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Glossary

annual out-of-pocket maximum - The maximum amount, per year, you are required to pay out of your own pocket for covered health care services after the deductible is met.

claim - An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.

copayment - A fixed dollar amount you are required to pay for covered services at the time you receive care.

covered service - A service which is covered according to the terms in your health care benefits plan.

dependent - An eligible person, other than the member (generally a spouse or child), who has health care benefits under the member's policy.

Health Insurance Portability and Accountability Act (HIPAA) - A federal law that outlines the rules and requirements employer-sponsored group insurance plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups.

Health Risk Assessment (HRA) - An assessment of a health care plan member's health status by taking into account that person's family health history and health-related behaviors to predict the member's likelihood of experiencing certain health issues.

individual coverage - Health care coverage for an individual with no covered dependents.

inpatient services - Services provided when a member is registered as a bed patient and is treated  as such in a health facility such as a hospital.

maximum annual benefit - The maximum dollar amount your health care plan will pay for health care services provided to you during one year.

member ID - A unique number that identifies you as a member of a particular health care plan (also known as an ID number or subscriber ID).

network - The group of doctors, hospitals and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.

out-of-pocket maximum - The maximum amount you have to pay for expenses covered under your health care plan, after any deductible is met, during a defined benefit period.

outpatient services - Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

pre-existing condition - A health condition for which an individual received medical care during a specified period of time immediately prior to the effective date of coverage.