Glossary

Glossary

Healthcare Glossary

Affordable Care Act

Also known as ACA, PPACA, or Obamacare, the Affordable Care Act is the comprehensive healthcare reform law enacted in March 2010. While the Affordable Care Act has many proponents and opponents, importantly, it enacted basic patient protections to help young people and those with pre-existing conditions access insurance coverage.

Appeal

A request to a health insurance company to review a decision denying a benefit, service, or payment.

Catastrophic Health Plan

Catastrophic Health plans have low monthly payments but a high deductible. These plans meet the requirements applicable to other Qualified Health Plans (QHPs, see definition below); however, monthly premiums for catastrophic health plans are typically lower than other QHPs while the out-of-pocket costs are higher.

Children's Health Insurance Program (CHIP)

Insurance program for children in families who earn too much to qualify for Medicaid, but not enough to be able to afford private insurance. In some states, CHIP also covers pregnant women.

Claim

A request for payment submitted to your insurer for services rendered.

COBRA

Stands for Consolidated Omnibus Budget Reconciliation Act, COBRA is a federal law that allows individuals to temporarily keep employer-provided health insurance after employment ends or another qualifying event. If someone elects COBRA coverage, they are responsible for 100 percent of the premiums.

Coinsurance

Your share of the costs of certain medical care or medications, calculated as a percentage of the total cost. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of the cost.

Copayment

A fixed amount you pay for certain medical care or medications. The amount can vary by the type of health care service.

Cost Sharing

The share of costs for services covered by your insurance that you pay out-of-pocket. This generally includes deductibles, coinsurance, and copayments. This does not include premiums or non-covered services.

Cost Sharing Reductions

Discounts that lower the amount individuals have to pay for deductibles, copayments, and coinsurance for plans on the individual and small group markets. Individuals who qualify for cost-sharing reductions also have a lower out-of-pocket maximum. The cost sharing reductions are paid to the insurer by the federal government. The Trump Administration decided not to pay the cost sharing reduction payments to insurers in 2018.

Coverage Standards

A standard of minimum coverage that applies to job-based health plans. If your employer's plan meets this standard and is considered "affordable", you won't be eligible for a premium tax credit if you buy a Marketplace insurance plan instead.
A health plan meets the minimum value standard if both of these apply:

  • It's designed to pay at least 60% of the total cost of medical services for a standard population.
  • Its benefits include substantial coverage of physician and inpatient hospital services.

Deductible

The amount you pay for health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've spent $1,000 on medical care or medications. However, some services, including preventive services, may not be subject to the deductible. Be sure to check your plan.

Drug Formulary

A list of medications covered by your pharmacy benefits. Formularies often have tiers with different levels of cost-sharing or coinsurance assigned to particular medications or therapies. Services assigned to a higher tier typically cost more than those assigned to a lower tier.

Essential Health Benefits (EHB)

A list of services that health insurance plans on the individual and small group market must cover under the Affordable Care Act. EHBs include outpatient services, emergency services, hospitalization, pregnancy and childbirth, mental health services, prescription drugs, laboratory services, chronic disease management, pediatric services, and more.

Exchange

Also known as the Health Insurance Marketplace, the Exchange is a service in every state (online, phone, and in-person) that helps people and businesses shop for and enroll in affordable insurance.

Exclusive Provider Organization (EPO)

A managed care plan where you can only use the doctors and hospitals within the EPO network. There are no out-of-network benefits (except in an emergency).

Explanation of Benefits

A statement sent by a health insurer detailing what medical treatments and/or services were paid for on behalf of the covered individual.

Family and Medical Leave Act (FMLA)

A federal law that guarantees up to 12 weeks of job protected leave for eligible employees when they need to take time off due to serious illness or disability, childrearing, or to care for a loved one. FMLA leave allows you to continue coverage under job-based insurance plans.

Group Health Plan

Health plans offered by employers that provide insurance coverage to employees and their families.

Health Maintenance Organization (HMO)

A health insurance plan that limits coverage to care from providers (generalists and specialists) who are part of a specific network (they work for or contract with the plan). These plans often focus on prevention and wellness. Under an HMO, all access to specialists and hospitalization must be facilitated through the member's Primary Care Physician (PCP).

High Deductible Plan (HDP)

A plan that usually has lower premiums and a high deductible – where you pay all of your healthcare costs until you meet your deductible and then the insurer pays a portion of your costs. This is usually combined with a health savings account (HSA). A high deductible plan may be an HMO, POS, PPO, or EPO plan.

High-Risk Pool Plan

Health insurance plans offered to individuals who have been locked out of the individual insurance market because of a pre-existing condition. Premiums for these plans can be up to twice as much as a healthy individual would pay for individual coverage.

Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance company. After a lifetime limit is reached, the insurance plan will no longer pay for services.

Medicaid

An insurance program that provides free or low-cost health coverage to low-income people, families and children, pregnant women, the elderly, and persons with disabilities. Many states have expanded their Medicaid programs to cover all people below specific income levels.

Medicare

A federal health insurance program for persons 65 and older and certain younger people with disabilities.

Medicare Part D Donut Hole/Coverage Gap

Period of time where there is a coverage gap in your Medicare D plan, which covers pharmaceuticals. Medicare Part D consists of four stages of coverage:

  • Deductible Stage: If your plan has a deductible, you usually pay the full cost of your drugs up to the deductible amount.
  • Initial Coverage Stage: During this stage, the plan pays its share of the cost and you pay a copayment or coinsurance for each prescription you fill until your total drug costs reaches $3,750 (changes year to year).
  • Coverage Gap/Donut Hole: During this stage, you've exceeded the initial coverage limit of your plan so the amount you pay for prescription drugs increases. If you have noticed that you are suddenly paying more for prescription drugs, you may be in the donut hole. This stage continues until your yearly out of pocket drug costs reach $5000 (changes year to year).
  • Catastrophic Coverage Stage: In this stage, you have left the donut hole and you pay only a small copayment or coinsurance amount for each prescription you fill.

On January 1, the member resets back at the Deductible Stage (if plan has deductible) or the Initial Coverage Stage (if plan does NOT have a deductible).

Metal Level

Plans are categorized by "metal levels"—Bronze, Silver, Gold, and Platinum. Metal levels tell you what portion of total health care costs plans will cover.

Navigator

Unbiased individuals or organizations who are trained and able to help consumers, small businesses, and their employees as they look for health coverage through the Health Insurance Marketplace. Navigator services are free to consumers.

Open Enrollment Period

The annual period when people can enroll in or make changes to their insurance coverage. Open enrollment occurs yearly in from November–December. Outside of open enrollment, individuals may be eligible to enroll in a health insurance plan during a Special Enrollment Period if they have a qualifying life event (QLE, see definition below).

Out-of-Pocket Maximum

The most you pay before your health plan begins to pay 100 percent of the cost for in-network services. This limit never includes your premium or care that your plan doesn't cover. Health plans count all in-network copayments, deductibles, and coinsurance payments to this limit.

Point of Service (POS)

A plan where you pay less if you use providers and hospitals that belong to the plan's network. You may be required to choose a primary care physician, who will make referrals to network specialists. You may receive care from non-network providers, but with higher out-of-pocket costs.

Pre-Existing Condition

A health problem, like Crohn's disease or ulcerative colitis, a person has before the date their health insurance starts.

Preauthorization

A term used by health plans to convey that before seeking certain health care services, patients must seek prior approval or permission. Services such as home health care and non-urgent surgeries often require preauthorization.

Preferred Provider Organization (PPO)

A plan where you have the option of receiving care from doctors, hospitals and specialists in the network or outside the network, and you don't always need a referral to see a specialist. However, you pay less if you use providers in the plan's network.

Premium

The amount you pay every month for health insurance.

Premium Tax Credits

A refundable tax credit designed to help eligible individuals or families with low or moderate income afford health insurance through the Health Insurance Marketplace. The amount of the premium tax credit is based on a sliding scale.

Prescription Drug Coverage

Health insurance that helps pay for prescription drugs.

Preventive Service

Most health insurance plans must cover at no cost to the consumer certain preventive services, such as flu shots and pap smears, as recommended by the U.S. Preventive Services Task Force.

Prior Authorization

Approval from a health insurer for coverage of a prescription or service.

Qualified Health Plan

An insurance plan certified by the Health Insurance Marketplace which provides essential health benefits, follows established limits on cost-sharing, and meets other minimum essential coverage requirements.

Qualifying Life Event (QLE)

A change in your life that makes you eligible to enroll in health insurance outside of the annual open enrollment period. QLEs include changes in household (marriage, divorce, or having a child), changes in residence, loss of health coverage, and more.

TRICARE

A healthcare program for active-duty and retired uniformed service members and their families.

UCR (Usual, Customary, and Reasonable)

The amount paid for a service in a geographic area based on what is typically charged for the same or similar medical service. This is sometimes used to determine the allowed amount.