building and equipment. This is separate from the doctor's own bill for treating you. Always verify these fees with your provider or insurer.
Federal Poverty Level (FPL): A measure of income put out by the government every year to see who is struggling financially. Programs like Medicaid and ACA marketplace use this number to see if you get help paying for care. Always verify the current numbers with an official government source.
Formulary: A list of prescription drugs that your health plan agrees to help pay for. If your medicine is not on this list, it might cost you a lot more. Always verify your medicine's coverage with your insurer or provider.
Fraud: When someone lies on purpose to get money from a health insurance company or government program. This is a crime that can result in heavy fines or jail time. Always verify bills and report suspicious charges to your insurer or an official government source.

G

Generic Drug: A medicine that has the same active ingredients as a brand-name drug but costs much less. Insurance plans usually prefer you take these to save money. Always verify drug options with your provider or insurer.
Grace Period: A short amount of time after your health insurance bill is due where you can still pay it without losing your coverage. If you miss this window, your plan can be canceled. Always verify your payment deadlines with your insurer or an official government source.
Grievance: A formal complaint you file with your health plan about bad customer service or poor treatment by a doctor. This is different from an appeal, which is about paying a bill. Always verify the complaint process with your insurer or an official government source.

H

Health Insurance Portability and Accountability Act (HIPAA): A federal law that protects your private medical records and gives you the right to see them. It stops doctors and insurers from sharing your health facts without your permission. Always verify your privacy rights with your provider or an official government source.
Health Maintenance Organization (HMO): A type of health plan that usually requires you to use doctors and hospitals inside their specific network. You normally have to get a referral from your main doctor to see a specialist. Always verify network rules with your insurer or provider.
High Deductible Health Plan (HDHP): An insurance plan with a lower monthly bill but a higher amount you must pay out of pocket before the plan helps. These plans often let you use a tax-free health savings account. Always verify plan details with your insurer or an official government source.

I

In-Network: Doctors, hospitals, and clinics that have a contract with your health plan to charge lower rates. Going to these places usually saves you a lot of money. Always verify a doctor's network status with your insurer or provider.
Inpatient: When you are formally admitted to a hospital by a doctor's order and stay overnight or longer for care. This type of care is billed differently than a quick visit. Always verify your admission status with your provider or insurer.
Itemized Bill: A detailed list from your doctor or hospital showing the exact cost of every single test, drug, and service you got. Asking for this can help you spot mistakes. Always verify these details with your provider or insurer.

J

Job-Based Insurance: Health coverage that you or a family member gets through an employer. The employer usually pays for part of the monthly cost. Always verify your benefit choices with your insurer, provider, or employer.

K

Kickback: An illegal payment or gift given to a doctor to reward them for sending patients to a certain hospital or using specific drugs. Federal laws strictly ban this practice to keep your care honest. Always verify your care options with your provider or an official government source.

L

Letter of Medical Necessity: A note from your doctor explaining to your health plan why a specific treatment or drug is needed for your health. This is often used during an appeal to prove you need the care. Always verify what this letter needs to say with your insurer or provider.
Lifetime Limit: A cap on the total money an insurance company will spend on your care over your entire life. The Affordable Care Act made it illegal for most plans to have these limits on essential health benefits. Always verify your coverage limits with your insurer or an official government source.
Long-Term Care: Services that help people with basic daily tasks like dressing and bathing over a long period, often in a nursing home. Medicare usually does not pay for this, but Medicaid might. Always verify coverage options with your insurer or an official government source.

M

Marketplace: A service run by the government where you can shop for and buy health insurance, often called the ACA marketplace. People with lower incomes can get tax credits here to lower their monthly bill. Always verify plan choices with an official government source.
Medicaid: A joint federal and state program that provides free or low-cost health care to millions of Americans. It helps low-income adults, children, pregnant women, and people with disabilities. Always verify your eligibility with an official government source.
Medical Debt Credit Reporting: Recent changes to the law mean that unpaid medical bills under $500 can no longer be put on your credit report. Paid medical debts must also be removed right away. Always verify your credit rights with an official government source.
Medical Necessity: A rule health plans use to decide if a treatment is actually needed to diagnose or treat your illness. If a plan thinks the care is just for convenience, they will not pay. Always verify what is deemed necessary with your insurer or provider.
Medicare: A federal health insurance program mainly for people who are 65 or older. It also covers some younger people with certain serious disabilities. Always verify program benefits with an official government source.

N

Network: The specific group of doctors, hospitals, and pharmacies that have agreed to work with your health plan. Using this group helps keep your out-of-pocket costs down. Always verify who is on this list with your insurer or provider.
No Surprises Act: A federal law that protects you from huge, unexpected medical bills if you get emergency care or are treated by an out-of-network doctor at a covered hospital without knowing. It bans balance billing in these specific cases. Always verify your bill protections with your insurer or an official government source.
Non-Covered Service: A medical test or treatment that your health insurance policy specifically refuses to pay for. If you choose to get it anyway, you will have to pay the full price. Always verify what services are excluded with your insurer or provider.

O

Open Enrollment Period: A set time once a year when you can sign up for health insurance or change your plan for the next year. If you miss this window, you cannot get coverage unless you have a major life change. Always verify dates with your insurer or an official government source.
Out-of-Network: Doctors or hospitals that do not have a pricing contract with your health plan. You will usually pay much more, or even the full cost, if you use them. Always verify network status with your insurer or provider before care.
Out-of-Pocket Maximum: The absolute most you will have to pay for covered services in a year using your own money. Once you hit this limit, your health plan pays 100% of the costs. Always verify your spending total with your insurer or provider.
Outpatient: Medical care where you are not admitted to stay overnight in a hospital. Examples include simple blood tests, urgent care visits, and same-day surgeries. Always verify your care setting with your insurer or provider.

P

Part A: The section of Medicare that helps pay for care in a hospital, a skilled nursing facility, or hospice. Most people do not pay a monthly premium for this part if they paid enough Medicare taxes while working. Always verify hospital benefits with an official government source.
Part B: The section of Medicare that pays for doctors' services, outpatient care, and medical supplies. You pay a monthly fee for this coverage, which is usually taken right out of your Social Security check. Always verify covered services with an official government source.
Point of Service (POS) Plan: A type of health insurance where you pay less if you use doctors in the plan's network. You usually have to pick a primary doctor and get referrals to see specialists. Always verify plan rules with your insurer or provider.
Preferred Provider Organization (PPO): A flexible health plan that lets you see any doctor, but you save money if you use ones in their network. You usually do not need a referral to see a specialist. Always verify your benefits with your insurer or provider.
Premium: The amount you must pay every month just to keep your health insurance active. You pay this whether you use medical services that month or not. Always verify payment amounts and dates with your insurer or an official government source.
Primary Care Provider (PCP): The main doctor or nurse you see for basic health checks and minor sicknesses. They help manage your overall health and send you to specialists if you need extra help. Always verify your chosen doctor is in-network with your insurer.

Q

Qualifying Life Event: A major life change, like having a baby, getting married, or losing your job, that lets you sign up for health insurance outside the normal yearly window. You usually only have a short time to apply. Always verify event rules with your insurer or an official government source.

R

Referral: A written order from your main doctor telling you to go see a specialist for a certain problem. Many health plans will not pay for the specialist unless you get this order first. Always verify referral rules with your insurer or provider.
Respite Care: Short-term relief for people who are acting as unpaid caregivers for a sick family member. Sometimes programs like Medicare hospice will pay for a temporary stay in a nursing home to give the family a break. Always verify coverage with your insurer or an official government source.

S

Skilled Nursing Facility (SNF): A special live-in medical center with round-the-clock nurses and physical therapy to help you recover after a hospital stay. Medicare and other plans have strict rules on how long they will pay for this care. Always verify coverage limits with your insurer or an official government source.
Special Enrollment Period: A short window of time where you can buy health insurance outside of the normal yearly sign-up time because you had a qualifying life event. You must apply quickly after the event happens. Always verify deadlines with your insurer or an official government source.
Specialist: A doctor who focuses on treating one specific disease or part of the body, like a heart doctor or a skin doctor. Care from these experts often costs a little more than seeing a regular doctor. Always verify network status with your insurer or provider.
Summary of Benefits and Coverage (SBC): A short, easy-to-read document that explains exactly what your health plan pays for and what it costs. The ACA marketplace requires all plans to provide this so you can compare choices fairly. Always verify your coverage details with your insurer or an official government source.

T

Telehealth: Medical visits done over a phone call or video chat instead of going into a doctor's office in person. Many plans cover this just like a regular visit, but the rules can change. Always verify telehealth options with your insurer or provider.

U

Usual, Customary, and Reasonable (UCR): The normal, average price that most doctors charge for a specific service in your city or town. Health plans use this average to decide how much they are willing to pay for out-of-network care. Always verify standard costs with your insurer or provider.

V

Vision Coverage: A special type of health plan that only helps pay for eye exams, glasses, and contacts. Regular health insurance usually does not cover these items for adults. Always verify your eye benefits with your insurer or provider.

W

Waiting Period: The amount of time you have to work at a new job before your employer-based health insurance actually starts. The law says this gap cannot be longer than 90 days. Always verify the start date with your employer, insurer, or an official government source.

X

X-Ray: A quick, painless medical test that uses safe amounts of radiation to take pictures of the inside of your body, usually your bones. It helps doctors see if you have a break or other problem. Always verify coverage with your insurer or provider.

Y

Yearly Deductible: The specific amount of your own money you have to pay for healthcare in one full year before your insurance takes over the bills. This amount resets to zero every new plan year. Always verify your progress toward this amount with your insurer or provider.

Z

Zero-Premium Plan: A health insurance plan that does not charge you a monthly bill. You can often find these on the ACA marketplace if you qualify for high tax credits, but you might still have copays or deductibles. Always verify total costs with your insurer or an official government source.