Everyone who is familiar with the cost of medical care or the complexities that come with it know that it can be a major headache. From the very moment you enter the doctor’s office, to having your prescription drugs filled, to different lab tests and screenings, to hospitalization and emergency- medical services and costs are extremely expense. It is very challenging for the average American to be able to understand these complexities, understand how insurance works much less be able to pay for it all on their own without having the assistance of a knowledgeable and trustworthy agent or financial help from the government.
Having health insurance shouldn’t be a choice, it is essential that one falls under the medical service providing community. However, to get a reliable and adequate healthcare coverage, you need to know these basic terms in this industry:
- Actuarial Value
- Affordable Care Act
- Affordable coverage
- Allowed Amount
- Annual Deductible Combined
- Annual Limit
- Balance Billing
- Benefit Year
- Children’s Health Insurance Program (CHIP)
- Community Rating
- Cost Sharing
- Creditable Coverage
- Dental Coverage
- Department of Health and Human Services (HHS)
- Dependent Coverage
- Domestic Partnership
- Drug List
- Durable Medical Equipment (DME)
- Emergency Room Care
- Emergency Services
- Employer Shared Responsibility Payment (ESRP)
- Employer or Union Retiree Plans
- Essential Health Benefits
- Excluded Services
- Exclusive Provider Organization (EPO) Plan
- External Review
- Federally Qualified Health Center (FQHC)
- Federally Recognized Tribe
- Fee For Service
- Flexible Benefits Plan
- Flexible Spending Account (FSA)
- Full-Time Employee
- Fully Insured Job-based Plan
- Generic Drugs
- Grandfathered Health Plan
- Group Health Plan
- Guaranteed Issue
- Guaranteed Renewal
- HIPAA Eligible Individual
- Habilitative/Habilitation Services
- Hardship Exemption
- Health Coverage
- Health Insurance
- Health Insurance Marketplace
- Health Maintenance Organization (HMO)
- Health Reimbursement Account (HRA)
- Health Savings Account (HSA)
- Health Status
- High Deductible Health Plan (HDHP)
- High Risk Pool Plan (State)
- High-Cost Excise Tax
- Home Health Care
- Hospice Services
- Hospital Outpatient Care
- Hospital Readmissions
- In-network Coinsurance
- In-network Copayment
- Individual Health Insurance Policy
- Inpatient Care
- Insurance Co-Op
- Job-based Health Plan
- Large Group Health Plan
- Lifetime Limit
- Long-Term Care
- Medical Underwriting
- Medically Necessary
- Minimum Essential Coverage
- Minimum value
- Network Plan
- Non-preferred provider
- Not Yet Accredited (Health Plan)
- Open Enrollment Period
- Out-of-Network Coinsurance
- Out-of-Network Copayment
- Out-of-Pocket Costs
- Out-of-Pocket Estimate
- Out-of-pocket maximum/limit
- Patient Protection and Affordable Care Act
- Physician Services
- Plan Year
- Point of Service (POS) Plans
- Policy Year
- Pre-Existing Condition
- Pre-Existing Condition (Job-based Coverage)
- Pre-Existing Condition Exclusion Period (Individual Policy)
- Pre-Existing Condition Exclusion Period (Job-based Coverage)
- Pre-existing Condition Insurance Plan (PCIP)
- Preferred Provider
- Preferred Provider Organization (PPO)
- Premium Tax Credit
- Prescription Drug Coverage
- Prescription Drugs
- Preventive Services
- Primary Care
- Primary Care Physician
- Primary Care Provider
- Prior Authorization
- Qualifying Life Event
- Rehabilitative/Rehabilitation Services
- Rider (exclusionary rider)
- Risk Adjustment
- Self-Insured Plan
- Service Area
- Skilled Nursing Care
- Skilled Nursing Facility Care
- Special Enrollment Period
- Subsidized Coverage
- Summary of Benefits and Coverage (SBC)
- Total Cost Estimate (for health coverage)
- UCR (Usual, Customary, and Reasonable)
- Uncompensated Care
- Urgent Care
- Vision or Vision Coverage
- Waiting Period (Job-based coverage)
- Well-baby and Well-child Visits
- Wellness Programs
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Affordable Care Act
The comprehensive Health Care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
Employer coverage is considered affordable – as it relates to the premium tax credit – if the employee’s share of the annual premium for self-only coverage is no greater than 9.5% of annual household income. People offered employer-sponsored coverage that’s affordable and provides minimum value aren’t eligible for a premium tax credit.
An agent or broker is a person or business who can help you apply for help paying for coverage and enroll you in a Qualified Health Plan (QHP) through the Marketplace. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer’s plans. Some agents and brokers may only be able to sell plans from specific health insurers.
Maximum amount on which payment is based for covered Health Care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing).
Annual Deductible Combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for Health Care or prescription drugs before the health plan begins to pay.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated Health Care costs for the rest of the year.
A request for your health insurer or plan to review a decision or a grievance again.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
The Health Care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
An agent or broker is a person or business who can help you apply for help paying for coverage and enroll in a Qualified Health Plan (QHP) through the Marketplace. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer’s plans. Some brokers may only be able to sell plans from specific health insurers.
A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Children’s Health Insurance Program (CHIP)
Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.
A request for payment that you or your Health Care provider submits to your health insurer when you get items or services you think are covered.
A non-profit organization in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state, or local level and can include doctors, hospitals, and businesses as member-owners. Co-ops will offer insurance through the Marketplace.
is the consumer’s share of the cost for a covered health service, calculated as a percentage of the amount allowed by the health plan for that service. The consumer would pay coinsurance plus any deductible owed. For example: the service allowed amount costs $100, the consumer would pay 20% or $20. The health plan would then be responsible for the remaining $80.
A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
is a fixed amount consumers pay for a health care service. The amount varies based on the type of service covered. For example: seeing a doctor will have a lower copayment, than an emergency room visit. Also recall in-network services will have lower copayments than out-of-network.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.
the amount a consumer owes for health care services before the health plan begins to pay. Some health services may be covered prior to meeting the deductible. Premiums and copayments do not count towards the deductible. For example: Deductible of the plan is $1000. The consumer must pay $1000 for services before the company pays for any subsequent service.
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a “stand-alone” dental plan.
Department of Health and Human Services (HHS)
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP). For more information, visit hhs.gov.
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
Two people of the same or opposite sex who live together and share a domestic life, but aren’t married or joined by a civil union. In some states, domestic partners are guaranteed some legal rights, like hospital visitation.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a Health Care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Room Care
Emergency services you get in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.
Employer or Union Retiree Plans
Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families. These plans are offered to people through their (or a spouse’s) former employer or employee organization. Many of these plans aren’t legally required to meet many of the provisions of the Affordable Care Act, including providing coverage for children up to age 26.
Essential Health Benefits
A set of Health Care service categories that must be covered by certain plans, starting in 2014. The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.
A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state. In others it is run by the federal government.
Health Care services that your health insurance or plan doesn’t pay for or cover.
Exclusive Provider Organization (EPO) Plan
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn’t yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, Health Care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The plan must accept this decision.
Federally Qualified Health Center (FQHC)
Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.
Federally Recognized Tribe
Any Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe.
If someone doesn’t have a health plan that qualifies as minimum essential coverage, he or she may have to pay a fee that increases every year: from 1% of income (or $95 per adult, whichever is higher) in 2014 to 2.5% of income (or $695 per adult) in 2016. The fee for children is half the adult amount. The fee is paid on the 2014 federal income tax form, which is completed in 2015. People with very low incomes and others may be eligible for waivers. See “What if someone doesn’t have health coverage in 2014?” for more information.
Fee For Service
A method in which doctors and other Health Care providers are paid for each service performed. Examples of services include tests and office visits.
Flexible Benefits Plan
A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans, and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage. Also known as a Cafeteria plan or IRS 125 Plan.
Flexible Spending Account (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year. There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year (Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.).
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
An employee who works an average of at least 30 hours per week (so part-time would be less than 30 hours per week).
Fully Insured Job-based Plan
A health plan purchased by an employer from an insurance company.
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
Grandfathered Health Plan
As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).
A complaint that you communicate to your health insurer or plan.
Group Health Plan
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn’t limit how much you can be charged if you enroll.
A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn’t limit how much you can be charged if you enroll.
HIPAA Eligible Individual
Your status once you have had 18 months of continuous creditable health coverage. To be HIPAA eligible, at least the last day of your creditable coverage must have been under a group health plan; you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare or Medicaid; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. When you’re buying individual health insurance, HIPAA eligibility gives you greater protections than you would otherwise have under state law.
Health Care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Under the Affordable Care Act, most people must pay a fee if they don’t have health coverage that qualifies as “minimum essential coverage.” One exception is based on showing that a “hardship” prevented them from becoming insured. More information will be available later in 2013.
Legal entitlement to payment or reimbursement for your Health Care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
A contract that requires your health insurer to pay some or all of your Health Care costs in exchange for a premium.
Health Insurance Marketplace
A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance.
Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Health Reimbursement Account (HRA)
Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.
Health Savings Account (HSA)
A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
Refers to your medical conditions (both physical and mental health), claims experience, receipt of Health Care, medical history, genetic information, evidence of insurability, and disability.
High Deductible Health Plan (HDHP)
A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
High Risk Pool Plan (State)
Similar to the Pre-Existing Condition Insurance Plan under the Affordable Care Act, for years many states have offered plans that provide coverage if you have been locked out of the individual insurance market because of a pre-existing condition. High-risk pool plans may also offer coverage if you’re HIPAA eligible or meet other requirements. High-risk pool plans offer health insurance coverage that is subsidized by a state government. Typically, your premium is up to twice as much as you would pay for individual coverage if you were healthy.
High-Cost Excise Tax
Under the Affordable Care Act starting in 2018, a tax on insurance companies that provide high-cost plans. This tax encourages streamlining of health plans to make premiums more affordable.
Home Health Care
Health Care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
A situation where you were discharged from the hospital and end up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn’t properly organized, or that you weren’t fully treated before discharge.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
The percent (for example, 20%) you pay of the allowed amount for covered Health Care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
A fixed amount (for example, $15) you pay for covered Health Care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.
Individual Health Insurance Policy
Policies for people that aren’t connected to job-based coverage. Individual health insurance policies are regulated under state law.
Health Care that you get when you’re admitted as an inpatient to a Health Care facility, like a hospital or skilled nursing facility.
A non-profit entity in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state or local level, and can include doctors, hospitals and businesses as member-owners.
Job-based Health Plan
Coverage that is offered to an employee (and often his or her family) by an employer.
Large Group Health Plan
In general, a group health plan that covers employees of an employer that has 101 or more employees. Until 2016, in some states large groups are defined as 51 or more.
A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.
A process used by insurance companies to try to figure out your health status when you’re applying for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits.
Health Care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Minimum Essential Coverage
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
A health plan meets this standard if it’s designed to pay at least 60% of the total cost of medical services for a standard population. Starting in 2014, individuals offered employer-sponsored coverage that provides minimum value and that’s affordable won’t be eligible for a premium tax credit.
An individual or organization that’s trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide Health Care services.
A health plan that contracts with doctors, hospitals, pharmacies, and other Health Care providers to provide members of the plan with services and supplies at a discounted price.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can’t be charged more because of your health status. Job-based plans can restrict coverage based on other factors such as part-time employment that aren’t related to health status.
Not Yet Accredited (Health Plan)
A plan that hasn’t been given a “seal of approval” by an independent company to show it meets national quality standards for health plans. There are many reasons why a health plan may not be accredited. For example, some plans have never gone through the accreditation process or have gone through the process with a different accrediting organization. Other plans are too new to be accredited or have started but not finished the accreditation process. Not being accredited doesn’t mean that a plan is lower quality than a plan that’s accredited.
Open Enrollment Period
The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For coverage starting in 2014, the Open Enrollment Period is October 1, 2013–March 31, 2014. For coverage starting in 2015, the proposed Open Enrollment Period is November 15, 2014–February 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event).
The percentage (for example, 40%) you pay of the allowed amount for covered Health Care services to providers who don’t contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
A fixed amount (for example, $30) you pay for covered Health Care services from providers who don’t contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
There can also be an out-of-pocket sharing in your plan. Out-of-pocket maximum is the highest amount of cost you incur towards your deductibles in a year. It is usually a specific amount, a fixed portion from your health insurance plan.
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
An estimate of the amount that you may have to pay on your own for Health Care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.
Patient Protection and Affordable Care Act
See Affordable Care Act
Health Care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
A benefit your employer, union or other group sponsor provides to you to pay for your Health Care services.
A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).
Point of Service (POS) Plans
A type of plan in which you pay less if you use doctors, hospitals, and other Health Care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer. (Note: In group health plans, this 12-month period is called a “plan year”).
A health problem you had before the date that new health coverage starts.
Pre-Existing Condition (Job-based Coverage)
Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.
Pre-Existing Condition Exclusion Period (Individual Policy)
The time period during which an individual policy won’t pay for care relating to a pre-existing condition. Under an individual policy, conditions may be excluded permanently (known as an “exclusionary rider”). Rules on pre-existing condition exclusion periods in individual policies vary widely by state.
Pre-Existing Condition Exclusion Period (Job-based Coverage)
The time period during which a health plan won’t pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.
Pre-existing Condition Insurance Plan (PCIP)
A program that will provide a health coverage option for you if you have been uninsured for at least six months, you have a pre-existing condition, and you have been denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. This program will provide coverage until 2014 when you will have access to affordable health insurance choices through the Health Insurance Marketplace, and you can no longer be discriminated against based on a pre-existing condition.
A decision by your health insurer or plan that a Health Care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
the amount that must be paid to a health insurance company for a health plan. Consumers and/or their employers pay this monthly, quarterly or yearly.
Premium Tax Credit
The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Drugs and medications that, by law, require a prescription.
Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.
Routine Health Care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of Health Care services for a patient.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of Health Care services.
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
Qualifying Life Event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Health Care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Rider (exclusionary rider)
A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy). In most states today, an exclusionary rider is an amendment permitted in individual health insurance policies that permanently excludes coverage for a health condition, body part, or body system. Starting in September 2010, under the Affordable Care Act, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.
A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their Health Care outcomes or Health Care costs.
Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Skilled Nursing Facility Care
Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
Special Enrollment Period
A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of Health Care.
Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.
Summary of Benefits and Coverage (SBC)
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
Total Cost Estimate (for health coverage)
The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage.
UCR (Usual, Customary, and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Health Care or services provided by hospitals or Health Care providers that don’t get reimbursed. Often uncompensated care arises when people don’t have insurance and cannot afford to pay the cost of care.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Vision or Vision Coverage
Vision coverage is a health benefit that at least partially covers vision care, like eye exams and glasses.
Waiting Period (Job-based coverage)
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
Well-baby and Well-child Visits
Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.
A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.