Health Insurance Glossary

A

Actuarial Value (AV)

A health insurance plan’s average total cost for covered benefits.

Advance Premium Tax Credit (APTC)

A tax credit a person can take in advance in order to lower a monthly health insurance payment for an Affordable Care Act Marketplace plan.

Affordable Care Act (ACA)

The law enacted in March 2010 with the aim to provide affordable health insurance options to more people among other healthcare reforms.

Attest/Attestation

A signature signing on an insurance application that professes that the information written on the application is true and correct.

B

Benefit Period

The time frame when health services are covered under your plan.

Biosimilar Biological Products

Generic versions of advanced medications and drugs.

Brand Name (Drugs)

A drug that’s protected by a patent and sold under a specific name or trademark.

Bronze Health Plan

One of the four Health Insurance Marketplace plans that usually have the lowest monthly premiums, but have the highest costs when the insured receives medical care.

C

Catastrophic Health Plan

A health plan that meets all the applicable requirements of Qualified Health Plans, but don’t cover any benefits aside from 3 primary care visits per year before the plan’s deductible is met. Qualified candidates from catastrophic health plans must be under 30 years old or are exempted from other Marketplace plans due to hardship.

Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs government-run healthcare services and provisions.

Children’s Health Insurance Plan (CHIP)

A government program that provides low-cost health insurance for children in families that don’t qualify for Medicaid yet cannot afford private health insurance.

Coinsurance

The percentage of costs you pay for a covered medical service after you had paid your deductible.

Condition

An illness, ailment, disease, injury, or disorder.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A federal law that allows you to temporarily keep health coverage after your employment ends or if you lose coverage as a dependent of a covered employee.

Copay

The fixed payment amount for covered medical services.

Cost Assistance

The amount of financial help the ACA is willing to pay for health insurance.

Cost Sharing Reduction (CSR)

A discount that lowers the cost of deductibles, coinsurance, and copayments for qualified candidates.

D

Department of Health and Human Services (HHS)

The federal agency that oversees CMS.

Deductible

The amount of covered out-of-pocket costs the insured is responsible to pay for each year before your coinsurance goes into effect.

Dental Coverage

Insurance coverage that helps pay for services and procedures involving dental health.

Dependent Coverage

Healthcare coverage for the insured’s family members such as spouses, children, or partners.

Disability

Something that limits the range of major life activities, including thinking, hearing, seeing, and walking.

Dollar Limits

The maximum amount that your insurance company will pay for your care.

Drug Formulary

The network of prescription drugs that is covered by your health plan and the copayment costs for those drugs.

Durable Medical Equipment (DME)

Supplies and equipment ordered by a healthcare provider for extended or everyday usage. Examples include wheelchairs, crutches, and other such items.

E

Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)

A comprehensive set of benefits covered by Medicaid to provide certain treatments for children.

Emergency Medical Condition

An ailment, injury, or condition that is so serious that a reasonable person would seek immediate care to avoid further harm.

Emergency Medical Technician (EMT)

A person who is certified to administer basic emergency care to victims of trauma, illness, or injury before and during transportation to a medical facility.

Employer Shared Responsibility Payment (ESRP)

The tax payment made by employers with a minimum of 50 employees if they do not provide minimum health insurance coverage to their employees as defined by the Affordable Care Act.

Excluded Services

Health procedures or services that are not covered by your health insurance plan.

Exclusive Provider Organization (EPO) Plan

A managed health plan in which services are covered if the insured gets care from specific doctors, specialists, or hospitals in the plan’s network.

Exemption

A person or persons who do not have to pay for health insurance coverage or pay a fee for not participating in the ACA due to certain hardships, life events, financial status, and other qualifying circumstances.

Exemption Certificate Number (ECN)

The number designated for individuals that are exempt from the fees or payments associated with the ACA.

F

Family and Medical Leave Act (FMLA)

A federal law that guarantees up to 12 weeks of job protected leave for employees when they need time to recover from a serious illness or injury, adopt a child, or to provide care for a family member.

Federal Poverty Level (FPL)

The guideline to determine the eligibility for health insurance cost assistance.

Federally Qualified Health Center (FQHC)

Nonprofit health clinics that are funded by the federal government to provide medical services to underserved areas and populations.

Formulary

A list of prescription medications that are covered by a prescription drug health insurance plan.

G

Generic Drugs

A prescription medication that contains the same active ingredient formula as a brand-name drug. They are as safe and effective as brand-name drugs, rated by the Food and Drug Administration (FDA).

Gold Health Plan

One of the four Health Insurance Marketplace plans. It usually has a higher monthly premium cost, but offers lower costs when you receive medical care.

Group Health Plan

A health plan typically offered by an employer or employee organization that provides health insurance coverage to employees and their families.

H

Hardship Exemption

See “Exemption.”

Health Assessment

A survey that measures are person’s current health and health risks.

Health Coverage

A legal entitlement to payment or reimbursement for the cost of a person’s health care services. This is typically granted by an insurance company, a group health plan offered in connection to the insured’s employment, or a government program.

Health Insurance

A contract that requires an health insurer to pay for the insured’s medical care costs, in part or in full, in exchange for a premium.

Health Insurance Marketplace

A marketplace provided by the ACA that helps people shop for and enroll in affordable health insurance policies.

Health Maintenance Organization (HMO)

A health insurance plan that only allows coverage and access to certain doctors and hospitals within its network. Typically, HMOs can get less costly rates for health services within its network than health providers outside of it.

Health Reimbursement Account (HRA)

Group health plans that are funded by employers in which employees can be reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year.

Health Savings Account (HSA)

A savings account that allows a person to set aside pre-taxed money to pay for qualified medical expenses, provided that the person has a High Deductible Health Plan (HDHP).

High-Cost Excise Tax

A tax on insurance companies that provide high-cost health insurance plans.

High Deductible Health Plan (HDHP)

A health insurance policy that has a higher deductible than the typical health insurance plan.

High-Risk Pool Plan (State)

A state-run insurance plan that provides coverage for people locked out of the individual insurance market due to having one or several pre-existing conditions.

Home and Community-Based Services (HCBS)

Support and services that provide help with daily tasks such as dressing and bathing, typically provided by state Medicaid programs.

Hospice Services

Services given to provide support and comfort for persons in the last stages of a terminal illness.

Hospital Readmissions

A circumstance where a person is discharged from the hospital but goes back for the same or related care within 30, 60, or 90 days. This number is often used to determine the quality of a hospital’s care.

Hospitalization

The term used when the ill or injured person requires admission as an inpatient and requires an overnight stay for additional treatment and/or monitoring.

I

In-Person Assistance Personnel Program

Organizations or individuals that are properly trained to help persons find health coverage options through the ACA Marketplace and fill out the proper forms.

Individual Health Insurance Policy

Health insurance plans that aren’t connected to a person’s place of employment.

Inpatient Services

Medical care received when a person is admitted to a hospital and a room and board charge is made.

J

Job-Based Health Plan

Health insurance that is offered and provided by an employer.

L

Large Group Health Plan

Health insurance that covers the employees of an employer that has 51 employees or more.

Lifetime Limit

The established cap on the total amount of benefits your insurance company will provide within your lifetime.

M

Medicaid

A government funded insurance program that provides free or low-cost health coverage for low-income persons, families, children, people with disabilities, and the elderly.

Medical Care

Services received from a healthcare provider or facility.

Medical Loss Ratio (MLR)

A financial measurement used in the Affordable Care Act to encourage health insurance plans to provide value to the persons who enroll into them.

Medically Necessary

Health services or supplies that meet the accepted standards of medicine and are determined to be essential to properly diagnose or treat an illness, injury, or other medical condition.

Medicare

A federally funded health insurance program that provides coverage for people 65 and older along with certain younger people with disabilities.

Medicare Advantage (Medicare Part C)

A type of Medicare plan that is offered by a private insurer contracted by Medicare to provide Part A and Part B benefits.

Medicare Part D

A Medicare program that helps provide compensation for prescription drugs.

Minimum Essential Coverage (MEC)

Any health insurance plan that meets the minimum coverage requirements as defined by the Affordable Care Act.

Modified Adjusted Gross Income (MAGI)

The calculations that help determine qualification for cost assistance for health insurance coverage or exemptions from the health insurance requirement.

N

Networks

The physicians and services that are covered in your health plan.

Non-Covered Charges

The cost for services and/or supplies that aren’t covered under a person’s health plan.

Non-Preferred Provider

A healthcare provider or facility that doesn’t have a contract with your health insurer to provide medical services.

O

Obamacare

See “Affordable Care Act.”

Open Enrollment Period

The annual period when people can enroll in a health insurance plan.

Outpatient Services

Medical care and services that don’t require an overnight stay in a hospital.

Out-of-Pocket Maximum

This the amount of maximum amount of money expected to pay for covered services during your health insurance’s policy period.

P

Platinum Health Plan

One of the four Health Insurance Marketplace plans. They typically have the highest monthly premiums, but the insurance pays the most for costs of medical care.

Pre-Existing Condition

A health problem that a person has prior to the date that new health care coverage starts. Some pre-existing conditions include diabetes, asthma, and cancer among several others.

Preferred Provider Organization (PPO)

A health insurance plan that features a network of providers, but allows more flexibility for the insured to pick a doctor or hospital outside of the preferred network.

Premium

The amount you pay for healthcare coverage, usually divided into monthly payments, quarterly payments, or a yearly lump sum.

Prescription Drug

A medication that requires a prescription from a licensed physician.

Preventive Services

Routine health services that help prevent or get early diagnoses of health problems. Some preventive services include screenings, physicals, check-ups, and patient counseling.

Primary Care Physician (PCP)

A doctor that directly provides and/or coordinates a range of health care services for a patient.

Provider

A physician, facility, hospital, or other licensed healthcare official.

Q

Qualified Health Plan

A health insurance plan that has been certified by the Health Insurance Marketplace and meets other requirements established by the Affordable Care Act.

Qualifying Life Event (QLE)

A significant change in a person’s life and/or lifestyle (getting married, having a child, etc.) that makes that person eligible for a Special Enrollment Period outside of the Open Enrollment Period.

R

Reinsurance

A system of reimbursement that protects insurers from very high claims in order to keep the insurance market stabilized and make health insurance coverage more affordable.

Rescission

A retroactive cancellation of health insurance policy. A rescission is typically illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the insurance plan’s terms and conditions.

Risk Adjustment

The statistical process that uses the current health status and predicts the health spending of health insurance enrollees.

S

Self-Insured Plan

A type of health insurance plan that has the employer collect premiums from enrollees and take on the responsibility of paying their employees’ medical claims.

Silver Health Plan

One of the four Health Insurance Marketplace plans. These plans typically require their enrollees to pay moderately-priced premiums in exchange for moderate payments for the cost of medical care.

Special Enrollment Period (SEP)

A time outside the annual Open Enrollment Period when you can sign up for a health insurance plan. SEP’s are typically granted to persons that have a baby, got married, or had another qualifying life event.

Small Business Health Options Program (SHOP) Marketplace

A health insurance exchange that assists small business owners to provide health insurance for their employees.

State Health Insurance Assistance Program (SHIP)

A state-run program that uses federal funding to provide free health coverage counseling to Medicare recipients.

Subsidized Coverage

Health insurance available at reduced cost or free for people with income below certain levels.

Summary of Benefits and Coverage (SBC)

A summary that allows potential enrollees compare the costs and coverage of available health plans, allow them to compare options based on price, benefits, and other features that may be relevant to enrollees.

T

Ten Essential Benefits

The required minimum benefits provided by any plan sold through the ACA’s marketplace. These benefits include insurance coverage for prescription drugs, maternity care, pediatric services, preventative services, laboratory services, mental health treatment, rehabilitation services, emergency services, outpatient care, and hospitalization.

TRICARE

A program that provides health care for active-duty and retired uniformed service members and their dependents.

Total Cost Estimate

The approximate total amount you may have to pay for health insurance coverage. This is calculated prior to the coverage’s start date and prior to health expenses accrued under the coverage.

U

Usual, Customary, and Reasonable (UCR)

The calculated amount paid for a health service in a geographical area that is based on what providers typically charge for the same or similar medical service.

Urgent Care

Care for an injury or illness which is serious enough that a reasonable person would seek immediate care, but is not an emergency.

Urgent Care Provider

A clinic, hospital, or physician that is qualified and certified to provide immediate medical help for non-emergency health conditions and injuries.

V

Value-Based Purchasing (VBP)

A form of payment that holds healthcare providers accountable for the cost and quality of care they provide by linking provider payments to improved performance by the medical care providers.

Vision Coverage

A health insurance benefit that covers, in part or in full, the cost of vision care and supplies such as eye exams, glasses, and contact lenses.

W

Wellness Programs

Programs typically provided by employers to improve the health of their employees. These can include discounts for gym memberships, programs to help people to stop smoking, weight loss counseling, and preventative health screenings.