Deductible Excluded Services An amount you could owe Health care services that your plan doesn’t pay for or during a coverage period cover. (usually one year) for covered health care Formulary services before your plan A list of drugs your plan covers. A formulary may begins to pay. An overall include how much your share of the cost is for each drug. deductible applies to all or Jane pays Her plan pays Your plan may put drugs in different costsharing levels almost all covered items 100% 0% or tiers. For example, a formulary may include generic and services. A plan with (See page 6 for a detailed drug and brand name drug tiers and different cost an overall deductible may example.) sharing amounts will apply to each tier. also have separate deductibles that apply to specific services or groups of services. A plan may also have only Grievance separate deductibles. (For example, if your deductible is A complaint that you communicate to your health insurer $1000, your plan won’t pay anything until you’ve met or plan. your $1000 deductible for covered health care services subject to the deductible.) Habilitation Services Diagnostic Test Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples Tests to figure out what your health problem is. For include therapy for a child who isn’t walking or talking at example, an x-ray can be a diagnostic test to see if you the expected age. These services may include physical have a broken bone. and occupational therapy, speech-language pathology, Durable Medical Equipment (DME) and other services for people with disabilities in a variety of inpatient andor outpatient settings. Equipment and supplies ordered by a health care provider for everyday or extended use. DME may include: oxygen Health Insurance equipment, wheelchairs, and crutches. A contract that requires a health insurer to pay some or Emergency Medical Condition all of your health care costs in exchange for a premium. A health insurance contract may also be called a “policy” An illness, injury, symptom (including severe pain), or or “plan.” condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If Home Health Care you didn’t get immediate medical attention you could Health care services and supplies you get in your home reasonably expect one of the following: 1) Your health under your doctor’s orders. Services may be provided by would be put in serious danger; or 2) You would have nurses, therapists, social workers, or other licensed health serious problems with your bodily functions; or 3) You care providers. Home health care usually doesn’t include would have serious damage to any part or organ of your help with non-medical tasks, such as cooking, cleaning, or body. driving. Emergency Medical Transportation Hospice Services Ambulance services for an emergency medical condition. Services to provide comfort and support for persons in Types of emergency medical transportation may include the last stages of a terminal illness and their families. transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or Hospitalization may pay less for certain types. Care in a hospital that requires admission as an inpatient Emergency Room Care / Emergency Services and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient Services to check for an emergency medical condition and care instead of inpatient care. treat you to keep an emergency medical condition from getting worse. These services may be provided in a Hospital Outpatient Care licensed hospital’s emergency room or other place that Care in a hospital that usually doesn’t require an provides care for emergency medical conditions. overnight stay. Glossary of Health Coverage and Medical Terms Page 2 of 6