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A

Actuarial Value – The percentage of healthcare costs a plan will cover on average.

Adverse Selection – When insurance companies end up with more high-risk individuals than expected.

Agranulocytosis – A severe drop in white blood cells, increasing infection risk.

Allowed Amount – The maximum amount an insurer will pay for a covered service.

Ancillary Services – Additional healthcare services (e.g., lab tests, X-rays, physical therapy).

B

Balance Billing – When a provider bills you for the difference between their charge and what insurance pays.

Beneficiary – A person who receives health insurance benefits.

Bundled Payment – A single payment covering multiple healthcare services.

Bursitis – Inflammation of a small fluid-filled sac near joints.

C

Capitation – A fixed amount paid per patient, per period, regardless of services used.

Carve-Out – A service excluded from a standard health insurance plan.

Claim – A request for payment submitted to an insurer for covered services.

Coinsurance – The percentage of costs you pay after meeting your deductible.

D

Deductible – The amount you pay before insurance starts covering costs.

Denial of Claim – When an insurance company refuses to pay for a service.

Dysphagia – Difficulty swallowing.

Durable Medical Equipment (DME) – Long-term medical devices like wheelchairs and oxygen tanks.

Drug Formulary – A list of prescription drugs covered by an insurance plan.

E

Electronic Health Record (EHR) – A digital version of a patient’s medical history.

Elimination Period – The waiting time before insurance benefits begin.

Explanation of Benefits (EOB) – A summary of what insurance covers and what you owe.

Exclusion – A medical service that is not covered by an insurance policy.

F

Fee-for-Service (FFS) – A payment model where providers are paid per service rather than per patient.

Formulary Tier – Levels of prescription drug coverage (lower tiers = cheaper drugs).

Flexible Spending Account (FSA) – A tax-free savings account for medical expenses.

Fibromyalgia – A disorder causing widespread pain, fatigue, and tenderness.

Fiscal Intermediary – A private company that processes Medicare claims.

G

Genomic Medicine – Using a person’s DNA to guide healthcare treatments.

Guarantor – The person financially responsible for a patient’s medical bills.

Glucometer – A device that measures blood sugar levels.

H

Health Maintenance Organization (HMO) – A type of health insurance with network restrictions.

Health Savings Account (HSA) – A tax-advantaged savings account for healthcare expenses.

Hematoma – A large bruise or blood collection under the skin.

High-Deductible Health Plan (HDHP) – A health plan with a higher deductible but lower premiums.

I

Indemnity Plan – A traditional insurance plan where you pay upfront and get reimbursed.

Inpatient Care – Care that requires hospital admission.

Insulin Resistance – A condition where the body doesn’t effectively respond to insulin.

Integrated Care – A healthcare system where providers work together across specialties.

J

Joint Commission – An organization that accredits healthcare facilities for quality standards.

Job-Based Insurance – Health insurance provided through an employer.

Jugular Vein Distention (JVD) – Buldge of the neck veins.

K

Ketosis – A metabolic state when the body burns fat for energy.

Kidney Dialysis – A treatment that filters waste from the blood when kidneys fail.

Keloid – A raised scar that forms after skin injury.

L

Length of Stay (LOS) – The number of days a patient stays in a hospital.

Long-Term Care Insurance – Coverage for extended medical and personal care.

Lymphadenopathy – Swollen lymph nodes.

Lifetime Maximum – The total amount an insurance plan will pay over a person’s lifetime.

M

Medical Necessity – A service or treatment deemed essential for a patient’s health.

Medigap – Additional insurance to cover Medicare gaps.

Morbid Obesity – Extreme obesity that affects health and mobility.

N-Z

Network Provider – A doctor or hospital contracted with an insurance company.

Non-Covered Service – A procedure or treatment that insurance won’t pay for.

Out-of-Pocket Maximum – The most you’ll have to pay for covered services in a year.

Palliative Care – Specialized care focused on relief from serious illness symptoms.

Premium – The amount you pay for insurance each month.

Prior Authorization – Insurance approval needed before covering certain treatments or medications.

Qualifying Life Event (QLE) – A life change (e.g., marriage, job loss) allowing special insurance enrollment.

Referral – A doctor’s approval to see a specialist.

Reimbursement – Money paid back by an insurer for covered services.

Special Enrollment Period (SEP) – A time outside open enrollment to sign up for insurance.

Telemedicine – Virtual healthcare via phone or video.

Utilization Review – Insurance evaluation of whether care was necessary.

Waiting Period – The time before insurance coverage begins.

Wellness Visit – A preventive check-up (covered by most insurance plans).

Zoonotic Disease – A disease that spreads from animals to humans.