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.

Employment income covered by the hospital insurance (HI) program.

All employment and self-employment creditable for Social Security purposes, except in a few employment situations (e.g., religious orders under a vow of poverty, foreign affiliates of American employers), or the employer must elect state and local government coverage. However, as of July 1991 coverage became mandatory for state and local employees who do not participate in a public employee retirement system. All new state and local employees have been covered by Social Security since April 1986 except ministers or self-employed members of certain religious groups who can opt out of coverage. Covered employment for hospital insurance includes all federal employees, whereas covered employment for the Old Age, Survivors, and Disability Insurance (OASDI) Program includes some, but not all, federal employees.

1. Under the Health Insurance Portability and Accountability Act (HIPAA), this is a health plan, clearinghouse, or health provider who transmits health information and financial and administrative transactions in electronic form in connection with a HIPAA transaction. 2. From the perspective of the medical transcription service owner or independent contractor, the covered entity is the client. The CE is responsible for the protection of health information and, if there is a violation, can request documentation from its business associates to prove their compliance.

Defined health care charges that an insurer will consider for payment as listed in the terms of an insurance policy or contract. Also called covered services or coverage.