Glossary Terms


advanced practice registered nurse (APRN)

A registered nurse who has additional education and training to manage common health problems and chronic conditions and prescribe treatments and medications.


When patients ask health insurers to reconsider a decision, such as to not pay a claim.



Information you or your doctor submits to your health insurer to receive payment for medical services.


Consolidated Omnibus Budget Reconciliation Act of 1986. A federal law that lets you and your dependents continue on your health plan after losing your job or spouse. You have to pay the total cost of the coverage, which ends after a certain period. 


The amount you pay out of pocket for covered medical services and products, such as a doctor's visit, medical procedure, hospital stay, or prescription drugs. Let's say your health plan has a 20 percent coinsurance for doctor office visits. If the visit costs $100, you pay $20. Your health plan pays the remaining $80.

coordination of benefits

A health plan will coordinate your benefits if you're covered under more than one health plan. If you have health insurance through your job and your spouse's plan, the health insurer will decide which plan pays first and which pays second. 


The amount you pay out of pocket for covered medical services and products, such as a doctor's visit, medical procedure, hospital stay, or prescription drugs. Let's say your health plan has a $20 copayment for doctor visits. If the visit costs $100, you pay $20. Your health plan pays the remaining $80.  

covered benefit

A medical service or supply that your health plan pays for. 



The amount you pay for medical services or products before your health insurance pays. Let's say you have a $1,000 deductible for hospital stays. Your hospital bill is $5,000. You pay $1,000 to meet the deductible and your health plan pays the plan benefit for covered services.


People who can receive health care coverage under your health plan, such as a spouse or child.

dual coverage

Coverage through two health insurance plans. If you have two jobs, for example, you could be covered by both employers. If you're married, you and your spouse could be covered by both employers.


electronic health record (EHR)

Your medical records and health history filed in a computer to help doctors provide you proper care. 

eligible charge

The maximum amount that a doctor or hospital charges, based on an agreement between the provider and health insurer. Let's say your doctor charges $100 for office visits, which is called the "actual" charge. If your health insurer negotiated a $75 eligible charge for doctor visits, the doctor can only charge $75. You then pay a portion of the eligible charge through a copayment or coinsurance. Your insurer pays the rest.     


A government website, or virtual marketplace, that allows people not covered through their job to shop for health insurance at competitive rates. Established under health care reform, the exchange is set to open by 2014. 


family plan

A health plan that covers you and your dependents, such as your spouse and children.

flexible spending account (FSA)

A savings account set up by an employer that employees can use to save pre-tax dollars and pay for medical or dependent care. Employees lose unspent money in the account at the end of the year.


A list of prescription drugs that are paid for by your drug plan.

for-profit insurer

Insurance companies that run their business to make a profit for shareholders or investors.


general practitioner

Your primary care provider (PCP) or regular doctor who you see most often for physicals, check-ups, and minor injuries and illnesses like a cold or flu. 

generic drug

A drug that works the same as a brand-name drug, but costs less because it does not have the same expensive research and advertising costs.


Hawaii Prepaid Health Care Act

A 1974 Hawaii law that requires companies to offer health insurance to their employees who work 20 hours or more a week for four weeks in a row. Companies may pay the entire cost of the premium or share the cost with their employees. Employers pay at least half of the premium for single coverage; the employee pays the rest, as long as the employee's share is not more than 1.5 percent of their wages.

health care reform

Called the Affordable Care Act (ACA), this law to reform the nation's health care system was signed by President Barack Obama in March 2010 to help more people get affordable, quality health care.  

health center

A group (or network) of doctors, hospitals, and clinics where you receive health care if you're in an HMO. Your health center contains your primary care provider and other specialty doctors and labs.

health maintenance organization (HMO)

A type of health plan with a network of hospitals and doctors that HMO members go to for health care. HMO members select a primary care provider and health center in this network to coordinate their care. You will pay more if you go to doctors and hospitals outside the HMO.

health plan

A way to receive and pay for health care services as established by health insurers or the government. Types of health plans include PPOs, HMOs, high-deductible health plans, and Medicare.

health reimbursement arrangement (HRA)

An account set up by an employer to pay for an employee's out-of-pocket medical costs. Only the employer can put money into an HRA.  

health savings account (HSA)

An account set up by an employer or individual to save money tax-free for medical expenses. The balance at the end of the year is "rolled over" to the next year.

health screening

Medical tests that detect certain health conditions like diabetes, cancer, or heart disease. They include mammograms for breast cancer, colonoscopies for colon cancer, and blood glucose tests for diabetes.

high-deductible health plan

A type of health plan with a high deductible, or amount you pay for health care services before your health plan begins paying. This plan typically has higher out-of-pocket costs and lower premiums.


individual plans

Health plans for people who don't have health insurance through a job. You typically pay the entire amount of the premiums, or monthly costs. 


A medical doctor who practices internal medicine and treats adults for a wide range of diseases.


mail-order prescription

A prescription drug that you can order through the mail instead of the pharmacy. Mail-order programs deliver a three-month supply of drugs taken long-term for chronic conditions, such as high blood pressure or high cholesterol. 


A combined state and federal program that gives health care to low-income people, including children, pregnant women, or people with a disability. Medicaid often pays for long-term care, such as nursing home care. 


A federal government program that gives health care to people age 65 and older or with a disability. It includes coverage for hospital (Medicare Part A), medical (Medicare Part B), and prescription drugs (Medicare Part D). Medicare Part A and B together are known as Original Medicare. Additional benefits can be provided through a Medicare Advantage plan (Medicare Part C). 

Medicare Advantage

A Medicare health plan offered by private insurers to provide hospital (Medicare Part A) and medical (Medicare Part B) coverage. It typically offers more benefits than Original Medicare. Also known as Medicare Part C.


negotiated rate

The fee a provider charges patients in a health plan. Your health insurer has a contract with the provider to charge this set lower rate, similar to a group discount. You must see a participating provider to get the negotiated rate.

nonparticipating provider

A doctor, hospital, pharmacy, lab, or health center that does not have a contract with your health plan to charge a set fee for services. It usually costs more to see a nonparticipating provider because they aren't limited to charging you a certain amount. 

nonprofit insurer

A health insurer whose goal is to break even (rather than gain money) each year. Premiums are determined by this goal, so nearly all member dues pay for health care expenses. A nonprofit is run by a board of community leaders, and some income from investments and reserves is used for community wellness programs.  


out-of-pocket costs

Expenses for medical care that aren't reimbursed by insurance. These include deductibles, coinsurance, and copayments.


participating provider

A doctor, hospital, pharmacy, lab, or health center that has a contract with your health plan to charge a set negotiated rate for services. It's almost always cheaper to see a provider that participates with your plan.

patient-centered medical home (PCMH)

Care that focuses on the quality of care you get, not the quantity. A team of providers works together to manage all of your health needs, so you get more well-rounded, personalized care. 

pharmacy benefit management (PBM) services

Services provided by a company to manage pharmacy benefits for a health plan. These services generally include processing and paying drug claims, developing the list of drugs that the plan will pay for, contracting with pharmacies in the network, and negotiating discounts and rebates with drug companies. 

preferred provider organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a large network of participating providers. You pay less if you see providers in the plan's network.


A monthly payment you make to your health insurer for insurance. Your employer may pay part or all of these payments for you.

preventive care

Routine health care that includes screenings, check-ups, and counseling to help prevent diseases or other health problems.

primary care provider (PCP)

A doctor or other provider who treats you for common illnesses, manages your preventive care and wellness, and refers you to a specialist when necessary. It's ideal to establish a long-term relationship with a PCP to get the best care.  



Hawaii's Medicaid program. The state pays a health insurer to give insurance to eligible low-income families and children, pregnant women, the elderly, and people with disabilities.


single plan

A health plan that covers just one person (not dependents like a spouse or children).


A provider who is an expert in a specific area of medicine, such as a podiatrist (foot doctor). Contact your health plan to find out if you need a referral from your primary care provider to see a specialist. 

supplemental insurance

Extra insurance you can buy for medical expenses not covered by your health insurance. This could include chiropractic care and acupuncture.

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