Healthcare Glossary

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).