Health Insurance Glossary

Schedule of Allowances
List of dollar amounts payable for medical and surgical procedures performed by a provider.
Second Opinion
The option or recommendation to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
Second Surgical Opinion (SSO)
Included among the features of Medical Management programs, SSO provides coverage for a second opinion from a qualified surgical specialist to group members seeking elective surgery. Mandatory SSO requires that group members seek the second opinion.
Separate/Stacked Out-of-Pocket Maximum
For individuals: the maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a calendar year for covered expenses. Once the out-of-pocket is met by the member, the plan pays 100 percent of the allowed amount for covered services for the rest of the benefit period.

For families: when one family member meets the individual out-of-pocket maximum dollar amount, his or her services will be covered at 100 percent up to the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must be met before the services for all remaining family members will be covered at 100 percent.
Self-Insurance
Practice of an individual, group of individuals, employer or organization that assumes complete responsibility for losses, which might be insured against, such as health care expenses. In effect, "self-insured" groups have no real insurance against potential losses and instead maintain a fund out of which is paid the contingent liability subject to self-insurance.
Service Area
The geographic area in which a health plan delivers health care through a contracted network of participating providers.
Service Description
A description of the services performed.
Skilled Nursing Facility (SNF)
A licensed institution (or a distinct part of a hospital) that provides continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
Specialist
A participating physician who provides non-routine care, such as a dermatologist or orthopedist.
Speech Therapy
Treatment of the correction of a speech impairment, which resulted from birth, disease, injury or prior medical treatment.
Step Therapy
A program designed to help you save on prescription drug costs. It ensures you receive a lower-cost but equally effective drug before “stepping up” to more expensive medication(s). If your doctor believes your treatment plan should begin with a more expensive drug, they may need to submit an authorization request to have it approved before it can be covered.
Subscriber
The employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract. See Policyholder.
Substance Abuse/Chemical Dependency
The use of any drug for purposes other than those for which it is normally intended or in a manner or in quantities other than directed. Chemical dependence is the compulsion to continue taking a drug to produce desired effects or to prevent the onset of ill effects that occur when it is not taken.
Summary of Benefits
An overview of how the total charges were considered in processing this claim.

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