Health Insurance Dictionary
Your coverage terms, explained in plain English.
Advanced Premium Tax Credit (APTC): A tax credit that is applicable to reduce your monthly premium for insurance plans acquired via the Health Insurance Marketplace®.
Affordable Care Act: The "Affordable Care Act" (ACA), also commonly referred to as "Obamacare," is a comprehensive healthcare reform law enacted in the United States in March 2010.
Agent: An agent is generally described as a licensed person authorized to sell insurance on behalf of one or multiple insurance companies.
Allowed Amount: This represents the highest amount that the plan will cover for a healthcare service that is within its coverage.
Annual Deductible: This is the amount of money you must pay out of pocket for covered healthcare services before your health insurance plan starts to pay.
Annual Limit: An insurance policy might impose a cap on the total financial coverage it provides within a single year for specific treatments, services, or for all the benefits it offers during that year.
Balance Billing: If you obtain services from a healthcare provider who is not part of your insurance network, the provider is not required to accept the insurer's payment as full payment and may invoice you for any remaining unpaid charges.
Benefits: The medical treatments or services included in a health plan, often referred to as a "benefits package."
Brand-name Drugs: A medication marketed by a pharmaceutical company under a distinct name or trademark safeguarded by a patent.
Broker: A broker is generally described as a licensed professional authorized to market insurance policies from multiple insurance companies. Their role involves acting in the best interests of their clients, ensuring they secure optimal coverage at a competitive cost. Additionally, it's worth noting that a broker may also function as an agent.
Bronze Health Plan: One of the Health Insurance Marketplace®'s four plan categories, often referred to as "metal levels," is the Bronze plan.Catastrophic Health Plan: The health insurance marketplace will offer a catastrophic plan choice. Catastrophic plans have reduced monthly premiums but commence coverage only after you've initially covered a specific expense for included services or exclusively cover higher-cost healthcare, such as hospitalizations.
CHIP: The Children's Health Insurance Program (CHIP) offers healthcare coverage to children with low to moderate income levels.
COBRA: This abbreviation represents the Consolidated Omnibus Budget Reconciliation Act of 1985. This federal legislation mandates that group health plans permit employees and their covered dependents to maintain their group coverage for a specified duration after experiencing a qualifying event that results in the loss of group health benefits.
Coinsurance: Your portion of the expenses for a covered healthcare service, computed as a percentage (e.g., 20%) of the approved cost for the service. Typically, you cover coinsurance in addition to any outstanding deductibles.
Coordination of Benefits: Coordination of benefits is used when a member has two health insurance plans. This process allows the two plans to work together, getting you the most out of your coverage.
Copayment: A fixed fee (e.g., $20) that a patient is required to pay when they see a healthcare provider.
Cost Share (Cost Sharing): The portion of expenses that you are responsible for paying directly, rather than being covered by your health insurance plan.
Cost-Sharing Reduction (CSR): A reduction that reduces the portion you need to cover personally for deductibles, coinsurance, and copayments.Diagnostic Test: Examinations conducted to determine the nature of your health issue.
Disease Management: A comprehensive strategy for effectively managing the entire disease treatment procedure, often entailing a shift from costly inpatient and acute care towards elements such as preventive medicine, patient guidance and instruction, and outpatient treatment.
Direct Primary Care: A direct primary care arrangement is a healthcare plan established between you and a healthcare provider. In this setup, you do not make monthly premium payments to an insurance company; rather, you pay a monthly fee directly to the healthcare provider.
Drug Formulary: A catalog of favored medications endorsed by a board of physicians and pharmacists.
Durable Medical Equipment: Apparatus and materials prescribed by a healthcare professional for regular or prolonged utilization.Embedded Deductible & MOOP: When an embedded deductible and out-of-pocket maximum are in place, family members have the option to pool their eligible expenses to fulfill the mandatory family deductible or out-of-pocket maximum.
Effective Date of Coverage: The commencement date of your insurance coverage.
Emergency Medical Care: Services offered for the initial outpatient management of a sudden medical condition, often within a hospital environment.
Essential Health Benefits (EHB): A set of 10 categories of services health insurance plans must cover under the Affordable Care Act.
Excluded Services: Healthcare services that your plan does not reimburse or include in its coverage.
Exclusive Provider Organization (EPO): A type of plan in which healthcare services are only included if you seek assistance from healthcare professionals and facilities that are part of the plan's network.
Explanation of Benefits: A document furnished to individuals following their receipt of healthcare services, detailing the portion covered by their insurance and the amount they are personally responsible for paying to the healthcare provider.
Family Coverage: Health insurance that extends to the primary policyholder, referred to as the "subscriber," as well as their spouse and any qualified dependents.
Federal Poverty Level (FPL): The annual income threshold for an individual or household, used by the Department of Health and Human Services on a yearly basis, for the purpose of establishing eligibility for specific programs and advantages. HHS Poverty Guidelines for 2024.
Flexible Spending Account (FSA): An employee-based arrangement enabling you to utilize untaxed funds for various medical costs.
Generic Drugs: A prescribed medication that serves as the generic substitute for a brand-name drug listed in your health plan's formulary.
Gold Health Plans: One of the four health plan categories, also known as "metal levels," within the Health Insurance Marketplace®.
Grace Period: A brief duration following the due date of your monthly health insurance payment.
Grandfathered Health Plan: A health plan that was in place when the Affordable Care Act was passed into law in 2010
Grievance: An expression of dissatisfaction or concern that you convey to your health insurer or plan.
Group Health Plan: A healthcare plan provided by an employer or employee organization, usually extending coverage to employees and their families.
Guaranteed Issue: A mandate stating that health plans are obliged to allow enrollment regardless of health condition, age, gender, or other factors that could anticipate the utilization of healthcare services.
Guaranteed Renewability: A mandate necessitating health insurers to renew coverage within a health plan, with exceptions for non-payment of premiums or fraudulent activities.
Health Insurance: An agreement stipulating that a health insurer will cover some or all of your healthcare expenses in return for a premium payment.
Health Insurance Marketplace: The Health Insurance Marketplace, also known as the Health Insurance Exchange, is an official website operated by the federal government.
Health Maintenance Organization (HMO): A plan that restricts coverage to services provided by doctors affiliated with or contracted by the HMO.
Health Reimbursement Arrangement (HRA): Health Reimbursement Arrangements (HRA) are group health plans funded by employers, allowing employees to receive tax-free reimbursements for eligible medical expenses up to a predetermined annual limit.
Health Savings Account: Through a Health Savings Account (HSA), you have the opportunity to allocate funds before taxes. Subsequently, when you seek medical attention or utilize hospital services, you can cover eligible expenses using your HSA funds.
HIPAA: A federal statute that outlines the regulations and criteria that plans must adhere to in order to furnish health insurance coverage for individuals and groups.
Home Health Care: Health care services and supplies you get in your home under your doctor’s orders.
Hospice Services: A care program offered to individuals diagnosed as terminally ill, as well as their families.
Hospitalization: Hospital care necessitating admission as an inpatient and typically involving an overnight stay.
Hospital Outpatient Care: Hospital care typically not necessitating an overnight stay.Individual & Family Out-of-Pocket Maximums: The maximum amount you are responsible for paying for covered services within a plan year. Once you have reached this amount through deductibles, copays, and coinsurance, your health plan covers 100 percent of the costs for covered benefits.
Individual Coverage HRA (ICHRA): Beginning January 1, 2020, employers have the option to provide their employees with an individual coverage Health Reimbursement Arrangement (HRA) in place of a conventional group health plan.
Individual Health Plan: Health insurance coverage for an individual without any covered dependents, also referred to as individual coverage.
Individual Responsibility Requirement: At present, the individual mandate remains operative, although the individual penalty has been reduced to zero.
Infusion Drug Care: Infusion drug therapies are commonly employed for chronic "maintenance" conditions such as asthma, immune deficiencies, or rheumatoid arthritis.
In-Network Providers: Services delivered by a physician or another healthcare provider under a contractual arrangement with the insurance company, typically covered at an enhanced benefit level.
Inpatient Care: Treatment received that necessitates admission to a hospital.
Insured Person: The individual for whom a contract holder (such as an employer or insurer) has committed to offering coverage.J-1 Visa Health Insurance: Health insurance specifically designed for individuals holding a J-1 visa.
Joint Policy: A health insurance policy that covers more than one individual under a single policy.
Key Employee: In the context of health insurance, a key employee is an individual whose contributions are considered essential to the success of a business.
Kidney Dialysis: Kidney dialysis is a medical treatment used to filter waste products and excess fluids from the blood when the kidneys are unable to perform this function adequately.Lifetime Maximum: The maximum amount of money that a health insurance plan will pay for covered services over the entire duration of an individual's or family's enrollment in the plan.
Mail service pharmacy: A pharmacy delivers your prescriptions directly to you via postal mail.
Managed care: A form of healthcare in which your primary care physician, also known as a primary care physician (PCP), takes a leading role in managing your health.
Marketplace: A platform for health insurance where individuals, families, and small businesses can explore their plan choices; evaluate plans according to costs, benefits, and other significant attributes; request and obtain financial assistance with premiums and cost sharing based on income; and select a plan and enroll in coverage.
Maximum allowance or maximum benefit allowance: The fee that a doctor or hospital can levy for providing you with a healthcare service or item.
Maximum Out-of-pocket Limit: The annual limit established by the federal government as the maximum amount that each individual or family can be obligated to pay for cost sharing throughout the plan year for covered, in-network services.
Medicaid: A program funded jointly by the federal and state governments that offers health care coverage for low-income children and families, as well as certain aged and disabled individuals.
Medical Cost-Sharing Group: A medical cost-sharing group, also known as health-sharing ministries, comprises individuals with similar beliefs who assist one another in covering their medical expenses.
Medical Discount Plan: A plan providing reduced rates for medical services.
Medical Group: A collective of physicians and other healthcare professionals who collaborate within a unified medical practice and have an agreement with a health plan to administer healthcare services to the plan's members.
Medical Underwriting: The procedure employed by insurance companies to assess your demographic details and medical background in order to ascertain eligibility for coverage and establish premium amounts.
Medically Necessary: Healthcare services or supplies necessary for diagnosing or treating an illness, injury, condition, disease, or its symptoms, and which adhere to recognized standards of medicine.
Medicare: A government initiative that offers health coverage to individuals aged 65 years or older.
Member: The individual for whom health care coverage has been provided by the policyholder (such as their employer) or any covered family members.
Minimum Essential Coverage: Health insurance that fulfills the individual responsibility mandate.
Minimum Value Standard: A fundamental benchmark used to gauge the percentage of approved costs that a plan provides coverage for.Network: Healthcare providers and medical facilities that have consented to accept your insurance.
Network Provider (Preferred Provider): A healthcare provider who has entered into a contractual agreement with your health insurer or plan, agreeing to offer services to plan members.
Non-Contracting Hospital: A hospital that has not entered into an agreement with a specific health plan to deliver hospital services to members covered by that plan.
Noncovered Service: Services that are not covered under your health insurance agreement.
Non-formulary Drug: A medication that is not included on your health plan's roster of covered drugs.
Non-Preferred Provider: A provider who lacks a contractual agreement with your health insurer or plans to render services to you.Open Enrollment Period: The designated time frame established to enable enrollment or renewal in a health plan, typically occurring once annually.
Out-of-Area Services: Healthcare received while traveling or outside your local area.
Out-of-Network Coinsurance: The percentage (e.g., 40%) of the allowed amount for covered healthcare services that you are responsible for paying to providers who are not part of your health insurance network.
Out-of-Network Copayment: A set fee (e.g., $30) that you pay for covered health care services received from providers who are not contracted with your health insurance or plan.
Out-of-network Provider: A term used to describe healthcare providers who do not have a contractual agreement with your insurance plan.
Out-of-Pocket Costs: Your medical expenses that are not covered by insurance and must be paid by you directly.
Out-of-Pocket Estimate: A projected calculation of the portion you might be responsible for paying out of pocket for healthcare or prescription drug expenses.
Out-of-pocket Maximum: The maximum amount you are required to pay for covered services within a plan year.
Outpatient Services: Healthcare services or treatments conducted in a medical provider's office, hospital, or facility that do not necessitate an overnight stay.
Outpatient Surgery: Surgical procedures performed at a hospital or healthcare facility that do not entail an overnight hospital stay.
Over-the-counter (OTC) drugs: Medications that can be bought over the counter without requiring a prescription.PCP: Abbreviation for Primary Care Physician, your primary or family doctor.
Pediatric Dental: Regular dental care for individuals up to 19 years old, encompassing oral examinations, x-rays, fillings, extractions, and additional services.
Pediatric Vision: Standard vision care for individuals up to 19 years old, including eye exams, prescription eyeglasses, and contact lenses.
Pharmacy: A location where prescribed medications can be obtained.
Pharmacy Benefit Manager (PBM): An organization responsible for overseeing and handling your prescription drug benefits.
Physical Therapy: Therapeutic interventions utilizing physical activity aimed at alleviating pain, restoring function, and mitigating disability following illness, injury, or limb loss.
Physician Services: Healthcare services provided or coordinated by a licensed medical physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine).
Plan Type: A classification of health care plans, including PPOs, HMOs, and EPOs.
Plan Year: A period of 12 months during which you receive benefits under a group health plan.
Point of Service (POS) plan: A type of plan where you pay reduced costs for using healthcare providers within the plan's network.
Policy Year: A 12-month duration of benefits coverage within an individual health insurance plan.
Preauthorization or Prior Authorization (PA): A determination made by your health insurer or plan regarding the medical necessity of a healthcare service, treatment plan, prescription drug, or durable medical equipment.
Pre-Existing Condition: Any health condition for which you've sought medical advice or treatment before your health insurance coverage began.
Preferred Centers: A Preferred Center is a surgical facility that has demonstrated its exceptional quality with minimal readmission and infection rates, high patient satisfaction, and more affordable costs for spine surgeries, as well as total knee and hip replacements.
Preferred Provider Organization (PPO): A plan offering reduced out-of-pocket expenses when utilizing providers within its network.
Premium: Your monthly payment for health insurance is called the premium.
Premium Tax Credit: A tax credit available to reduce your monthly insurance payment, known as the premium, when you enroll in a plan through the Health Insurance Marketplace. This tax credit is determined based on the income estimate and household information provided in your Marketplace application.
Prescription Drug Coverage: Health coverage or insurance that assists in covering the costs of prescription drugs and medications.
Prescription Drug List (PDL)/Formulary: A compilation of medications covered by your prescription drug plan.
Prescription Drugs: Medications and pharmaceuticals that are legally mandated to be obtained with a prescription.
Prescription Drug Tiers: Prescription drugs are categorized based on cost, brand-name or generic status, and other criteria. Tier 1 drugs have the lowest copayment and typically consist of generic versions of brand-name drugs.
Preventive Dental Care: This pertains to dental services such as oral examinations, X-rays, cleanings, and fluoride treatments for children.
Preventive Medical Care: This emphasizes preventing health issues and detecting conditions early for better chances of recovery, often covered by your plan at no extra cost.
Preventive Services: Regular health care involving screenings, check-ups, and patient counseling aimed at preventing illnesses, diseases, or other health issues.
Provider directory: A roster of physicians, medical facilities, and additional healthcare professionals.Qualified High-Deductible Health Plan (HDHP)/Health Savings Account (HSA)-eligible plan: A health insurance plan qualified for a health savings account (HSA) has a higher deductible compared to non-eligible plans.
Qualified Medical Expenses (QMEs): Medical expenses eligible for tax-free withdrawals from a Health Savings Account (HSA) include out-of-pocket costs like doctor visits, hospital care, prescription drugs, and more. For a comprehensive list, refer to IRS publication 502.
Qualifying Life Event (QLE): A change in your situation – like getting married, having a baby, or losing health coverage – that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.
Reasonable charge: The standard fee for a healthcare service charged by a doctor or hospital.
Recission: The retroactive termination of a health insurance policy in accordance with the plan's terms.
Reconstructive Surgery: Medical procedures and subsequent care necessary to rectify or enhance a bodily component due to congenital abnormalities, accidents, injuries, or medical ailments.
Recurrent Benefit: An added benefit payout provided by critical illness products for the recurrence and reappearance of an illness.
Referral: A written authorization from your primary care doctor allowing you to consult with a specialist or receive specific medical services.
Rehabilitative/Rehabilitation: Health care services aimed at helping individuals maintain, regain, or enhance skills and abilities necessary for daily living, which may have been lost or impaired due to illness, injury, or disability.
Renewal: When you enroll in health coverage again with the same company or on the same health plan.
Retail pharmacies: Pharmacies situated within conventional retail stores.Schedule of Benefits (SOB): A concise summary outlining the member's deductible and coinsurance obligations at the beginning of a plan year, often included with member ID cards.
Self-Insured Plan: A plan commonly found in larger organizations where the employer directly manages premiums from participants and assumes the responsibility for covering medical claims for employees and their dependents.
Service Area: A geographic region within which a health insurance plan allows individuals to enroll, often based on residency.
Short-term Limited Duration (STLD) or Temporary Coverage: Short-term health insurance plans provide coverage ranging from one to 36 months and generally exclude coverage for preexisting conditions, maternity, or mental health.
Silver Health Plan: Silver plans, one of the four categories of Health Insurance Marketplace® plans, are positioned in the middle tier.
Skilled Nursing Care: Home health services provided by a licensed nurse in your residence or nursing home are termed as skilled care, whereas those offered by a licensed technician or therapist are also referred to as skilled care.Skilled Nursing Facility: Skilled nursing care and rehabilitation services offered daily in a skilled nursing facility constitute skilled nursing facility care.
Social Security: A mechanism that provides financial assistance to retirees, disabled individuals, their spouses, and dependent children, depending on their documented earnings.
Social Security Benefits: The monthly payment you receive from Social Security Disability, Retirement (including Railroad retirement), or Survivor's Benefits.
Social Security Survivors Benefits: Social Security benefits based on your record in the event of your death, which are paid to:
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Widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22
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Children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22
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Parents if you provided at least one-half of their support
Specialist: A physician whose primary practice focuses on fields other than internal medicine, general medicine, obstetrics/gynecology, pediatrics, or family practice.
Special Enrollment Period (SEP): A Special Enrollment Period (SEP) is a period outside the yearly Open Enrollment Period when individuals can sign up for health insurance.Special Health Care Need: Pediatric specialists address the unique health care and associated requirements of children with chronic physical, developmental, behavioral, or emotional conditions, which often exceed those of typical children.
Specialty Drug: A prescription medication endorsed by the insurance company, designated as such by the FDA due to its necessitating special handling, storage, training, distribution requirements, and/or therapy management.
Step therapy: Certain plans may necessitate your physician to initiate treatment with a specific drug listed on the formulary.
Subscriber: A policyholder or member who consistently fulfills all eligibility criteria and is enrolled under the policy as a primary individual, not as a dependent.
Subsidized Coverage: Health insurance accessible at discounted or no cost for individuals with incomes falling below specific thresholds.Subsidy or Premium Tax Credit: Assistance from the government to help pay for the monthly insurance bill for those that qualify.
Summary of Benefits and Coverage (SBC): A clear and concise overview designed to facilitate straightforward comparisons of costs and coverage among different health plans.Surprise Bill: An unforeseen "balance bill" arising from services provided by an out-of-network provider that you believed to be within your network.
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Term: The duration during which coverage remains active.
Telehealth: A virtual meeting with a healthcare provider conducted remotely, typically via video chat or phone, rather than an in-person visit at a medical facility.
TTY/TDD: A device designed for individuals with hearing impairment to facilitate telecommunications.
UCR (Usual, Customary and Reasonable): The payment for a medical service in a particular geographic area, typically based on the usual charges by providers in that area for the same or similar medical service.
Urgent Care: Care for an illness, injury, or condition that is urgent and requires prompt attention, but is not severe enough to warrant emergency room care.
Urgent Care Centers: A medical facility outside of a hospital setting that provides immediate care for injuries and illnesses requiring prompt attention but not severe enough to warrant an emergency room visit, staffed by physicians, nurses, and x-ray technicians.
Utilization management: When we assess the care you're receiving to ensure it meets specific standards.Value-Based Care: This refers to a healthcare delivery model in which providers are rewarded for achieving better patient outcomes, reducing medical costs, and improving the overall quality of care.
Vision Coverage: Vision coverage refers to health insurance benefits that specifically cover services related to vision care, such as eye exams, prescription eyewear (glasses and contact lenses), and treatment for certain eye conditions.
Voluntary Benefits: These are additional benefits that employers may offer to their employees, but participation is optional.Waiting Period: A waiting period in health insurance refers to the specified period of time that must pass before certain benefits are available under the policy.
Walk-in-clinic: A walk-in clinic is a medical facility where patients can receive care without requiring prior appointments or existing patient status.
Well-baby and Well-child Visits: Regular physician appointments for comprehensive preventive health services that are scheduled during infancy and occur annually until the child turns 21.
Wellness Programs: A wellness initiative designed to enhance and advocate health and fitness, typically provided via the workplace or directly by insurance plans to their members.
Women, infant and children program (WIC): A state nutrition initiative aimed at supporting pregnant women, new mothers, and young children in maintaining a healthy diet and overall well-being.X-ray: An X-ray is a type of electromagnetic radiation used in medical imaging to produce images of the internal structures of the body, such as bones and organs.
Yearly Maximum: This term refers to the maximum amount of money that a health insurance plan will pay for covered services within a single policy year.
Zero Copay: Zero copay refers to a situation in which the insured individual does not have to make any out-of-pocket payments, such as copayments, coinsurance, or deductibles, for certain covered medical services or prescriptions.
Zone Rating: Zone rating refers to the practice of dividing geographic areas into zones based on various factors such as demographics, health care utilization, and health outcomes.
