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Glossary of Terms

A

Affordable Care Act

A new, comprehensive law passed in 2010, aimed at reforming America's health care system to improve access and affordability for more Americans.

allowable amount

The maximum amount determined by the healthplan to be eligible for consideration of payment for a particular service, supply or procedure.

allowable charge

The maximum amount a healthplan will reimburse a doctor or hospital for a given service.

annual deductible

The amount of eligible expenses you are required to pay annually before reimbursement by your healthplan begins.

annual limit

An insurance plan may limit the dollar amount it will pay during one year for a certain treatment or service, or for all benefits provided in a year.

annual out-of-pocket

The maximum amount, per year, you are required to pay out of your own pocket for covered health care services.


B

benefits

The health care items or services covered by an insurance plan. Your insurance plan may sometimes be referred to as a "benefit package."


C

catastrophic plan

The health insurance exchange will include a catastrophic plan option. Catastrophic plans have lower premiums, but begin to pay only after you've first paid a certain amount for covered services, or just cover more expensive levels of care, like hospitalizations. Catastrophic plans are an option to consider for young adults and people for whom coverage would otherwise be unaffordable.

claim

An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.

claim form

A form generally filled out by a provider and submitted to your healthplan for consideration of payment of benefits under that healthplan.

COBRA

A federal act that requires group healthplans to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee and termination of employment.

coinsurance

A percentage of an eligible expense that you are required to pay for a service covered by your healthplan.

Coordination of Benefits (COB)

An arrangement where, if you or your dependents are covered under more than one group healthplan, the plans work together to coordinate reimbursement for the medical services you received.

copayment

A fixed dollar amount you are required to pay for a covered service at the time you receive care.

covered person

The person in whose name a health care policy is issued and, in the case of family coverage, the member's/subscriber's dependents.

covered service

A service that is covered according to the terms in your health care policy.


D

deductible

A fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

dependent

A person, other than the member/subscriber (generally a spouse or child), who receives health care coverage under the member's/subscriber's policy.

domestic partner

A person with whom the member/subscriber has entered into a long-term, committed relationship. The relationship must meet the health care plan's specific criteria for a domestic partner.

drug formulary

A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.


E

effective date

The date on which your health care coverage begins.

emergency medical care

Services provided for the initial outpatient treatment of an acute medical condition, usually in a hospital setting. Most healthplans have specific guidelines to define emergency medical care.

employer responsibility

Starting in 2015, if an employer with at least 50 full-time equivalent employees doesn't provide affordable health insurance and an employee uses a tax credit to help pay for insurance through a Health Insurance Exchange, the employer must pay a fee to help cover the cost of tax credits.

essential health benefits

Some benefits will be included in every insurance plan. Beginning in 2014, most insurance plans you can choose from – whether you buy on the health insurance exchange or go directly to the insurance company of your choice – will include many benefits that are meant to make sure basic health concerns are covered.

exclusions

Specific medical conditions or circumstances that are not covered under a health plan.

Explanation of Benefits (EOB)

The form sent to you after a claim has been processed by your healthplan. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, reasons for denying payment and the claims appeal process.


F

family coverage

Health care coverage for a member/subscriber and his/her eligible dependents.

Federal Poverty Level (FPL)

A level of income issued annually by the Department of Health and Human Services  used to determine eligibility for certain programs and benefits. FPL will be used to determine the amount of tax credit you qualify for to offset the cost of purchasing health insurance.


G

generic substitute

A prescription drug that is the generic equivalent of a drug listed on your health plan's formulary.

grandfathered health plan

A health plan that was in place when the new health care law was passed into law. A grandfathered plan is exempt from some requirements of the new law. The grandfather rule enables businesses and families to keep the plan they have, if they wish to. 

group

A group of people covered under the same health care policy and identified by their relation to the same employer.

guaranteed issue

A requirement under the Affordable Care Act that health plans must permit you to enroll in some form of insurance coverage regardless of health status, age, gender or other factors.


H

Health Maintenance Organization (HMO)

An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers.

High Risk Pool Plan (State)

Plans that provide coverage if you have a serious health condition that prevents you from getting private insurance.  The new law established the Pre-existing Condition Insurance Plan. Some states also have their own high risk pool plan. In 2014 when guaranteed issue goes into effect, many states may choose to no longer offer a high risk insurance pool plan.

HIPAA

A federal law which outlines certain rules and requirements employer-sponsored group healthplans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups; most recently amended to add privacy rules which became effective April 14, 2003.


I

individual health insurance plan

Health care coverage for an individual with no covered dependents. Also knows as individual coverage.

in-network

Covered services provided or ordered by your primary care physician (PCP) or another network provider referred by your PCP.

individual mandate

Starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay a penalty on your income tax filing. You won't have to pay an assessment if you have very low income and coverage is unaffordable to you, or for other reasons including your religious beliefs. You can also apply for a waiver asking not to pay an assessment if you don't qualify automatically.

inpatient services

Services provided when a member/subscriber is registered and treated as a bed patient in a health care facility such as a hospital.

insured person

The person to whom health care coverage has been extended by the contract holder, sometimes referred to as a member/subscriber.


J


K


L

lifetime limit

A cap on the total lifetime benefits you may get from your insurance company, either on all coverage or for a certain condition.  A health plan may have a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime), or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services. Under the new health care law, lifetime limits are no longer allowed in most cases.


M

maximum allowance

A fixed amount that providers agree to accept as payment in full for a particular covered service.

maximum annual benefit

The maximum dollar amount your healthplan will pay for a particular health care service or for all health care services provided to you during one year.

Medicaid

A joint federal and state funded program that provides health care coverage for low-income children and families, and for certain aged and disabled individuals.

medical group

A licensed group of doctors or health care providers that contract with a health plan to deliver health care services to plan members/subscribers.

Medicare

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65.

Medicare Part A

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part A provides basic hospital insurance coverage automatically for most eligible persons.

Medicare Part B

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part B provides benefits to help cover the costs of doctors' services.

Medicare Part C

The federal program established to provide health care coverage for eligible senior citizens and certain eligible disabled persons under age 65. Medicare Part C (also known as Medicare+Choice) expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries.

member

The person to whom health care coverage has been extended by the contract holder (generally their employer); sometimes referred to as the insured or insured person; generally used in the health maintenance organization (HMO) context.


N

network

The doctors, hospitals and other health care providers that a health plan has contracted with to deliver health care services to its members/subscribers.


O

open enrollment period

The period of time set up to allow you to choose from available health insurance plans, usually once a year. The first open enrollment period for the new health insurance exchange begins in October 2013.

out-of-network

Services not provided, ordered or referred by your primary care physician (PCP).

out-of-pocket maximum

The maximum amount you have to pay for eligible expenses under your health plan during a defined benefit period.

outpatient services

Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.


P

preauthorization

The process by which a member/subscriber or their primary care physician (PCP) notifies the healthplan, in advance, of plans for the member/subscriber to undergo a course of care such as a hospital admission or a complex diagnostic test.

pre-existing condition

A condition, disability or illness that you have been treated for before applying for new health coverage.

Preferred Provider Organization (PPO)

A healthplan that provides covered services at a discounted cost for subscribers who use network health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network; the subscriber generally pays a greater portion of the cost for such services.

preferred drug list

A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a healthplan's prescription drug list are automatically covered under that plan.

premium

The ongoing amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for insurance coverage. Typically, you will also have a co-payment or deductible amount in addition to your premium.

prescription drugs

Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.

preventive services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

primary care physician (PCP)

The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all healthplans require a PCP.

provider

A licensed health care facility, program, agency, doctor or health professional that delivers health care services.


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