We're Here To Help

A


Actuarial Value (AV)
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. 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 healthcare needs and the terms of your insurance policy.
Adherence
Taking medications as prescribed or following a treatment plan as prescribed by your healthcare provider.
Admitting Rights
Allow a doctor to admit a patient to the hospital.
Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act or ACA, and generally referred to as Obamacare – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The Affordable Care Act’s main focus is on providing more Americans with access to affordable health insurance, improving the quality of healthcare and health insurance, regulating the health insurance industry, and reducing healthcare spending in the US. The law contains hundreds of different provisions that address different aspects of “the healthcare crisis” in the US.
Agent
An agent or broker is a person or business who sells insurance and can help you enroll in a Qualified Health Plan (QHP) through the Marketplace, as well as in a plan not sold through the Marketplace. They can make specific recommendations about which plan you should enroll in, and also help you apply for help paying for coverage. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into plans. Some agents and brokers may only be able to sell plans from specific health insurance companies.
Annual Limits
A cap on the benefits your insurance company will pay in a year while you're enrolled in a health insurance plan. These caps are sometimes placed on 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 healthcare costs for the rest of the year.
Appeal
A request for your health insurance company or the Health Insurance Marketplace to review a decision that denies a benefit or payment.

B


Balanced Billing
Also called “extra billing” or “surprise billing." The practice of a healthcare provider billing a patient for the difference between what the patient's health insurance chooses to reimburse and what the provider chooses to charge.
Brand Name Drugs
A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over-the-counter.
Broker
An agent or broker is a person or business who sells insurance and can help you enroll in a Qualified Health Plan (QHP) through the Marketplace, as well as in a plan not sold through the Marketplace. They can make specific recommendations about which plan you should enroll in, and also help you apply for help paying for coverage. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into plans. Some agents and brokers may only be able to sell plans from specific health insurance companies.
Bronze Plan
A health plan under the Marketplace in which the plan will cover 60% and you would be responsible for 40% of the costs of all covered benefits (on average). 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 healthcare needs and the terms of your insurance policy.
Business Associate
Under HIPAA, a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.

C


Catastrophic Plan
Health plans that meet all of the requirements of Qualified Health Plans (QHPs) but that don't cover any benefits other than three primary care visits per year before the plan's deductible is met. The premium amount you pay each month for healthcare is generally lower than that for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a "hardship exemption" because the Marketplace determined that you’re unable to afford health coverage.
Children’s Health Insurance Program (CHIP)
Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women. Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply any time. If you qualify, your coverage can begin immediately, any time of year.
Co-Insurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Co-Payment
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Complementary and Alternative Medicine (CAM)
Therapies, often combined with mainstream medical therapies, that are used to aid in the treatment of a diagnosis. Examples include chiropractic services, acupuncture, and meditation.
Cost Sharing
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
Covered Entity
Defined in the HIPAA rules as (1) health plans, (2) healthcare clearinghouses, and (3) healthcare providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.

D


Deductible
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Drug Interactions
When one drug affects the activity of another drug. Consumption of certain foods and beverages in combination with some drugs may also impact drug activity.

E


Employer-Sponsored Coverage
Employer-sponsored health coverage is when a person’s employer provides their health insurance. It is the most common type of health insurance. About 149 million nonelderly Americans receive their health benefits through an employer.
Essential Health Benefits
A set of 10 healthcare service categories that must be covered by most plans, starting in 2014. Essential health benefits must include items and services within at least the following 10 categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) pregnancy, maternity and newborn care; (5) mental health and substance use disorder services, including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care.
Exclusive Provider Organization (EPOs)
A managed care plan where services are covered only if you go to healthcare providers, specialists, or hospitals in the plan’s network (except in an emergency).
Extended Day Supply (EDS) Network Pharmacy
A group of pharmacies that are contracted to provide eligible members an extended supply of most commonly prescribed maintenance medications.
External Appeal
A review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn't yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan's decision or overturns all or some of the plan’s decision. The plan must accept this decision.

F


Financial Assistance
The federal government provides two types of assistance plans to cover health insurance costs for those who qualify. The first is through tax credits, the second is through cost sharing reductions.
Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

G


Generic Drugs
A prescription drug that has the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
Gold Plan
Under the Marketplace, a health plan in which the plan will cover 80% and you would be responsible for 20% of the costs of all covered benefits (on average). 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 healthcare needs and the terms of your insurance policy.

H


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 except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Health Savings Account (HSA)
A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses if you have a “high deductible” health insurance plan. Combining a High Deductible Health Plan with a Health Savings Account (HSA) allows you to pay for certain medical expenses, like your deductible and copayments, with untaxed dollars. High-deductible plans usually have lower monthly premiums than plans with lower deductibles. Unlike a Flexible Spending Account (FSA), HSA funds roll over year to year if you don't spend them. You can take the funds with you if you change jobs or leave the work force. Your HSA may also earn interest. You can start an HSA through your own bank or other financial institution.
High Deductible Health Plan (HDHP)
A plan with a higher deductible than a traditional insurance plan. Usually the monthly premium is lower, but you have to pay more health care costs yourself (your deductible) before the insurance company starts to pay its share. A high deductible plan can be combined with a health savings account or a health reimbursement arrangement. This allows you to pay for certain medical expenses with untaxed dollars. For 2018, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family.
HIPAA
Health Insurance Portability and Accountability Act of 1996. (See Privacy Rule) The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs.

I


Immunization Record
Provides a history of all the vaccines you or your child received. This record may be required for certain jobs, travel abroad, or school registration.
Immunizations
Immunizations, or vaccines, safely and effectively use a small amount of a weakened or killed virus or bacteria or lab-made protein that imitate the virus in order to prevent infection by that same virus or bacteria. Common immunizations include those for polio, hepatitis, and influenza.
In-Network Provider
Healthcare providers that have contracted with your insurance company to accept certain negotiated (i.e., discounted) rates. You will typically pay less if you go to a healthcare provider or receive a treatment in-network.
Individual Mandate
Provision under the Affordable Care Act (ACA) that requires most Americans to obtain and maintain health insurance, or an exemption, each month or pay a tax penalty.
Individual Market
When people purchase health insurance on their own. More than 19 million people purchase health insurance on their own. Because individual health insurance is not subsidized by employers or through the tax code, each consumer must pay the entire cost of the premium.
Internal Appeal
The process by which you ask your insurance company to do a full and fair review of its decision to deny payment for your claim or treatment of a condition.

L


Lifetime Limits
A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose 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.

M


Marketplace
A resource established under the Affordable Care Act (ACA) where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state; in other states it is run by the federal government.
Medicaid
A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.
Medicare
A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
  • Medicare Part A: Covered services that are considered “medically necessary to treat a disease or condition.” This may include hospital care, skilled nursing facility care, nursing home care, hospice, and home health services.
  • Medicare Part B: Part B covers two types of services – Medically necessary services that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice, and preventive services that prevent illness (like the flu) or detect it at an early stage when treatment is likely to work best.
  • Medicare Part D: Medicare Prescription Drug Plans (Part D) add prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

O


Open Enrollment Period
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2018 in the Health Insurance Marketplace runs from November 1, 2017 to December 15, 2017. Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage. Job-based plans may have different Open Enrollment Periods. Check with your employer. You can apply and enroll in Medicaid or the Children's Health Insurance Program (CHIP) any time of year. See www.healthcare.gov for additional information on open enrollment.
Out-of-Network Provider
An out-of-network provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate. Some health plans, like HMOs, do not reimburse out-of-network providers or professionals at all, which means that as the patient, you would be responsible for the full amount charged by your healthcare provider. Other health plans offer coverage for out-of-network providers, but your patient responsibility would be higher than it would be if you were seeing an in-network provider.
Out-of-Pocket Cost
Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
Out-of-Pocket Maximum
The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost sharing, or spending for non-essential health benefits. The maximum out-of-pocket limit for any 2017 Marketplace plan is $7,150 for an individual plan and $14,300 for a family plan.”

P


Patient Portal
A secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as recent doctor visits.
Patient’s Bill of Rights
List of guarantees for those receiving healthcare. It may take the form of a law or a non-binding declaration. Typically, a patient's bill of rights guarantees patients information, fair treatment, and autonomy over medical decisions, among other rights.
Personal Health Record (PHR)
Health record where health data and information related to the care of a patient is maintained by the patient.
Platinum Plan
Under the Marketplace, a health plan in which the plan will cover 90% and you would be responsible for 10% of the costs of all covered benefits (on average). 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 healthcare needs and the terms of your insurance policy.
Point of Service Plan (POS)
A type of plan in which you pay less if you use doctors, hospitals, and other healthcare 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.
Preauthorization
A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and healthcare providers outside of the network for an additional cost.
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 Tax Credit
New tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you're due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
Prescription Drugs
Drugs and medications that, by law, require a prescription.
Preventive Care
Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
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 healthcare services for a patient.
Privacy Rule
The federal HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, healthcare clearinghouses, and those healthcare providers that conduct certain healthcare transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.
Protected Health Information (PHI)
Any information about health status, provision of healthcare, or payment for healthcare that can be linked to a specific individual. Under the HIPAA privacy rule, this is interpreted rather broadly and includes any part of a patient's medical record or payment history.

Q


Qualified Health Plan
A major medical health insurance plan that covers all the mandatory benefits of the Affordable Care Act. A Qualified Health Plan is also eligible to be purchased with a subsidy, also known as a premium tax credit.

R


Retail Health Clinic
Walk-in medical clinics in retail settings that are staffed by nurse practitioners and physician assistants who specialize in family healthcare and are trained to diagnose, treat and write prescriptions for common illnesses such as strep throat and ear, eye, sinus, bladder and bronchial infections. Minor wounds, abrasions and joint sprains are treated, and common vaccinations such as influenza, tetanus, pneumococcal disease, and Hepatitis A & B are available. In addition, retail health clinics offer a wide range of wellness services, including sports and camp physicals, smoking cessation and TB testing. Routine lab tests, instant results, and education are available for those with diabetes, high cholesterol, high blood pressure or asthma.

S


Screenings
Screenings are tests that look for diseases before you have symptoms. Screening tests can find diseases early, when they're easier to treat. You can get some screenings in your healthcare provider’s office. Others need special equipment, so you may need to go to a different office or clinic.
Security Rule
The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.
Sexually Transmitted Infections (STIs)
An infection transmitted through sexual contact, caused by bacteria, viruses, or parasites.
Silver Plan
Under the Marketplace, a health plan in which the plan will cover 70% and you would be responsible for 30% of the costs of all covered benefits (on average). 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 healthcare needs and the terms of your insurance policy.
Specialty Medication
Usually injectable, infused, oral or inhaled. Specialty medications require close supervision and monitoring.

T


Telemedicine
The use of telecommunication and information technologies in order to provide clinical healthcare at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities.
Third Party Administrator (TPA)
An organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.
Tier
Drug tiers are how we divide prescription drugs into different levels of cost. Drugs in Tier 1 will be your cheapest options. Drugs in Tier 5 will be the most expensive.

U


Universal Patient Compact
A statement of principles established by the National Patient Safety Foundation (NPSF) to help create and maintain strong partnerships between patients and healthcare providers.
Urgent Care
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.

V


Vaccine Information Statements (VIS)
Information sheets produced by the Centers for Disease Control and Prevention (CDC). The statements explain both the benefits and risks of a vaccine to adult vaccine recipients and the parents or legal guardians of children and adolescents who are receiving the vaccines. Federal law requires that VISs be handed out whenever certain vaccinations are given.

The terms in this glossary are based on definitions provided by the U.S. Department of Health and Human Services.