Glossary of Health Insurance Coverage Terms
This glossary provides general information. It defines medical terms you may see. It’s not a complete list. Your health plan may define these terms in your plan documents. Look at your plan documents for details. Not sure where to look? Check your Summary of Benefits and Coverage to find out how to get a copy of your policy or plan document.
Advance Premium Tax Credit
A tax credit designed to help pay for your monthly premium, when you take it in advance. Or you can wait and take the tax credit at the end of the year when you file your taxes. Whether or not you qualify for this financial help depends on factors including your family size and estimate annual household income for the year the insurance will be in effect. If your actual income does not match your estimate, you may owe or be owed money on your tax return.
Aggregate Family Deductible
In a family plan with an aggregate deductible, an individual deductible. Before medical bills can be covered, the entire amount of the deductible must be met. It can be met by one family member or by a combination of family members.
When you go to the doctor, there’s an “allowed amount” that the health care provider is allowed to bill for services. This is the maximum amount on which payment is based for covered health care services.
Annual Household Income
The total income for a family in a calendar year.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. 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.
If your health insurer denies a claim, you have the right to appeal the ruling. An appeal is a request for your health insurer or plan to review a decision.
When a provider 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. This only applies to out-of-network providers when your health insurance plan includes out-of-network benefits (which most of them do not). A preferred provider, one that is participating in your insurance company’s provider network, may not balance bill you for covered services.
The healthcare items or services covered under a health insurance plan. Covered benefits and exclude services are defined in the health insurance plan’s coverage documents.
An agent or broker can help you apply for a health plan. They can make suggestions about which plan to enroll in. Health insurers often pay them for enrolling consumers. But their services are free to you. Brokers and agents can also help small businesses choose health plans.
The organization of your treatment across several healthcare providers. Medical homes an Accountable Care Organizations are two common ways to coordinate care.
Catastrophic Health Plan
Catastrophic plans are for people under age 30 and those who qualify based on income or other factors. With this plan, the premiums you pay are generally low. But the costs you pay for health care are generally high.
Children’s Health Insurance Program (CHIP)
CHIP provides low-cost or free health coverage to children under age 19. The program is for children in families who qualify based on income.
Chronic Disease Management
An integrated care approach to managing illness that includes screenings, checkups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your healthcare costs if you have a chronic disease by preventing or minimizing the effects of a disease. A request for payment that you or your healthcare provider submits to your health insurer after you receive items or services you think are covered.
A federal law that may allow you to temporarily keep health coverage after your employment ends, after you lose coverage as a dependent of the covered employee, or as a result of 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.
This is a percentage of the cost of care that you may have to pay. You pay coinsurance plus any deductibles you owe. For instance, if the health plan’s allowed amount for an office visit is $100 and you’ve met your deductible, a coinsurance of 20% means you pay $20. The health insurance or plan pays the rest of the allowed amount.
A fixed amount (for instance, $15) you pay for a covered health care service. This is also called a copay. Most of the time, you make the payment when you receive the service. The amount can vary by the type of covered health care service.
Cost Sharing Reduction
A discount lowers how much you have to pay for deductibles, copays and coinsurance. In other words, you pay less for services at the doctor’s office, hospital or pharmacy. You can get this discount if you qualify based on income and choose a silver level health plan. Native Americans may qualify for other cost-sharing benefits, too. Native Americans do not need to choose a silver level plan to get this discount.
A health insurance plan fits into one of four metal tiers or coverage levels: Bronze, Silver, Gold, and Platinum and are intended to help you narrow your options based on your budget and health needs. The levels are based on how you and your insurance company will split costs for that plan and have nothing to do with quality of care. The lowest level, Bronze, will typically have the lowest premiums but the insurance company will pay the lowest percentage of costs when you receive care (60% for example). The higher levels, Gold and Platinum, will typically have higher premiums, but the insurance company will pay a higher percentage of the costs when you receive care (80%, for example).
The amount you owe for covered health care services before your health plan starts to pay. For instance, if your plan has a deductible of $1,000, then you have to pay $1,000 of your own money before the plan will start covering your costs. The plan pays for some services at 100% with no deductible.
A dependent child is a child up to age 26 who can be claimed as a dependent on the parent’s tax return. When you apply for health coverage, you’ll include details about your dependent children.
A limit in a range of major life activities. This includes limits on activities such as seeing, hearing, and walking and on tasks such as thinking and working. Because different health insurance programs may have different disability standards, please check the program you’re interested in for its disability standards.
Emergency Medical Condition
An illness, injury or symptom that is serious or life-threatening. It is so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Room Care
Services you get in an emergency room.
Enrollment counselors are available at hospitals, clinics and schools. They provide help to guide you through enrollment. Help is available at no cost to you.
Essential Health Benefits
A minimum set of benefits covered by all health plans in the Marketplace. This includes:
• Outpatient services
• Emergency services
• Hospital treatment
• Maternity and newborn care
• Mental health services
• Prescription drugs
• Rehabilitation services and devices
• Lab services
• Preventive and wellness services
• Pediatric care
Health care services that your health insurance or plan doesn’t pay for or cover.
Federally Recognized Tribe
A group recognized as an Indian tribe by the Department of the Interior. May include any Indian or Alaska Native tribe, band, nation, pueblo, village, rancheria or community.
Fee for Not Having Health Insurance
If you don’t have health insurance, you might have to pay a fee when you file your taxes. There are some exceptions. For instance, you don’t have to pay the fee if you’re a member of a federally recognized tribe or eligible for services through an Indian Health Services provider. Read more about the fee on HealthCare.gov.
Guaranteed Issue/Guaranteed Renewal
Anyone who is eligible can get a health plan regardless of health status, age, gender or other factors. Anyone can renew their plan as long as they keep paying premiums.
Health insurance is a contract with an insurer. You pay a monthly fee for health insurance. The insurer pays for some of your health care costs in return.
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. Services may also include help for their families.
When you receive care in a hospital, you may be admitted as an inpatient. You may stay in the hospital overnight or for a number of days.
Hospital Outpatient Care
When you receive care in a hospital, you may receive care and go home the same day. Outpatient care means you don’t need to stay the night.
Your household includes you, your spouse (if you’re married) and any children you claim as dependents on your taxes. When you apply for a health plan, you’ll need to fill out some details about your household.
A health plan network is the group of providers contracted with your health plan to provide services. You’ll typically pay less for health services from providers in the plan’s network. Review your plan documents to learn more about in-network and out-of-network costs.
Medicaid is a state program providing health coverage to low-income people. The program may cover adults, children and people with disabilities. You can check if you qualify when you apply through the Marketplace.
A health plan network is a group of facilities, providers and suppliers. They have contracted with your health insurer to provide health care services. The network usually includes doctors, hospitals and clinics where you can go for health care.
Open Enrollment Period
A window of time when people can enroll or renew health plans through the Marketplace. This year, open enrollment is from Nov. 1 to Dec. 15.
A health plan network is the group of providers contracted with your health plan to provide services. You’ll typically pay more for health services from providers who are not in the plan’s network. Review your plan documents to learn more about in-network and out-of-network costs.
These include any costs that you pay for your health care services. When you visit the doctor, you might pay for services right away in the form of a copay. Or, you might be billed later for your share of the costs. You’ll be responsible to pay your deductible and coinsurance amounts. These are your out-of-pocket costs.
Your plan protects you by placing a limit on how much you have to pay. Once you reach the plan’s out-of-pocket maximum, it will pay for covered services at 100 percent. You will no longer have to pay any copays or coinsurance. You will still need to pay your monthly premium.
A doctor who directly provides or coordinates a range of health care services for a patient. There are two types of doctors. An M.D. is a medical doctor. A D.O. is a doctor of osteopathic medicine.
The amount that must be paid for your health insurance or plan.
Premium Subsidy/Premium Tax Credit
Premium subsidies, also called advanced premium tax credits, can help you pay for a health plan. They are only available through the Marketplace. If you qualify based on your income, a premium subsidy can lower the cost of your premium. That means you pay less every month. Or, you may claim the credit when you file your taxes.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Medicines that by law require a doctor’s order.
Routine health care visits to help you stay healthy. This includes screenings, vaccines, checkups and counseling to prevent illness and other health problems.
Health services to prevent or treat common illnesses. A primary care provider (PCP) can be a doctor, nurse, clinical nurse specialist or physician assistant. The PCP provides, coordinates or helps you access a range of health care services.
A health care provider can be a doctor, nurse, clinical nurse specialist or physician assistant.
Qualifying Life Events
A change in your life can make you eligible to enroll in health coverage during special enrollment. You may be able to enroll or change your health plan if you:
• Get married or divorced
• Have a baby
• Move to a new state
• Lose other health coverage
• Gain U.S. citizenship or membership in a federally recognized tribe
• Have other special circumstances
Shopping groups include the household members with whom you can shop and enroll in a health plan. The shopping group is based on the program eligibility of each household member. Factors that impact eligibility include American Indian/Alaska Native status, income, age, and/or tax relationships.
Special Enrollment Period
A time outside of open enrollment when you may be able to enroll or change your health plan. You may be able to enroll in a health plan during a 60-day special enrollment period if you have life changes. These include getting married or divorced, having a baby, losing coverage and other special events.
A doctor or provider specialist focuses on a certain area of medicine or a group of patients. They diagnose, manage, prevent or treat certain types of symptoms and conditions.
Summary of Benefits and Coverage (SBC)
An easy-to-read summary that lets you compare costs and coverage between health plans. You can compare options based on price, benefits and other features. You can view the SBC when you shop for coverage. Or, you can request it from your health insurance company.
When you need quick medical care, but it’s not an emergency.