Florida Healthy Kids - Definitions

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Insurance companies and health care professionals, like doctors and nurses, sometimes use uncommon words. They also sometimes use common words in different ways than you would normally hear in everyday conversation.

This section explains some words and phrases you may come across:

  • In the Florida Healthy Kids Member handbook;
  • When contacting Member Services; or
  • When taking your child to the doctor.

Appeal means a written request you make to your child’s health or dental insurance company to review the insurance company’s decision to deny a service or payment.

Copayment or Copay means a specified amount you pay to a health care provider, like a doctor, when your child receives services.

Covered Benefits or Covered Services means services, supplies, devices and other products a health or dental plan pays for as part of Florida Healthy Kids coverage.

Dental insurance means coverage that pays for some or all of an enrollee’s dental care services in exchange for a monthly premium.

Durable medical equipment (DME) means supplies and devices intended for repeated or continuous use over a long time that a provider prescribes to help treat a medical condition.

Emergency medical condition means an injury or illness, including severe pain, that needs care right away to avoid serious danger to your child’s life or pregnancy, or to avoid serious damage to your child’s health.

Emergency medical transportation means ambulance rides to a nearby hospital or medical facility to treat an emergency medical condition.

Emergency room care or emergency department care means services received at the emergency room of a hospital or at a standalone emergency room facility.

Emergency services means medical care your child receives to treat an emergency medical condition.

Enrollee means a child who is enrolled in a health or dental plan through Florida Healthy Kids.

Excluded services means health care services, supplies, devices, and other products that a health or dental plan does not pay for because they are not a covered benefit.

Grievance means a formal complaint you make to your child’s health or dental insurance company about some aspect of your child’s health care services. Habilitation services and devices means medical services and devices to help a patient learn, improve or keep skills or functions used for daily living.

Health insurance means coverage that pays for some or all of the cost of health care services for an enrollee in exchange for a monthly premium.

Home health care means home visits by a nurse to provide skilled nursing care prescribed by a doctor.

Hospice services means health care services to manage a terminal illness.

Hospitalization means care provided after inpatient admission to a hospital. Hospitalization usually means a patient will stay at the hospital overnight.

Hospital outpatient care means care provided in a hospital that does not require staying overnight or admission as an inpatient.

Medically necessary means treatment, services, equipment or supplies needed to diagnose, prevent or treat an injury or illness and which is:

  • Consistent with the symptoms, diagnosis, and treatment of an enrollee’s condition;
  • Provided in accordance with generally accepted professional medical standards and the health or dental plan’s medical coverage guidelines;
  • The most appropriate level of supply or service for the diagnosis and treatment of the enrollee’s condition;
  • Not primarily intended for the convenience of the enrollee, the enrollee’s family, or the health care provider; and
  • Approved by the appropriate medical body or health care specialty involved as effective, appropriate and essential for the care and treatment of an enrollee’s condition.

Network means the doctors, other health care professionals, hospitals, other health care facilities, pharmacies, and medical supply companies a health or dental plan has contracted with to provide covered benefits to enrollees.

Non-participating provider or out-of-network provider means a doctor, other health care professional, hospital, other health care facility, pharmacy, or medical supply company that a health or dental plan has not contracted with to provide covered benefits to enrollees. Care provided by out-of-network providers is only covered for the treatment of emergency medical conditions.

Plan means the health or dental insurance policy an insurance company offers to enrollees to provide Florida Healthy Kids coverage.

Preauthorization or prior authorization means approval from the health or dental insurance company is required before services are provided; otherwise, the insurance company will not pay for those services.

Participating provider or network provider means a doctor, other health care professional, hospital, other health care facility, pharmacy, or medical supply company that has a contract with a health or dental plan to provide covered benefits to enrollees.

Premium means the dollar amount you pay every month to keep your child enrolled in Florida Healthy Kids coverage.

Prescription drug coverage means the prescription medication services, supplies, and products a plan pays for as part of Florida Healthy Kids covered benefits.

Prescription drugs means medications for which the law requires a prescription before purchase or use.

Preventive care means routine health care that includes screenings and check-ups to prevent or detect illness or disease before symptoms are noticed.

Primary care provider or primary care physician or PCP means the health care professional your child sees for basic care and most health problems. The PCP refers (sends) your child to other doctors when special care is needed and coordinates your child’s treatment.

Provider means an appropriately licensed individual or entity providing health care services.

Referral means written approval from your child’s primary care provider for your child to see a specialist or receive certain services. The health plan, dental plan, or the specialist may require a referral for your child to be seen.

Rehabilitation services and devices means medical services and devices that help a patient get back, improve, or keep skills and functions for daily living that were lost or damaged because of an illness or injury.

Skilled nursing care means health care services that can only be safely and correctly performed by a licensed nurse.

Specialist means a doctor with extra training who only treats certain health problems, body parts or age ranges and who does not act as a primary care provider.

Urgent Care means treatment for an injury or illness needed within 24 hours to avoid becoming an emergency.

Well-child visit means an annual preventive care checkup by your child’s PCP.