GLOSSARY OF HEALTH INSURANCE AND HEALTHCARE TERMS
This glossary of health insurance and healthcare terms defines commonly used terms, is intended for educational purposes and may differ from language used in your policy.
Health services provided to members who are not confined to a health care institution.
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).
A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside of the Marketplace beings January 1 of year and ends December 31 of the same year. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
A certain percent you must pay each benefit period after you have paid your deductible.
The amount you pay to a healthcare provider at the time you receive services. Not all plans have a copay.
A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or 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.
The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.
CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS)
The federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Program, and the federally facilitated Marketplace.
The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time).
FLEXIBLE SPENDING ACCOUNT (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. If you don’t spend by the end of the year there are no carry-over FSA funds.
FEE FOR SERVICE
A method in which doctors and other health care providers are paid for each service performed.
FEDERAL POVERTY LEVEL
A measure of income issued every year by the Department of Health and Human Services (HHS). FPL are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. These drugs are as effective and safe as brand-name as stated by the Food and Drug Administration (FDA).
HEALTH MAINTENANCE ORGANIZATION (HMO)
Offers healthcare services only with specific HMO providers. Under an HMO plan, you might have to choose a primary care doctor. The doctor will be your primary physician and will refer you to other HMO specialist when needed. Services from providers outside of the HMO plan are hardly ever covered.
HEALTH SAVINGS ACCOUNT (HSA)
An account that lets you save for future medical costs. Money put in the account is not subject to federal income tax when deposited. Funds can build up and be used year to year. They are not required to be spent in a single year. Must be paired with certain high-deductible health insurance plans (HDHP).
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
United States legislation that provides data privacy and security provisions for safeguarding medical information. Signed into law by President Bill Clinton in August 1996.
HIGH-RISK POOL PLAN (STATE)
Similar to Pre-Existing Insurance Plan under the Affordable Care Act, for patients that have been locked out of the individual insurance market because of pre-existing conditions. High-risk pool plans offer health insurance coverage that is subsidized by a state government. Typically, the premium for high-risk pools are twice as much as if you were healthy.
Services received when admitted to a hospital and a room and board charge is made.
The percent you pay of the allowed amount or covered health care service to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Medicare and most health insurance plans don’t pay for long-term care.
A federally funded health care program that is run at the state level to assist lower income families or individuals paying for long-term medical and custodial care costs.
A process used by insurance companies to try to figure out your health status when you’re applying for health insurance coverage to determine whether to offer coverage, at what price, and with what exclusions or limits.
A federal program for people age 65 or older that pays for certain healthcare expenses.
MEDICARE PART D
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage plan that includes drug coverage.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A healthcare provider who is part of a plan’s network.
OPEN ENROLLMENT PERIOD
The yearly period when people can enroll in a health insurance plan. 2017 Open Enrollment ended January 31, 2017. 2018 Open Enrollment runs from November 1, 2017 to December 15, 2017.
Services that do not need an overnight stay in a hospital. Often these services are provided in a doctor’s office, hospital or clinic.
Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost.
PATIENT CENTERED OUTCOME RESEARCH
Research that compares different medical treatments and interventions to provide evidence on which strategies are most effective in different populations and situations.
POINT OF SERVICE (POS)
A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
PREFERRED PROVIDER ORGANIZATION (PPO)
A type of insurance plan that offers more extensive coverage for the services of healthcare providers who are part of the plan’s network, but still offers coverage for providers who are not part of the plan’s network. PPO plans generally offer more flexibility than HMO plans, but premiums tend to be higher.
Payments you make to your insurance provider to keep your coverage. These payments have certain due dates.
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, diseases, or other health problems.
PRIMARY CARE PROVIDER
A physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patent access a range of health care services.
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. Without a referral from your primary care doctor, the plan may not pay for the services.
SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP) MARKETPLACE
A health insurance exchange that helps small business owners provide medical and dental insurance to their employees. Some smaller employers qualify for tax credits if they buy health insurance through the SHOP Marketplace.
SPECIAL ENROLLMENT PERIOD
A time outside of the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including loss of coverage, moving, getting married, having a baby, or adopting a child.
STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP)
A state program that gets funding from federal government to provide free local health coverage counseling to people with Medicare.
Health coverage available at reduced or no cost for people with incomes below certain levels.