Term Definitions
With health insurance coverage, there are many terms that can be difficult to understand. Below is a list of words and meanings that you may come across as you use your CCHP health plan. For a complete list of health insurance terms and meanings, please click Healthcare.gov's glossary.
Calendar year: the period beginning January 1 and ending December 31.
Coinsurance: the percentage of expenses you pay for the calendar year after your deductible has been met.
Copayment (or copay): a fixed amount you pay for a specific health care visit or service. Your copay is generally a smaller amount than what the total cost of that office visit or service would be.
Covered services: services or supplies specified in your insurance contract, as well as any supplements, endorsements, addenda or riders, for which benefits are given, subject to the terms, conditions, limitations and exclusions of your contract.
Deductible: the total dollar amount you pay for medical services before your insurance plan begins to pay for services. Depending on the plan you have, premiums and copays don’t count toward your deductible.
Formularies: lists of generic and brand-name prescription drugs. A formulary also includes the coverage amount or copay you will need to pay for each prescription.
Inpatient: a patient who is being treated in a hospital/treatment facility and stays there for at least one full night.
Limits: Some insurance plans limit the amount of coverage you can get in a year for a specific treatment or service. For example, your specific plan may cover up to three mental health visits or up to [$X00] of speech therapy per year.
Medical emergency: An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. If you have a life-threatening emergency, call 911.
Member: the eligible person or dependent who is enrolled under Together with CCHP. Out-of-network provider: a licensed health care provider or medical facility that is not contracted with the health plan as a participating in-network provider with CCHP's BadgerCare Plus or Together with CCHP plan.
Out-of-pocket limit: This is the most you will have to pay for health care services during a policy period (usually 12 months) before your health plan pays 100% for covered benefits. Please note: the amount you spend on premiums doesn’t count toward your out-of-pocket limit.
Outpatient: Care one might receive in one of the following locations: a hospital department, ambulatory surgical facility, urgent care facility or physician's office where the patient leaves the same day.
Premiums: the dollar amount that needs to be paid by the members for an insurance plan. If you do not make your payments, your coverage will be canceled and you will no longer have health insurance coverage.
Primary care provider (PCP): a medical doctor (MD) or doctor of osteopathy (DO), a nurse practitioner, general practitioner, pediatrician, or internist as allowed under state law.
Referral: an order by a member's PCP asking and recommending that the member receive services from another physician in accordance with the terms of the member’s Schedule of Benefits.
Specialist: a medical doctor (MD) or doctor of osteopathy (DO) who specializes in a certain area of study, such as cancer or heart disease. Note: a family practitioner, general practitioner, pediatrician, and internist are not considered a specialist.
Urgent care: medical services provided by an urgent care facility in emergencies or after a doctor’s office hours.