Health Insurance Glossary

The Affordable Care Act is a comprehensive health care reform law that went into place in early 2010. It is also known as the ACA or Obamacare. The law enacted several reforms and consumer protections around health insurance. The main goals of the law include:

• Make affordable health insurance available to more people. It provides subsidies, also known as premium tax credits, that lower costs for households with incomes between 100% to 400% of the federal poverty level.

• Seek to expand the Medicaid program by covering all adults with an income below 138% of the federal poverty level.

• Support medical care delivery methods designed to lower the costs of healthcare.

The maximum dollar amount that the insurance company will pay for a covered health care service.

A benefit period is the length of time during which the policyholder of their dependents may file and receive payment for covered services. The benefit period for health insurance can vary depending on if it is a stand-alone policy or a group policy, such as an employer sponsored plan. Individual plans have benefit periods valid for one year and will require payment of a new premium to continue coverage.

Carrier refers to the insurance company that administers the policy. They are often referred to as the health insurance carrier or health insurance company.

A request for payment that you or your health provider submits to your health insurance company when you receive items or services that are covered.

Coinsurance is your share of the costs of a covered health care service. The amount is calculated as a percent of the allowed amount of the service. For example, if your coinsurance is 20%, you would pay 20% on all covered services until you reach the out-of-pocket maximum.

Coinsurance is your share of the costs of a covered health care service. The amount is calculated as a percent of the allowed amount of the service. For example, if your coinsurance is 20%, you would pay 20% on all covered services until you reach the out-of-pocket maximum.

The deductible is the amount that you pay for health care services before your insurance plan starts to pay. For example, if your deductible is $4,000 then you will pay the first $4,000 of covered services first before insurance begins to pay.

Health insurance that is provided and obtained through an employer. It includes coverage for current employees and their families as well as retired employees. This is the most common way that Americans obtain health insurance.

A network of individual medical care providers, or group of medical care providers, that have written agreements with an insurer to provide health insurance to its subscribers. An EPO is a managed care plan where services are only covered if you go to a doctor, specialist, or hospital that is in the plan’s network. Exceptions are made in the case of an emergency. A primary care provider is not necessary in this type of plan.

An account that you put money into that you can use to pay for specific out-of-pocket health care expenses. No taxes are paid on this money.

An insurance that covers the whole or part of the risk of a person incurring a medical expense. Subscribers pay a monthly premium or payroll tax so the insurer can provide the money to pay for health care expenses and spread the risk over a large number of people.

A health insurance organization where subscribers pay a predetermined fee in return for medical services provided by physicians and healthcare workers registered within the organization. An HMO may require you to live or work in its service area to be eligible for coverage.

A type of US employer-funded health benefit plan that reimburses employees for out-of-pocket medical expenses. In some cases, it can pay for health insurance plan premiums. Employees receive these reimbursements tax-free and unused amounts may be rolled over to be used in subsequent years.

A savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. It can be used to pay for deductibles, copayments, coinsurance, and other medical expenses. It can only be used if you have a High Deductible Health Plan (HDHP).

A health insurance plan that has a lower monthly premium, but a higher deductible. Therefore, you pay more for health care costs before the insurance company starts to pay its share than compared to other plans with a lower deductible with higher monthly premiums. This type of plan can be combined with a Health Savings Account (HSA) to help pay for medical expenses out of a tax-free account.

Medical treatment that is administered to a patient whose condition requires treatment within a hospital or healthcare facility and requires formal admission to the hospital or facility by a doctor.

A person who acts as the primary caretaker of a child or minor. They have the legal authority to care for the personal and property interests of another person. There are typically three types of guardianship:

• Guardianship of an incapacitated senior

• Guardianship of a minor

• Guardianship for developmentally disabled adults

An insurance plan that will pay for long-term care in the event that you are unable to care for yourself due to chronic condition(s) or disability. This can include assisted living, nursing home care or in-home health care. These services are typically covered by health insurance, Medicare or Medicaid plans.

Health care services or supplies that are needed to diagnose or treat a condition or its symptoms that meet an accepted standard of medicine.

The federal health insurance program that is available to:

• people who are 65 or older

• certain younger people with disabilities

• people with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a transplant

An in-network provider is a doctor or facility that has negotiated a contracted rate with your health insurance company.

An annual period in which individuals and employees can enroll in a health insurance plan. They can also drop or make changes to their health insurance plan during this time.

Unlike an in-network provider, an out-of-network provider is a doctor or facility that does not have a negotiated contracted rate with your insurance company. Therefore, utilizing these doctors or services may cost more money.

The maximum amount of money you have to pay in a given plan year on health insurance. Once you have reached this amount after paying your deductible, coinsurance and copayments, your insurance will pay for 100% of the covered healthcare costs.

Medical care provided that does not require a prolonged stay at a hospital or facility. Outpatient services include checkups or visits to clinics or even surgical procedures, as long as you are allowed to leave the facility on the same day. It tends to be less expensive than other inpatient services.

A type of managed care plan that has qualities of both HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) plans. Participants in this type of plan designate an in-network primary care provider (like an HMO) but they may go outside of the provider network for health care services (like a PPO). 

A health condition that an individual had before the date that coverage starts.

A type of managed care health plan that provides benefits for visiting an in-network physician or facility but also provides some coverage for out-of-network providers. With this type of plan, you may also be able to visit any provider without a referral from your primary care doctor.

Health insurance or an insurance plan that covers some of the cost of prescription drugs and medications.

A doctor or physician that provides the first contact for an individual with a health concern and provides ongoing care. Some health insurance plans require a designated primary care provider.

A person or company that provides health care to an individual. A doctor is most often thought of as a provider but other examples of providers include a physical therapist, pharmacy, speech therapist, imaging facility, urgent care center, etc. 

A special event that allows you to enroll in or change your health insurance options outside of the annual open enrollment period. Examples of qualifying life events include getting married, having a baby or losing healthcare coverage.

A written pre-approval from a primary care doctor that sometimes must be obtained in order to see a specialist or get certain types of health care services. Referrals are most often seen in HMO and POS plans.

An amendment to a health insurance policy. Some riders help to add coverage for certain conditions, for example adding a maternity rider for pregnancy coverage. Exclusionary riders (excludes coverage for a health condition, body part or body system) have not been permitted on any health insurance since 2014.

A type of managed care plan that provides a temporary insurance solution to fill gaps in coverage. It may be useful if you are between jobs, waiting for other coverage to begin, without health insurance or waiting to become eligible for Medicare enrollment. It is also known as temporary or term health insurance.

A specific time in which you can enroll in health insurance outside of the annual Open Enrollment period, if certain criteria are met. The certain criteria are known as Qualifying Life events and include getting married, having a baby or losing your current healthcare coverage. If you qualify for a Special Enrollment Period, you typically have 60 days to enroll in a plan following the qualifying life event.

A healthcare professional that works in clinical or nonclinical settings and focuses on a specific area of medicine or has more training in a specific area of health care.

A type of walk-in healthcare clinic that provides care for illnesses or injuries that need immediate attention but are not life threatening and would not require the services of an emergency room. Conditions that can be treated at an urgent care clinic can include:

• Mild allergic reaction

• Nausea

• Diarrhea

• Conjunctivitis (pink eye)

• Ear infection

• Sore throat

• Fever

• Sprains/Strains

• Insect bites

• wounds/abscess

• Etc.