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A sudden, unforeseen event that causes trauma to the body.

Adverse Benefit Determination

A decision by a health insurer to deny, reduce or terminate a requested health care service or payment in whole or in part, including all the following:

  • A determination that the health care service does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, including experimental or investigational treatments.
  • A determination of an individual’s eligibility for individual health insurance coverage, including coverage offered to individuals through a non-employee group, to participate in a plan or health insurance coverage.
  • A determination that a health care service is not a covered benefit.
  • The imposition of an exclusion, including exclusions for pre-existing conditions, source of injury, network or any other limitation on benefits that would otherwise be covered.
  • Not to issue individual health insurance coverage to an applicant, including coverage offered to individuals through a non-employer group.
  • To rescind coverage on a health benefit plan.

Annual Open Enrollment

The annual period during which an individual may enroll himself or herself and his or her eligible dependents in a health insurance plan.


An action you take if you disagree with a health insurer’s decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with the insurer’s decision to stop services that you are receiving. For example, you may ask for an appeal if the insurer doesn’t pay for a drug, item or service you think you should be able to receive.

Balance Billing

When a provider (such as a doctor or hospital) bills a patient more than the plan’s allowed cost-sharing amount.

Billed Charges

The non-discounted schedule of charges for services that the health care provider would use to invoice a patient for services rendered.

Brand Name Drug

A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Contract Year

The 12-month period beginning on the effective date or any renewal date of the contract between SummaCare and you.


An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%).

Coordination of Benefits

The provision that applies when a person is covered under more than one group medical program. It requires that payment of benefits will be coordinated by all programs to eliminate over insurance or duplication of benefits.


An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Cost Sharing

Amounts you have to pay when services or drugs are received. (This is in addition to the plan’s monthly premium.) Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific service or drug is received; or (3) any “coinsurance” amount a plan requires when a specific service or drug is received. A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. For example, if your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your daily cost-sharing rate is $1 per day. This means you pay $1 for each day’s supply when you fill your prescription.

Covered Benefits

Health care services to which a covered person is entitled under the terms of the health benefit plan.

Covered Person

An eligible person who enrolls and is eligible for and receives covered benefits under the plan.

Custodial Care

Care comprised of services and supplies, including room and board and other institutional services, that is provided to an individual, whether disabled or not, primarily to assist in the activities of daily living.


The amount you must pay for health care or prescriptions before your health plan begins to pay.


Any negotiated reduction or variation from the schedule of billed charges (including capitation) that a health care provider otherwise would require a patient and/or the patient’s third party payer to pay to that provider.

Durable Medical Equipment (DME)

Certain medical equipment that is ordered by your doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider for use in the home.

Emergency Medical Condition

A medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual or that of a pregnant woman or her baby in serious jeopardy; serious impairment to body functions; or serious dysfunction of any body organ or part.

Emergency Services

Health care services available seven days per week, 24 hours per day in order to prevent jeopardy to a covered person’s health status, which would occur if such services were not received as soon as possible including, where appropriate, ambulance transportation and indemnity payments for out of area coverage.

Episode of Illness or Injury

A period of consecutive days beginning with the first day (not included in a previous Episode of Illness or Injury) on which a member is furnished health care services for a single diagnosis and any conditions directly related to the diagnosis, and ending with the last day in which the member is furnished healthcare services related to that diagnosis and any condition directly related to that diagnosis.

Essential Health Benefits

These include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services including oral and vision care. Essential health benefits are not subject to lifetime or annual dollar maximums, but are subject to the terms and conditions permitted under federal law as set forth in your policy.

Expense Incurred

An expense results when the service or the supply for which it is charged is actually provided.

Family Coverage

Coverage for you and one or more of your eligible dependents.

Generic Drug

A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.


A type of complaint you make about a health insurer or pharmacy, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Home Health Aide

A person who provides care of a medical or therapeutic nature and reports to and is under the direct supervision of a Home Health Care Agency.

Home Health Care Agency

A public or private agency or organization, or part of one, that mainly provides skilled nursing and other therapeutic services. It must be legally qualified in the state or locality in which it operates. It must keep clinical records on all patients. The services must be supervised by a physician or registered nurse, and they must be based on policies set by associated professionals, which include at least one physician and one registered nurse.

Home Health Care Plan

A plan for continued care and treatment of a covered person in his or her home. To qualify, the plan must be established in writing by a participating physician who certifies that the covered person would require confinement in a hospital if he or she did not have the care and treatment stated in the plan. The Home Health Care Plan is subject to review and prior approval by the SummaCare Health Services Management Program.

Hospice Care Agency

An agency or organization properly licensed in the state in which it operates, has terminal care available 24 hours a day, 7 days a week and provides or arranges for hospice care services or supplies.

Hospice Care Plan

A plan that is supervised by a participating physician and involves a team consisting of:

  • A participating physician who provides hospice care;
  • Licensed nurses;
  • A licensed mental health specialist;
  • A licensed social worker.

The hospice care plan must:

  • Provide the patient’s plan of care;
  • Provide regular reviews of the patient’s care;
  • Inform the proper persons of any change in the patient’s condition; and
  • Comply with governmental regulations.

Hospice Facility

A facility that is properly licensed in the state in which it operates and is engaged mainly in providing palliative care to terminally ill patients.


An institution that:

  • Provides medical care and treatment of sick and injured persons on an inpatient basis;
  • Is properly licensed or permitted legally to operate as such;
  • Has a physician on call at all times;
  • Has licensed graduate registered nurses on duty 24 hours a day;
  • Maintains facilities for the diagnosis and treatment of illness and for major surgery; and
  • Meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

In no event will the definition of hospital include an institution or any part of one that is a convalescent/extended care facility, or any institution, which is used primarily as:

  • A rest facility;
  • A nursing facility;
  • A facility for the aged; or
  • A place for custodial care.


Any physical or mental sickness or disease that manifests treatable symptoms and that requires treatment of a physician. This definition also includes pregnancy.


Any bodily damage or harm sustained while the person is covered under the plan and that requires treatment by a physician.


A life insurance company, sickness and accident insurer, multiple employer welfare arrangement, public employee benefit plan or health insuring corporation.

Maximum Allowable Charge

The amount billed for covered services for which benefits are available under the contract.

Maximum Out-of-Pocket Amount

The most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums and prescription drugs do not count toward the maximum out-of-pocket amount.


A joint federal and state program that helps with medical costs for some people with low incomes and limited resources.

Medically Necessary

The classification given to services, supplies and drugs needed for the prevention, diagnosis or treatment of your medical condition that meet accepted standards of current medical practice. The fact any provider may prescribe order, recommend or approve a service or supply does not, of itself, make that service medically necessary.

A service or supply will not be considered as medically necessary if:

  • It is provided only as a convenience to the covered person;
  • It is not appropriate treatment for the covered person’s diagnosis or symptoms;
  • It exceeds (in scope, duration or intensity) that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment.


The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE (Program of All-Inclusive Care for the Elderly) plan, or a Medicare Advantage Plan.

Medicare Advantage Plan (or Medicare Part C)

A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. Medicare services are covered through this plan and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Medicare Part D

The voluntary Medicare Prescription Drug Benefit Program. See your formulary for a specific list of drugs covered under Part D.


A group of health care providers that have contracted with a health insurer to provide covered services at a discount and accept the discounted price as the full payment for those services.


A covered person who is treated on a basis other than as an inpatient in a hospital or other covered facility. Outpatient care includes services, supplies and medicines provided and used at a hospital or other covered facility under the direction of a physician to a person not admitted as an inpatient.

Participating Physician, Practitioner or Other Provider

Any physician, hospital, or other health services physician, practitioner or other provider who has a contract with a health insurer to provide covered services to covered persons.


A legally qualified person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).


Doctor of Dental Surgery (D.D.S.); Doctor of Podiatry (D.P.M.); Licensed Clinical Psychologist (Ph.D.); Certified Nurse Midwife (C.N.M.) acting within the scope of his or her license, under the direction and supervision of a licensed physician; Physician Assistant (P.A.); Licensed Social Worker (L.S.W.); or Licensed Physical Therapist (L.P.T.) or Licensed Speech Therapist (L.S.T.) acting within the scope of his or her license, and performing services ordered by a Doctor of Medicine or a Doctor of Osteopathy.

Preferred Provider

Any physician, practitioner or other provider who has a contract with a health insurer to provide covered services to covered persons.


The periodic payment to Medicare, an insurance company or a health care plan for health or prescription drug coverage.

Primary Care Physician

The doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them.

Prior Authorization

Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets “prior authorization” from our plan.

Prosthetics and Orthotics

Medical devices ordered by your doctor or other health care provider to replace an internal body part or function. These include, but are not limited to, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed, including ostomy supplies and enteral and parenteral nutrition therapy.


A person or organization responsible for furnishing health care services, including a hospital, skilled nursing facility, rehabilitation facility, ambulatory surgery center or physician.

Reasonable and Customary Charges (R&C)

Charges made for medical services or supplies that are the amount normally charged by the physician, practitioner or other provider for similar services and supplies, and do not exceed the amount ordinarily charged by most physicians, practitioners or other providers of comparable services and supplies in the locality where the services or supplies are received.

Rehabilitation Services

Services such as physical therapy, speech and language therapy and occupational therapy.

Room and Board

Charges made by a hospital or other covered institution for the cost of the room, general duty nursing care, and other services routinely provided to all inpatients, not including special care units.

Routine Patient Care

All health care services consistent with the coverage provided in the health benefit plan or public employee benefit plan for the treatment of cancer, including the type and frequency of any diagnostic modality, that is typically covered for a cancer patient who is not enrolled in a cancer clinical trial, and that was not necessitated solely because of the trial.

Semi-private Charge

The charge made by a hospital for a room containing two or more beds not including the charge made by the hospital for special care units.

Skilled Nursing Facility

Any institution, other than a hospital, which meets all of the following requirements:

  • Maintains permanent and full-time facilities for bed care of 10 or more resident patients;
  • The services of a physician;
  • Has a registered nurse (R.N.) or physician on full-time duty in charge of patient care, and one or more registered nurses (R.N.s) or licensed vocational nurses (LVNs), or licensed practical nurses (LPNs) on duty at all times;
  • Maintains a daily medical record for each patient;
  • Is primarily engaged in providing continuous skilled nursing care for sick or injured persons during the convalescent stage of their illness or injury;
  • Is operating lawfully as a convalescent/extended care facility in the jurisdiction where it is located or meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations; and
  • Has a written agreement with at least one other hospital providing for the transfer of patients and medical information between the hospital and convalescent/extended care facility. In no event, however, will a convalescent/extended care facility include an institution, which is primarily: (a) a place for rest; (b) a place for the aged; (c) a place for drug addicts, alcoholics, the blind or deaf; (d) a place for the mentally ill or retarded; or (e) a hotel or similar place.

Special Care Units

A specific hospital unit providing concentrated special equipment and highly skilled personnel for the care of critically ill patients requiring immediate, constant and continuous attention. This term will include charges for intensive care, coronary care and acute care units of a hospital but does not include care in a surgical recovery or post-operative room. The unit must meet the required standards of the Joint Commission on Accreditation on Healthcare Organizations (JCAHO) for special care units.

Urgent Care

Services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.

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