Common Terms

Advance Health Care Directive—a signed form that tells your doctor and your family and close friends what kind of care you want and who can make decisions for you if you cannot speak for yourself

AIM—a state program that covers health care for low-income pregnant women whose income is too high to get Medi-Cal or whose health insurance would make them pay more than $500 for care during pregnancy

Benefit—a service your health insurance covers. For example, emergency care and preventive care are common benefits.

California Children's Services—a state program that helps pay for treatment for children with chronic conditions or diseases and for children with physical limitations

Child Health and Disability Prevention Program (CHDP)—a state program that provides checkups and shots for children with low incomes

COBRA/Cal-COBRA—laws that let you stay on your group health plan for up to 36 months if you loose your job, your hours are cut, or you retire

Co-insurance—a percent of the cost of a service that you must pay each time you see a doctor, get a prescription, or get other services

Complaint—a request asking your health plan to solve a problem or change a decision about your care. Also called an appeal or a grievance.

Consent form—a form you sign before you get treatment. When you sign the form, you are saying that you understand what will be done and that you agree to it.

Co-pay/co-payment—a flat fee you pay each time you see a doctor, fill a prescription, or get other services

Emergency care—care you need right away. It is an emergency if you reasonably believe that not getting care right away could be dangerous to your life or to a part of your body.

Evidence of Coverage (EOC)—a written guide from your health plan that explains what the plan does and does not cover and the rules you must follow for getting care

Flexible spending account—a short-term savings account that lets you set aside pre-tax income and use it to pay for health care or child care during the year

Formulary—a list of the prescription drugs your health plan pays for

Generic drug—a drug that costs less because no company owns the patent on it or can set the price

Group coverage—health insurance you get through your job

Healthy Families—a state program that covers health care for children in families with a low income

HIPAA—a law that protects your right to buy individual health insurance after you use up your COBRA/Cal-COBRA

HMO—a kind of managed care plan in which you must get all your health care services from the doctors and other providers in the network. HMO stands for health maintenance organization.

HMO Help Center—a state program within the Department of Managed Health Care that provides assistance to people to help them understand their health care benefits and rights and solve problems with their HMO or Blue Cross/Blue Shield PPO

IMR (Independent Medical Review)—a no-cost review of your case by doctors who are not part of your health plan who decide whether your HMO must give you the treatment you need after the HMO has denied you. You can apply for an IMR through the Department of Managed Health Care’s HMO Help Center.

Individual coverage—health insurance you buy yourself

Inpatient care—care for which you are in a hospital for at least 24 hours

Medi-Cal—California's program to help people with low incomes get health care services. Services are free or low-cost, depending on your income.

Medical group—a group of doctors who have a business together. Medical groups include primary care doctors, specialists, and other providers.

Medicare Advantage—managed care health plans for people who have Medicare

Member Services/Customer Service—a number at your HMO you can call to get answers to questions about your plan or help with a problem getting care

Network—all the doctors, medical groups, labs, hospitals, and other providers that work for the HMO or PPO or have a contract with it

Open enrollment—the period each year during which you can join a plan or change plans if your employer offers more than one plan

Outpatient care—care that does not require an overnight stay in a hospital

PPO—a kind of managed care plan in which you can choose to get your health care from the doctors and other providers in the network or go outside of the network and pay a higher cost. PPO stand for preferred provider organization.

Pre-approval — permission from your medical group or health plan to get a service that requires a referral from your doctor. Also called authorization or prior-authorization.

Pre-existing condition—an illness or injury you have before you join a health plan

Premium—what your health plan charges each month to maintain your health care coverage

Preventive care—care, like tests and exams, that helps your doctor prevent problems or find them before they become serious. Also called routine care.

Primary care doctor—your main doctor who gives you most of your care and refers you for other services when you need them. Also called a primary care physician or PCP.

Provider—a trained medical professional, clinic, lab, hospital, or other health care facility that gives you health care services

Referral—a slip you must have from your doctor before you can get care from a specialist, a screening test, or other care that your doctor cannot give you

Second opinion—advice from a second doctor about your choice of treatments or the cause or nature of your illness. A second opinion can be within your plan or outside the network if you have a referral from your doctor and approval from your plan.

Side effect—a symptom that is the result of a medication you take or a treatment you have

Specialist—a doctor who has extra training in one field of medicine, such as care for people with heart problems or for women who are pregnant

Standing referral—a referral that allows you to see a specialist without getting a referral from your primary care doctor each time

Summary of Benefits—a short list of your benefits and costs

Urgent care—care you need soon, usually within 24 hours, for a medical situation that is serious but is not an emergency

Yearly deductible—the amount you must pay each year before your health plan starts to pay. Also called annual deductible.

Yearly out-of-pocket maximum—the most you have to pay for most health care services in a year. In some cases, you may still have to pay co-pays for some services.

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