Glossary

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Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing (activities of daily living).

A federal act which sets guidelines for Medicare and insurers.

A limited time period in which enrollment applications for coverage elections or changes may be made. Certain changes such as adding a spouse upon marriage or adding a newborn child may be made at any time during the year.

The physician or other provider who specifically prescribes the health care service being reviewed.

The use of health care providers who have not contracted with the health plan to provide services. Depending on your contract, out-of-network services may not be covered. Please refer to your contract for specific benefit coverage.

Reimbursement for covered services provided by out-of-network providers and suppliers. Out-of-network benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket costs. Depending on your contract, out-of-network services may not be covered. Please refer to your contract for specific benefit coverage.

Expenses that plan members must pay with their own money as part of their health coverage. Such costs as a rule include deductibles, copayments and coinsurance.

The maximum dollar amount per calendar year of co-insurance expenses payable by you for covered medical services rendered by out-of-network providers.

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

Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.