To speak, write, and argue in favor of something — such as health-care needs. As a noun, "advocate" means a person who does those things.
Alternative or complementary care
Non-medical health-care interventions such as massage therapy, naturopathy, chiropractic, and acupuncture.
Capitation
A contracted payment that a physician receives from an insurance company for providing health care. This payment is usually a set amount per member per month. The physician is paid whether or not
the patient receives medical services.
Claim
The bill for health-care services that is submitted to an insurance company for payment.
Co-insurance
The amount of charges that you must pay on a claim, i.e., the portion of the claim that your insurance does not cover.
Copay
A set amount that you must pay when you get a doctor's prescription filled at a pharmacy, i.e., the portion of the cost of the prescribed medicine that your insurance company requires you to pay.
Complaint
A written expression of dissatisfaction that includes a request for a response that can be sent to your health-care provider, insurance company, or the Oregon Insurance Division.
Continuity of care
Continuing care for a limited period, at the insurer's expense, from a provider who has left the insurer's provider network.
Coordination of benefits
When two or more companies insuring the same patient work together to pay medical bills.
Creditable coverage
Insurance coverage that a person has just before starting coverage under a new policy.
Deductible
An amount you must pay out-of-pocket for health care before an insurance company begins to pay your claims. Some plans do not have deductibles.
Enrollee
A person enrolled in an insurance plan. The policy may be paid for by the enrollee or someone else.
ERISA
Employee Retirement Income Security Act, a federal law that covers most private, self-insured benefit plans through which employers provide health care and other benefits to employees.
Exclusions and limitations
Medical conditions and services and some illnesses and causes of accidents that a health-insurance plan will not pay for.
External review
Decision by an independent review organization certified by the state in a dispute between a patient and an insurer.
Formulary
A list of prescription medications covered by an insurance company.
Gag clause
An insurance company's requirement that physicians not tell patients about medical-treatment options that the company does not cover. Gag clauses are unlawful.
Grievance
A written expression of dissatisfaction that includes a request for a response. It can be sent to your health-care provider or insurance company.
Health-benefit plan
Comprehensive health insurance or medical insurance.
Network
The doctors and clinics authorized by an insurer to provide health care to the patient members of a managed-care group.
Pre-existing condition
A medical problem or illness that you had before your insurance policy took effect.
Premium
A monthly fee paid to an insurance company for coverage.
Policyholder
A person or employer who pays the premiums for an insurance contract or policy.
Preauthorization
A written promise, which may include some conditions, from an insurer to pay for a specific medical treatment for a patient who made the request.
Proprietary
Information that a company considers a trade secret that it will not disclose to the public.
Self-insured health plan
A method some employers use to pay for employee health care instead of buying health insurance from an insurance company.
Service area
The geographical area in which an insurance company offers coverage and in which it has contracted providers.
Utilization review
A process that insurance companies use to reduce their costs by paying only for medically necessary services.
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