Glossary of Terms
We’ve included a glossary of health insurance terms that may be used here at Moffitt or with your health plans customer service representatives.
Affordable Care Act- Often called “health care reform,” this is a 2010 federal law that changed certain rules regarding health insurance coverage in the United States. For example, key provisions to extend coverage to uninsured Americans and lower healthcare costs. Learn more at healthcare.gov.
Associated Costs- Costs that are related to a cancer diagnosis but not specifically due to medical care given to treat the disease; also called non-medical costs. Transportation and childcare during treatment are two common associated costs for people with cancer.
Authorization- Written approval from your insurance carrier to receive medical care at Moffitt Cancer Center.
Cancer Resource Services (CRS)- Cancer Resource Services (CRS) is a program provided by United Healthcare that offers United Healthcare patients access to a network of premier cancer centers. United Healthcare patients should call CRS at 866-936-6002 to verify eligibility for this specialized coverage.
Carrier- An insurance company that issues policies and makes payments to medical providers for its members.
Children’s Health Insurance Program (CHIP)- A medical coverage source for individuals under age 19 whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage.
Claim- A request made to an insurance company to pay for services covered by a patient’s policy.
Clinical trial- A research study to test a new treatment or drug.
Consolidated Omnibus Budget Reconciliation Act (COBRA)- A federal law that allows employees in danger of losing health insurance under certain circumstances, such as leaving a job or reducing their hours, to pay for and keep their insurance coverage for a limited time. Learn more at healthcare.gov/unemployed/cobra-coverage
Co-Insurance- The amount (usually a percentage) of the healthcare costs for which you have to pay. You pay co-insurance even if your deductible has been met. For example, you may pay 20 percent of the cost of medical services after meeting the deductible.
Co-Payment- A set fee, in dollars, that an insurance provider requires a patient to pay each time care is received. For example, a visit to the oncologist may cost a patient $30 each time; the insurance provider pays the rest of the visit's costs. The amount of the co-pay is set by the insurance provider, not the doctor's office.
Deductible- The amount of approved health care costs an insured patient must pay out-of-pocket each year before the health care plan begins paying any costs.
Disability insurance- Insurance that provides an income on either a short-term or a long-term basis to a person with a serious illness or injury that prevents the person from working.
Health Exchange- A key provision of the Affordable Care Act, established to provide a selection of competing health insurance providers, each offering different qualified plans. All qualified plans must meet standards established and enforced by the federal government. Learn more at healthcare.gov
Health Maintenance Organization (HMO) - A managed care plan that requires its members to use the services of their network of physicians, hospitals, or other healthcare providers. If you’re a member of an HMO, you are required to choose a primary care physician who must provide you with a referral to see a specialist.
In-Network- Physicians, hospitals, or other healthcare providers who have a managed care contract with your insurance plan. The fees of these providers are covered by the plan. You may still be responsible for a co-payment.
Indemnity Health Plans- Also called a fee-for-service plan. An insurance plan that allows you to see medical providers of your choice. You are responsible for paying a percentage of total charges no matter which medical provider you see.
Long-Term Disability (LTD)- Insurance (LTD) helps replace some of your income for an extended period when you cannot work at all or can only work part-time because of a disability. To be covered by LTD, you or your employer must pay a monthly premium.
Managed Care- An insurance plan that contracts with a network of healthcare providers. Your financial responsibility is significantly less when provided in-network. EPOs, HMOs, POS, and PPOs are managed care plans.
Medicaid- A state program that provides medical benefits to eligible people who have a low income level as well as to people with disabilities. Learn more at cms.gov
Medicare- A federal health insurance program that covers the cost of hospitalization, medical care, and some related services for people 65 years or older and for people with disabilities. Learn more at medicare.gov
Medigap Insurance- Extra health insurance that you buy from a private company to pay health care costs not covered by Original Medicare, such as co-payments, deductibles, and health care if you travel outside the U.S. Medigap policies don't cover long-term care, such as stays in a nursing facility, or dental care, and vision.
Network- A group of physicians, specialists, hospitals, outpatient centers, pharmacies, and other providers who has signed a contract with an insurance company to provide healthcare services to their subscribers.
Non-Covered Procedure or Service- A medical procedure or service that an insurance plan considers medically unnecessary (or experimental) and therefore does not cover.
Out-of-Network- Health care providers or facilities that are not part of an HMO or PPO plan's approved list or network are considered “out of network” (as opposed to being on an approved list or “in network”). Out-of-network care often costs patients more than in-network care and may involve a deductible and require pre-approval for certain services.
Out-of-pocket Costs- Expenses that must be paid from a patient's personal financial resources; any expense not covered by insurance.
Patient Financial Clearance Unit- A team available to assist with authorization requests, status of authorization and benefits eligibility. Contact Information here
Point of Service (POS)- A health plan that contracts with a group of providers to offer medical services at discounted rates. When seeing an in-network specialist, such as an oncologist, you must obtain a referral from your primary care physician. POS plans allow you to seek care outside of the PPO network, but the insured party has a greater out-of-pocket expense.
Precertification- The process of requesting approval from an insurance plan for specific services before they happen, such as a treatment, procedure, or hospital stay; also called pre-approval. Many hospitals and clinics have precertification coordinators, patient navigators, or case managers who help patients with cancer through this process.
Preferred Provider Organization (PPO)- This is a type of private health insurance in which a person has access to a network of approved doctors, called in-network doctors. In PPOs, patients typically do not need a referral for specialist care.
Premium- The amount a person or company pays each month to keep insurance coverage.
Primary Care Physician (PCP)- A general or family practitioner who is your personal physician and first contact within a managed care system. The PCP will usually direct the course of your treatment and refer you to other doctors and/or specialists in the network if specialized care is needed.
Provider- Any medical professional (physician, nurse practitioner, etc.) or institution (hospital, clinic, etc.) that provides medical care.
Referral- In many managed care plans, you need to get a referral form before you get care from anyone except your primary care doctor. If you do not first get a referral, the plan may not pay for your care. Patients in HMO plans must also obtain authorization for treatment from the carrier prior to an appointment at an out-of-network facility.
Reasonable and customary fees- The average cost for health services in a geographic area that insurance plans use to decide how much they will pay for those services. If a doctor's fees for a service are higher than average, the patient must pay the difference.
Short Term Disability- Insurance can replace a portion of your income during the initial weeks of a disabling illness or accident. Policies can cover from the first 6 months up to a year of a disability, providing coverage during the waiting period of most Long Term Disability Insurance plans.
Specialist care- Healthcare given by a doctor who has been trained in treating a specific type of health problem or specific group of people. For instance, an oncologist is a doctor who specializes in treating cancer.
Supplemental insurance- A supplemental insurance policy helps cover expenses not covered by your primary insurance or the costs you pay as part of your existing plan. This policy generally covers deductibles, co-insurance, co-payments, and other out-of-pocket expenses. It may also offer additional benefits, such as compensation for lost earnings due to missed work.
Standard of Care- Items or services needed for reasonable and necessary care for diagnosis or treatment.
For more information call Moffitt's Patient Appointment Center (813-745-3980) or Cancer Answers (888-663-3488)