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Health Care Glossary — Definition of Terms

  • Understanding Health Insurance
Some health insurance terms can be confusing. To combat this, we’ve compiled a list of the most commonly used terms and provided clear definitions, so you can make informed decisions about your health insurance.







A






Actuarial Value

The percentage of total average costs for in-network essential health benefits that a plan will cover. For example, if a plan has an actuarial value of 70% on average, the insured would be responsible for 30% of the costs of the benefits, up to the out-of-pocket maximum. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care use. Actuarial value is NOT the same as coinsurance.


Advanced Premium Tax Credit

Also known as a "Premium Subsidy," this is a tax credit you can use right away to help reduce the cost of an individual health plan purchased through the Health Insurance Marketplace.

Eligibility for this tax credit is based on income level (those with incomes between 100% and 400% of the federal poverty level). The amount for the premium subsidy is based on the individual’s income, and the cost of the second lowest-priced silver plan available to the consumer through the Health Insurance Marketplace.


Affordable Care Act (ACA)

This is the comprehensive health care reform law enacted in March of 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law. This is often times referred to as “health care reform. “



Allowed Amount

Maximum amount on which payment is based for out-of-network covered health services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference.

Note: This definition is intended to be educational and may or may not vary from your actual policy. In any such case, the policy governs.



Ancillary Services

Services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, X-rays and anesthesia.



Appeal

A request for your health insurer to review a decision or a grievance again.



Applicable Large Employer

You employed an average of at least 50 full-time employees (including full-time equivalents) on business days during the last calendar year.

To determine large employer status, calculate the number of full-time employees (including full-time equivalents) you employed in each month of the last calendar year by using the following formula:
  • First, count all employees working 30+ hours as full-time employees.
  • Second, add up all hours worked by part-time employees in a month and divide by 120. This is your number of full-time equivalents.
  • Add the number of full-time employees and full-time equivalents together. If the total is 50 full-time equivalents or more (based on the last calendar year) then you are subject to the employer mandate and a possible tax penalty.

There may be instances in which an employer is considered a small employer under state law, but is also considered an applicable employer for purposes of the employer mandate.




B






Balance Billing

When a provider bills you 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. An in-network provider cannot balance bill you for covered services.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Benefits

This refers to the health care items or services covered under a health insurance plan (but also refers to benefits covered by other types of plans, like a dental plan). Covered benefits and excluded services are defined in the plan's coverage documents.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Behavioral Health

Generally, this is also known as “Mental Health.” This includes conditions such as depression, schizophrenia and anxiety. Behavioral health conditions are listed in the latest edition of the International Classification of Diseases (ICD).



Brand Name Drug

A prescription drug sold by a pharmaceutical company that is protected under a patent or trade name.




C






Calendar Year

The period beginning January 1 of any year through December 31 of the same year.



Catastrophic Plan

An individual major medical plan that is minimum essential coverage and includes essential health benefits but is not categorized as a metallic plan. This is a high-deductible plan that begins to pay for covered services only after the out-of-pocket maximum has been reached. To be eligible for this plan you must be younger than 30 or have received a certificate of exemption (affordability or financial hardship) from the Health Insurance Marketplace.


Certificate of Coverage

This is your health insurance policy. It contains the benefits, limitations and exclusions of coverage provided by your insurance carrier. You will get this document after you sign up for a plan.



Children’s Health Insurance Program (CHIP)

Insurance program jointly funded by the state and federal government that provides health coverage to low-income children. In some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage may be eligible for CHIP.



Claim

This is when you or a provider makes a request to be paid by a health insurance carrier for health services. An example is when your doctor submits a bill to your insurance carrier for care you received during an office visit.



COBRA

Fully known as the “Consolidated Omnibus Budget Reconciliation Act,” this is 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’ll pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.



Coinsurance (On Major Medical Plans)

This is the percentage of covered expenses you are responsible for after you meet your deductible, up to a set limit (out-of-pocket maximum). For example, a coinsurance percentage of 25% means that after the deductible has been met, you pay 25% of covered expenses and the insurance carrier pays 75% until the out-of-pocket maximum has been met. After the maximum is met, the plan pays 100% of covered expenses.



Coinsurance (On Short Term Medical Plans)

Coinsurance is the percent of medical expenses you pay after your deductible and any applicable access fees. You usually share the cost of covered expenses with the insurance carrier. For example, a coinsurance percentage of 20% means that, after the deductible and any applicable access fees, you pay 20% of the covered expenses and the insurance carrier pays 80%, until the out-of-pocket maximum is met.



Consolidated Omnibus Budget Reconciliation Act (COBRA)

This is 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’ll pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.



Contract Year

The period of time from the effective date of a contract to the expiration date of the contract.



Coordination of Benefits (COB)

Rules that are put in place to help decide the payment of benefits when there are two or more health plans. This helps eliminate overinsurance or duplication of benefits.



Copayment

Also known as, “Copay,” this is a fixed amount (for example, $25) you pay for a covered health care service or prescription, at the time of the service.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Cost of Living Adjustment (COLA)

COLA is based on the percentage increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers. It is calculated from the third quarter of the last year a COLA was determined to the third quarter of the current year. If there is no increase, there can be no COLA.



Cost Sharing

The share of costs that you pay out of your own pocket. This term includes deductibles, coinsurance and copayments, or similar charges. It does not include premiums, balance billing amounts for out-of-network providers, or the cost of non-covered services.



Cost-Sharing Reduction (CSR)

A discount that lowers the amount you have to pay out of pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan that is from the silver category. If you’re a member of a federally recognized tribe, you may qualify for additional cost sharing benefits.


Covered Person

A person who is eligible to receive benefits under an insurance carrier’s plan.



Creditable Coverage

Health insurance coverage under any of the following:

  • A group health plan
  • Individual health insurance
  • Student health insurance
  • Medicare
  • Medicaid
  • CHAMPUS and TRICARE
  • The Federal Employees Health Benefits Program
  • Indian Health Service
  • The Peace Corps
  • Public Health Plan
  • Children’s Health Insurance Program
  • State health insurance high risk pool




Custodial Care

For those that need help with daily life activities like bathing, dressing or eating, this is care provided by someone that does not have to be trained in medicine.




D






Deductible (or Plan Deductible)

The amount you pay, in addition to your premium, each calendar year before the plan pays for covered medical expenses. Major medical plans under the Affordable Care Act provide payment for many in-network preventive services even before your deductible is met.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Dependent

An individual who relies on another person for support, or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan. Note: Under the Affordable Care Act, children under age 26 are considered dependents.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Drug List

Also known as a “Drug Formulary,” this is a list of prescription drugs (and specialty pharmaceuticals) that an insurance carrier designates as eligible for benefit payment consideration. Drug lists are subject to change at any time without notice.



Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include, but is not limited to: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.




E






Effective Date

Also known as the “Coverage Start Date,” this is the date insurance coverage begins for a covered person.



Eligible Dependent

A dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for whom premium payment is made.



Eligible Expenses

The amount of the provider bill that is the lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan, payable by the insurance carrier. If you have a PPO plan, it will be the rate agreed to by the provider and the insurance carrier. If you use an out-of-network provider, it will be the maximum allowable amount which is calculated per your policy.



Emergency Treatment

Also known as “Emergency Services” or “Emergency Room Care,” this is the treatment, services or supplies for a medical condition that develops suddenly and unexpectedly and needs to be treated immediately.



Employer Shared Responsibility Payment

This applies to some businesses with 50 or more full-time employees who don't offer insurance, or whose coverage doesn't meet certain minimum standards.


Essential Health Benefits

A list of ten categories of services that fully-insured major medical insurance plans must include. Most plans (individual major medical plans and fully insured small business plans) must offer these benefits, but the specifics within each category will vary by state.

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care


Explanation of Benefits (EOB)

The statement sent to you from your health insurance company listing the health services you received, the amount billed, the eligible expenses and the payment made by the health insurance company. This is not a bill.


F






Family and Medical Leave Act

A Federal law that allows for up to 12 weeks of leave from the workplace when employees need time off to care for a newborn, to adopt a child, to care for a family member or to recover from illness or injury.



Family Plan

An insurance plan that covers you (the primary) and one or more of your dependents (spouse, child, etc.).



Federal Poverty Level (FPL)

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits, like a premium tax credit.



Full-Time Employee

An employee who works an average of at least 30 hours per week (part time would be less than 30 hours per week).




G






Generic Drug

A prescription drug that has the same active ingredients as an equivalent brand name drug or that can be used to treat the same condition as a brand name drug. It does not carry any drug manufacturer's brand name on the label and is not protected by a patent or trade name. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.



Grandfathered Plans


Plans effective on or before the passage of the Affordable Care Act on March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if significant changes are made that reduce benefits or increase costs to consumers.


Grandmothered Plans

Major medical plans that were sold prior to 2014, but are not considered grandfathered plans.These plans exist in states that followed the federal transitional policy. These plans are no longer sold, and include some, but not all, of the Affordable Care Act mandates.



Group Fully Insured

Fully insured group plans offer traditional medical coverage for employers and their employees. Coverage includes preventive care and everyday care, as well as coverage for unexpected illnesses and accidents. All plans are minimum essential coverage and meet the minimum value standard under the Affordable Care Act.



Group Health Plan

In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.


Guaranteed Issue

A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services.



Guaranteed Renewal

A requirement that your health insurance issuer must offer to renew your individual and small group major medical policy as long as you continue to pay premiums. Except in some states, guaranteed renewal doesn't limit how much you can be charged if you renew your coverage. Assurant Health Short Term Medical plans and Group Self-Funded programs are not guaranteed renewal.




H






Habilitative Services

Also known as “Habilitation Services,” these are health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Hardship Exemption

Under the Affordable Care Act, most people must pay a tax penalty if they don’t have health coverage that qualifies as minimum essential coverage. Those who qualify for a hardship exemption do not have to pay the tax penalty. Hardship exemptions may be granted for such things as affordability, bankruptcy and homelessness.



Health Care Practitioner

A person licensed by the state to provide medical care or treatment.



Health Care Provider Network

A group of health care practitioners, facilities and suppliers, who have agreed to accept a contracted rate as payment in full for specific treatment, services or supplies.



Health Care Reform


More formally known as the “Affordable Care Act,” this is the comprehensive health care reform law enacted in March of 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.


Health Insurance

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.



Health Insurance Marketplace

Also known as the “Marketplace,” this is an online insurance exchange where individuals and small businesses can see a choice of health plans that meet certain benefits and cost standards. In some states, the Marketplace is run by the state. In others it is run by the federal government.


Health Maintenance Organization (HMO)

A type of health insurance plan that usually limits coverage to care from doctors who work for, or contract with, the HMO. It generally won't cover out-of-network care (care provided by doctors who are not part of the HMO) except in an emergency. In most HMO plans, members choose a primary care physician (PCP) within the HMO's network. The PCP provides routine care and refers members to network doctors if special care is needed.



Health Savings Account (HSA)

A Health Savings Account (HSA) is a savings plan you can set up to help you save for future health care costs. When a health plan is HSA-compatible, it means a tax-advantaged HSA can be attached to the health plan. There are specific requirements for a health insurance plan to be HSA compatible. HSA's allow the owner to:

  • Open an account with pre-tax funds
  • Pay for qualified medical expenses, like expenses that apply to your deductible, with pre-tax money
  • You pay no taxes on interest, and the account is yours to keep

Assurant Health is not engaged in rendering tax advice. Please see a qualified tax professional for tax advice.


High-Risk Pools

Before the Affordable care Act, these state programs were designed to provide health insurance to residents who were considered medically uninsurable and were unable to buy coverage in the individual market.



Home Health Care

Services provided by a state-licensed home health care agency as part of a program for care and treatment in a covered person’s home.



Hospice

An organization that provides medical services in an inpatient, outpatient or home setting to support and care for persons who are terminally ill, with a life expectancy of 6 months or less, as certified by a physician.



Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.




I






Individual Mandate

A requirement that all individuals obtain coverage by a health insurance plan that meets basic minimum standards (minimum essential coverage). Individuals who aren’t covered by qualifying health insurance may be required to pay a tax penalty. Those with very low income may apply for a waiver of this penalty.



Inpatient

Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.



Insured

A person who has obtained health insurance coverage under a health insurance plan.




L






Lifetime Maximum

The maximum amount of benefits the plan will pay toward medical bills for each covered person. After the Affordable Care Act, major medical plans no longer include lifetime maximums. All Assurant Health Short Term Medical plans have a $2 million lifetime maximum.




M




Major Medical Insurance (For Individuals and Families)

Also known as “Individual major medical” or “ACA-Compliant Plans,” this is a type of medical insurance plan that provides benefits for a broad range of health care services, both inpatient and outpatient. Under the Affordable Care Act, these plans are minimum essential coverage, cover the ten categories of the essential health benefits (as well as pre-existing conditions) and have no lifetime maximums.


Marketplace

Also known as the “Health Insurance Marketplace,” this is an online insurance exchange where individuals and small businesses can see a choice of health plans that meet certain benefits and cost standards. In some states, the Marketplace is run by the state. In others it is run by the federal government.



Medicaid

A joint federal and state program, Medicaid helps cover medical expenses for low-income individuals. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.



Medical Loss Ratio (MLR)

The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. If an insurance company does not meet the required medical loss ratio (MLR), it must return rebates (a portion of the premium paid by the covered person) to customers.



Medical Underwriting

Refers to the use of medical and health information in the evaluation of an applicant for coverage.



Medically Necessary

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.



Medicare

This is the federal health insurance program available to people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).



Metallic Plans

The series of plan types that meet the essential health benefit requirements as defined by health care reform laws. Bronze, silver, gold and platinum refers to the progressively increasing range of coverage levels and corresponding pricing structure.


Minimum Essential Coverage (MEC)

The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act and not be subject to the tax penalty.



Minimum Value

This is an Affordable Care Act requirements that determines whether an employee who is offered coverage through his or her employer can get a subsidized Marketplace plan. A group health plan meets this standard if it's designed to pay at least 60% of the total cost of medical services for a standard population. Individuals offered employer-sponsored coverage that provides minimum value and that’s affordable won’t be eligible for a premium tax credit.




Modified Adjusted Gross Income (MAGI)

Generally, MAGI is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. This figure is used to determine eligibility for Medicaid, CHIP and subsidized Marketplace plans.



N






National Network

A network that includes doctors and hospitals in a number of states.


Navigator

A guide (an individual or organization) provided by the federal government at no charge to help consumers, small businesses, and their employees shop for health coverage on the Marketplace and complete the necessary eligibility and enrollment forms.



Network

A network is comprised of a wide range of doctors, specialists, hospitals, labs, pharmacies and other health care facilities. Health insurance companies contract with these providers who agree to accept certain payments for services.



Non-Grandfatherd Plans

Plans issued after March 23, 2010. Plans with non-grandfathered status must conform to the applicable reform requirements as of the first plan year after January 1, 2014. Only grandfathered and grandmothered plans are not required to comply with all Affordable Act requirements.



Nonparticipating Provider

Also known as “Out-of-Network Provider,” this is a health care provider who does not have a contract with your health plan. You might pay more when you visit this kind of doctor, hospital or other health care professional. Because there is no contracted rate, you may also have to pay over and above what your insurance company determines is allowable.




O






Occupational Therapy

This is inpatient or outpatient treatment that helps you resume life activities after an illness or injury. A health care practitioner, who is an occupational therapist, uses purposeful activities or assistive devices that focus on all of the following:
  1. Developing daily living skills
  2. Strengthening and enhancing function
  3. Coordination of fine motor skills
  4. Muscle and sensory stimulation


Office Visit

An in-person meeting between a covered person and a health care practitioner in the health care practitioner’s office.



Open Enrollment

The period of time set up to allow individuals to choose from available plans, usually once a year. The next open enrollment period starts November 1, 2015 for plans that start on January 1, 2016.



Out of Network

This refers to doctors, hospitals, pharmacies, and other providers who do not belong to a health plan’s network, and therefore do not include network discounts.



Out-of-Pocket Maximum

Sometimes listed as the “Out-of-Pocket Limit,” this is the total amount you and your covered family members must pay before covered medical expenses are paid 100% by Assurant Health. The maximum can include deductibles, coinsurance or copays (where applicable) as defined by the contract. This limit never includes your premium, balance-billed charges for out-of-network treatment or health care your health insurance plan doesn’t cover (it also doesn't include access fees for those with a short term medical plan). When you reach your out-of-pocket maximum, your plan pays 100% of covered expenses for the remainder of the calendar year. For the Assurant Health Short Term Medical plan, the out-of-pocket limit also does not include access fees or the deductible.



Outpatient

This is when you receive care at a medical facility but you’re not admitted as an inpatient to the facility. The term may also refer to the health care services that you receive.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.




P






Participating Pharmacy

A pharmacy that is under contract with an insurance carrier to provide prescription drugs or specialty pharmaceuticals to the covered person through its Participating Pharmacy Network.



Participating Provider

This is a provider within your plan’s network that has been contracted to render medical services or supplies to you for a pre-negotiated fee. Providers include doctors, hospitals, pharmacies and other medical facilities.



Pediatric Dental

"Pediatric Dental" is included as a category of essential health benefits under the Affordable Care Act. This category includes coverage for children aged 18* or younger, and provides benefits for services such as routine exams, cleanings, and specialists fees. Also note that orthodontics are covered in some, but not all, states.

*Age requirements and benefits may vary by state



Pediatric Vision

"Pediatric Vision" is included as a category of essential health benefits under the Affordable Care Act. This category includes coverage for children aged 18* or younger, and provides benefits for eye exams and eye wear.

*Age requirements may vary by state



Penalty

Also known as a “Fee,” if you don’t have a health plan that qualifies as minimum essential coverage, you may have to pay a fee for the year you don’t have the required coverage. In 2015 the fee is the higher of these two dollar amounts: 2% of your income; or $325 per adult ($162.50 per child), up to a maximum of $925. The fee increases every year. You’ll pay the fee on the federal income tax return you file for the coverage year. People with very low incomes and others may be eligible for exemptions.


Pharmacy

An establishment where prescription drugs are dispensed by a licensed pharmacist in accordance with all applicable state and federal laws.



Physical Therapy

This is treatment given by a licensed physical therapist who uses therapeutic exercises and other services to alleviate pain and improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and functional activities of daily living.



Plan Year

A 12-month period of benefits coverage. For individual major medical plans and some group health plans, this may be the same as the calendar year. For other plans, it may not align with the calendar year. To find out when your plan year begins, check your plan documents. For short term medical policies, the plan year is the term of the contract.



Point-of-Service Plans (POS)

These plans permit you to choose providers outside your plan’s network but still encourage you to use network providers.



Policyholder

The person to whom the policy is issued.



Pre-Existing Condition

A health problem that existed or was treated during the 12-month period immediately prior to the effective date of your health insurance coverage.



Preauthorization

Sometimes called “prior authorization,” or “prior approval,” this is a decision by your insurance company or plan that a health care service, treatment, prescription drug or durable medical equipment is medically necessary. Your health insurance or plan may require preauthorization for certain medical services before you receive them, except in an emergency. However, preauthorization isn’t a promise that your health insurance or plan will cover the cost.



Preferred Provider Organization (PPO)

A type of network that contracts with a wide range of medical providers, such as hospitals, doctors and specialists. When you have a health plan that has a PPO network, you pay less if you use providers that belong to the plan’s network. You can still use doctors, hospitals, and providers outside of the network, but you won’t get any network discounts and there could be higher cost-sharing limits for using providers outside the network.


Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.



Premium Subsidy

Also known as an “Advanced Premium Tax Credit” or “Premium Tax Credit,” this is a tax credit you can use right away to help reduce the cost of an individual health plan purchased through the Health Insurance Marketplace.

Eligibility for this tax credit is based on income level (those with incomes between 100% - 400% of the federal poverty level). The amount for the premium subsidy is based on the individual’s income, and the cost of the second lowest-priced silver plan available to the consumer through the Health Insurance Marketplace.



Prescription Drug

Any medication that has been fully approved by the Food and Drug Administration (FDA) for marketing in the United States; and can be legally dispensed only with the written prescription order of a health care practitioner in accordance with applicable state and federal laws.



Preventive Services

Also known as, “Preventive Benefits” or “Wellness Benefits,” these are covered services that are intended to prevent disease or to identify disease while it is more easily treatable. Through the Affordable Care Act, major medical plans are required to cover a number of preventive services at 100% which means the customer does not have to pay a copayment, coinsurance or deductible toward the cost of the services (cost sharing). Preventive/wellness benefits include things such as screenings, vaccinations and mammograms. Benefits typically vary based on age and gender.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Primary Care Physician (PCP)

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. On some plans, you can only see a specialist when you receive a referral from your primary care physician. PPO networks generally do not require referrals from primary care physicians. HMO plans generally do require referrals.



Provider

A doctor, hospital, health professional and other entity, or institutional health care provider that provides a health care service.




Q






Qualified Health Plans

Under the Affordable Care Act, this is an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other legal requirements. A qualified health plan will have a certification by each Marketplace on which it is sold.



Qualifying Life Event

A change in your life that makes you eligible for a 60-day special enrollment period to enroll in health coverage. Some examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry or have a baby).



R






Rate Review

This is a process that allows state insurance departments to review rate increases before they are applied to plans. Rate increases are posted at healthcare.gov Diagonal Arrow.



Rehabilitative Services

Also known as “Rehabilitation Services,” this is specialized treatment that can help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Note: This definition is intended to be educational and may vary from your actual policy. In any such case, the policy governs.



Retail Health Clinic

A licensed facility staffed by a health care practitioner, which is attached to or part of a store, in order to provide general medical treatment or preventive medicine services.




S






Self-Funded Program

Type of plan where the employer takes on the responsibility of paying employees’ and dependents’ medical claims, usually with some stop-loss coverage to help with larger claims. These employers may contract for insurance administrative services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.



Short Term Medical Insurance

Sometimes referred to as “Temporary insurance,” these plans provide coverage for a limited period of time. Typically, these plans offer coverage from one month (30 days) up to six months (180 days). These plans are not minimum essential coverage, do not cover preventive services or pre-existing conditions and do not renew when the plan ends.


Special Enrollment Period

This is a 60-day period triggered by a qualifying life event (such as job loss, marriage, birth of a child, etc.) that allows you to sign up for individual health coverage that is minimum essential coverage, regardless of whether or not it happens during the open enrollment period.



Specialist

Also known as a “Specialty Care Provider,” this is a health care practitioner who is classified as a specialist in a specific medical field and is not considered a primary care doctor.



Specialty Pharmaceuticals

These are types of prescription drugs that may:

  • Be used to treat rare or certain chronic diseases
  • Have a highly targeted, cellular mechanism of action
  • Require injection or other parenteral or unique method of administration
  • Require special administration and monitoring
  • Be regularly supplied by designated specialty pharmacy providers



Subsidy

Financial assistance that can be obtained through the Marketplace and other approved state-based Exchanges. Two forms of financial assistance are available: an advanced premium tax credit (or premium subsidy) that can help lower the amount of premium one pays, and a cost-sharing reduction that will limit the plan’s maximum out-of-pocket costs (and for some, reduce other cost sharing amounts like deductibles, coinsurance or copayments). Subsidies are only available for certain groups of individuals and families.

Try our subsidy estimator to see if you qualify for a premium subsidy.


Summary of Benefits and Coverage

This is a document required by the Affordable Care Act. It is a summary of what a plan covers and what your share of costs will be. It also lists the plan benefits, limitations and exclusions and is provided in the same format across all plans for quick comparison.


Supplemental Plans

Plans that provide benefits in addition to benefits provided under major medical plans. Some examples of supplemental plans are dental, accident and critical illness insurance plans. These plans can help pay for costs not covered by major medical plans such as medical expenses under your deductible, travel expenses, and child care expenses. They should not be used as a replacement for comprehensive medical coverage and do not meet minimum essential coverage requirements.



U






Urgent Care

Treatment or services provided for a sickness or an injury serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.