Our health insurance glossary helps you understand the meaning of important terms related to health insurance.

Health Insurance Glossary


View the Glossary of Health Coverage and Medical Terms for help understanding your Summary of Benefits and Coverage.


Authorization

The approval of care, such as hospitalization; pre-authorization may be required before admission takes place or care is given by specialty care providers.

 

Behavioral Health
Diagnosis and treatment of mental health and substance abuse disorders.

 

Benefit
Specific health services provided to plan members as described in the employer group or subscriber contract, which could include primary care, hospitalization, outpatient care, ambulatory or emergency services.

 

Certificate of Coverage
Member Certificate issued to the plan subscriber of coverage which defines the benefits available to members (usually through their employer group contract) and the essential terms and conditions affecting eligibility, coverage conditions and termination of coverage. For members covered under the State of Wisconsin Health Benefits Program, the It’s Your Choice booklet contains the complete description of their benefits.

 

Claim
Information submitted by a provider or covered member to establish that medical services were provided to a covered member from which processing for payment to the provider or covered member is made.

 

Coinsurance
The percentage of the fee for medical services that are paid by the subscriber directly to the provider.

 

Copayment
A fixed amount paid by the subscriber for certain office visits, pharmacy prescriptions, or other covered services.

 

Deductible
A predetermined amount of money a member or family must pay per benefit period before Unity will make a payment toward a covered service.

 

Dependent
An individual who receives health insurance through a spouse, parent or other family member.

 

Fee Schedule
The maximum amount of money Unity will reimburse a hospital or provider for covered services.

 

Formulary
A reference document used by participating medical practitioners and pharmacists that lists prescription drugs covered by the health plan for those who have drug coverage.

 

Brand Drug
A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer's brand name.

 

Generic Drug
A chemically equivalent copy designed from a brand-name drug whose patent has expired (typically less expensive and sold under the common name).

 

HMO (Health Maintenance Organization)
A form of health insurance in which members prepay a premium for health services and which generally includes a defined set of services made available through a defined panel of physicians at a preset price.

 

HSA (Health Savings Account)
A tax advantaged savings vehicle subscribers can establish when they have a High Deductible Health Plan.

 

Member
One who is enrolled within a prepaid health program for health services through an individual or group contract (includes both subscribers and their enrolled dependents).

 

My Choice Fee Schedule
The maximum amount of money Unity will reimburse non-contracted PCPs, specialists and hospitals for covered services rendered to members who have My Choice coverage.

 

Network
A defined group of providers, typically linked through contractual arrangements, which supplies a full range of primary and acute health care services.

 

Nurse Practitioner
Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician. Nurse Practitioners cannot serve as a PCP for Unity members, but are available for routine exams, urgent/problems visits, and follow-up care.

 

Out-of-Pocket
Portion of health services or health costs that must be paid for by the plan member, including deductibles, copayments, coinsurance and certain charges in excess of Usual, Customary and Reasonable Charge.

 

POS (Point of Service)
A type of managed care plan that combines characteristics of both an HMO and PPO. Members pay lower out-of-pocket costs when they receive care from in-network providers.

 

PPO (Preferred Provider Organization)
A health insurance plan in which members pay lower out-of-pocket costs when they
receive care from providers participating in the network.

 

Physician Assistant (PA)
A health care professional who is licensed to provide patient education, evaluation, and health care services. A physician assistant works under the supervision of a doctor to provide medical care. PAs cannot serve as a PCP for Unity members, but are available for routine exams, urgent/problems visits, and follow-up care.

 

Practitioner
An individual who supplies health care services, i.e., physician, psychologist, nurse practitioner.

 

Provider
A supplier of health care services, i.e., pharmacies, hospitals or other health care facilities that provide services to members.

 

Schedule of Benefits {or} Summary of Benefits and Coverage
A definition of health care benefits specifically identified as available to the enrolled member which includes the limit or degree of service that member is entitled to receive based upon his or her contract with a health plan or insurer.

 

Subscriber
The eligible person in whose name a health insurance certificate or insurance policy is held.

 

Usual, Customary and Reasonable (UCR)
The amount covered by Unity based upon the customary charges of all providers within a given geographic area for the same or similar service.