Medicare Health Care Glossary

General Health Care Glossary

Health plan approval necessary prior to the receipt of care.

Certificate of Creditable Coverage
A written certificate issued by a group health plan or health insurance plan that states the period of time you were covered by your health plan.

The amount you may be required to pay for services after you pay any plan deductibles. This is typically a percentage of the allowed cost of the service provided.

Coordination of Benefits
The method for determining which insurance company is primarily responsible for payment of services when a Member is covered under more than one policy.

The amount you pay for a medical service, such as a doctor visit, lab, x-ray, prescription, etc. This is usually a set amount according to your benefit plan.

The amount you must pay for health care or prescriptions, before your prescription drug plan or insurance plan begins to pay if your plan has a deductible. Not every benefit may apply to your deductible.

Disposable Medical Supplies
Any medical equipment this is used only once, or a limited number of times before being disposed of. Examples: diabetic testing supplies, ostomy supplies, or needles.

Durable Medical Equipment
Medical equipment that is ordered by a doctor for use in the home. Examples: walkers, wheelchairs, or hospital beds.

Emergency Care
Any care your reasonably believe is an emergency or when you believe that your health is in serious danger. You should use the Emergency Room when your condition is so serious that you are not able to call your Primary Care Physician (PCP), you call your PCP and he or she tells you to go to the Emergency Room, or you are so sick or badly hurt that you feel you may be seriously harmed if you don’t get help right away.

Explanation of Benefits (EOB)
An EOB may be sent to you each time you receive services. The EOB will detail services received and show you amounts owed, by you, for these services. You will receive an EOB monthly but only if services were paid by RMHP within the previous month. Some plans may not receive and EOB.

A list of drugs covered by your health benefit plan.

Health Insurance Portability and Accountability Act (HIPAA)
Health Insurance Portability and Accountability Act of 1996: U.S. government legislation that ensures a person's right to buy health insurance after losing a job, establishes standards for electronic medical records, and protects the privacy of a patient's health information.

Inpatient Care
Health care that you get when you are admitted to a hospital or skilled nursing facility.

Medically Necessary
Services or supplies that are needed for the diagnosis and/or treatment of your medical condition.

Member Billing Statement (MBS)
A MBS shows you the health care services you or a dependent may have received and the deductibles or copayments due to RMHP. Your MBS is mailed monthly and only if services have been considered for payment within the previous month. The provider of service will have already been paid and your Member responsibility is owed directly to RMHP. Some plans may not receive and MBS.

Non-Formulary Drugs
Drugs not on a plan-approved drug list (Formulary).

Providers who do not contract with RMHP or are located out-of-state are non-participating and a preauthorization may be needed in order for RMHP to consider payment of claims.

Out-of-pocket Maximum (annual)
This is the maximum amount that you pay per plan year if your benefit covers an out-of-pocket maximum. This does not include plan premiums. This may include deductibles. RMHP provides coverage-in-full after you have met your annual out-of-pocket maximum.

Outpatient Hospital Care
Medical or surgical care furnished by a hospital, when you have not been admitted to the hospital

Providers contracting with RMHP are considered in-network for our Members to see.

A preauthorization is permission to see a provider for certain services that require review and approval prior to receiving those services. A preauthorization is usually required, based on your plan type, to see a non-participating provider.

The monthly cost of a health plan.

Primary Care Physician (PCP)
A doctor who is trained to give you basic care. Your PCP is the doctor you see first for most health problems. He or she makes sure that you get the care you need to keep you healthy and should be the primary point for health care needs.

Skilled Nursing Facility
A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services. This is not a long term or custodial care facility (nursing home).

A doctor who treats only certain parts of the body, certain health problems, or certain age groups.

Urgent Care
If your condition is enough to be of concern but not an emergency, you may go to an Urgent Care provider. These providers are available after hours and usually on weekends. Receiving urgent care is generally less expensive than going to the Emergency Room.