Healthcare Glossary
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.
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.