Determination by a health plan or insurance company whether to pay for or provide a medical service for specific clinical manifestations.

Month, day, and year on which a group’s or individual’s health insurance coverage starts. Also called enrollment date.

Under a Medicare Part D plan, the step in which the patient pays all of the expenses for eligible drugs, until he or she has spent $3850. This step is sometimes referred to as the doughnut hole, also spelled donut hole.

Illness or injury described in a health insurance plan that may limit insurance coverage on a procedure.

Several varieties (contract types) of health insurance benefit plans exist:1. Individual coverage is a plan in which only one person has been accepted into the health plan. Maternity care and obstetrical services are included as benefits, but routine newborn services are not included.2. Family coverage is for the subscriber and the spouse who have been accepted into the health plan. Maternity care, obstetrical services, and routine newborn services may be included as benefits.3. Family coverage with dependents is a plan that covers maternity care, obstetrical services, and routine newborn services to the subscriber but not to the children.4. Family coverage is a plan in which the subscriber, spouse, and subscriber’s or spouse’s enrolled dependents who are his or her children are in the health plan. Maternity care, obstetrical services, and routine newborn services are benefits to the subscriber or the subscriber’s spouse but not to the children.A significant other rather than spouse is a newer change to the coverage terminology. Also known as contract type.

Medically necessary health care service or item that is included in a health insurance plan and that is paid for either partially or fully. Some medically necessary services may not be a benefit of an insurance policy (e.g., custodial care may be necessary but not covered). Also called covered services.

Dollar amounts for medical services and supplies that the insurance plan will pay either partially or fully because they are covered benefits.

Medication that a health insurance plan will pay a pharmacy when the drug is dispensed to a member or subscriber of the plan.