Glossary

IN THIS SECTION


A

Affordable Care Act

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

Annual Deductible

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

Annual Dollar Limit

A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. Limits may be placed on particular services or on the dollar amount of covered services. After an annual limit is reached, you must pay all associated health care costs for the rest of the 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, sometimes called a "benefit package."



C

Catastrophic Plan

The health insurance exchange will include a catastrophic plan with lower premiums. The plan begins to pay only after you've first paid a certain amount for covered services. This type of plan will only be available to those who qualify.

Claim

An itemized bill for services that have been provided to a plan member, spouse or dependent.

Coinsurance

Your share of the costs of a covered health care service — usually a percentage of an eligible expense. You may pay 20% of an allowed service while your health insurance plan pays 80%. Generally, your coinsurance applies after you meet your deductible.

Copayment

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

Cost Sharing Subsidies

Federal funds available for eligible people to help reduce health insurance out-of-pocket costs such as deductibles, coinsurance or copayments.

Covered Person

The person in whose name a health care policy is issued (the member) and — under family coverage — the member's dependents.

Covered Service

A service that is covered according to the terms of your health insurance policy.



D

Deductible

A fixed amount of expenses you are required to pay before you are reimbursed for a covered service. For example, if your deductible is $1,000, your plan won't pay anything for some services until you've met your $1,000 deductible.

Dependent

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

Drug Formulary

A list of commonly prescribed drugs. Not all drugs in an insurance plan's prescription drug list are automatically covered under that plan.



E

Effective Date

The date your health care coverage begins. Emergency Medical Care Services provided for outpatient treatment of a sudden onset medical condition, usually in a hospital.

Employer Responsibility

Starting in 2014, if an employer with at least 50 full-time 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

Beginning in 2014, most insurance plans you can choose from will include coverage for certain benefits considered "essential" for basic good health. These benefits will be covered whether you go through the health insurance exchange or go directly to the insurance company of your choice.

Exclusions

Specific medical conditions or circumstances that are not covered under a health plan. In 2014, exclusions go away for most insurance plans.

Exchange

See health insurance exchange.

Explanation of Benefits (EOB)

The form sent to you after a claim has been processed by your health care provider. The EOB explains the actions taken on the claim, including the amount paid, the benefit available and the amount you may owe the provider, and other information, such as how to appeal a claim decision.



F

Family Coverage

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

Federal Poverty Level (FPL)

A level of income used by the Department of Health and Human Services to determine eligibility for certain programs and benefits. FPL is one factor that will be used to determine the amount of tax credits you may qualify for to help with the cost of buying health insurance through a health insurance exchange.



G

Grandfathered

A health plan that was in place when the new health care law was signed into law on March 23, 2010. A grandfathered plan is exempt from some requirements of the new law.

Group Plan

A group of people covered under the same health care policy through the same employer.

Guaranteed Coverage

The Affordable Care Act says that insurers must allow you to enroll in insurance regardless of health status, age, gender or other factors.



H

Health Insurance Exchange

The new market where millions of people can shop for, compare and buy health insurance beginning on October 1, 2013. Also called health insurance marketplaces, these exchanges can be accessed via a website or with a phone call. Insurance plans will be offered at various coverage and price levels.

High Risk Pool Plan (Illinois)

These government-offered health plans provide coverage for people with serious health conditions. They are a temporary bridge until the Affordable Care Act's preexisting condition requirements go into effect. That provision says that all people can get health insurance coverage regardless of their health conditions.



I

Individual Health Insurance Plan

Health care coverage for an individual with no covered dependents.
In-Network Covered services provided or ordered by your primary care physician (PCP) or another provider who is in the specific network of providers that your health plan has contracted with.

Individual Mandate

Starting in 2014, the law requires Americans and legal residents to get and maintain health care insurance. You must be enrolled in a health insurance plan that meets basic minimum standards. If you're not, you may be required to pay a penalty on your annual income tax return. You may not have to pay that penalty if you have very low income or for other reasons, including religious beliefs.

Inpatient Services

Services provided when a member/subscriber is admitted into in a health care facility such as a hospital.

Insured Person

The person a contract holder (an employer or insurer) has agreed to provide coverage for, often referred to as a member/subscriber.



L

Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance plan, either on all coverage or for a certain condition. Beginning in January 2014, lifetime limits will no longer be allowed in most cases.



M

Medicaid

A joint federally and state-funded program that provides health care coverage for low-income children and families, and for certain older or disabled people. A provision of the law significantly expands the program in the states that agree to the expansion.

Medicare

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

Member

The person a contract holder (generally an employer) has agreed to provide coverage for, sometimes referred to as the insured or insured person/subscriber.



N

Network

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



O

Open Enrollment Period

The period when you make changes to your health plan coverage or choose a new health plan. They usually occur once a year. The first open enrollment period for purchasing insurance on the health insurance exchange begins October 1, 2013, and goes through March 31, 2014. The next opportunity to enroll will be a year later.

Out-of-Network

Services provided by health care professionals or at facilities that are not not in the network of contracted providers and facilities in your health plan.

Out-of-Pocket Maximum

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

Outpatient Services

Treatment 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 members or their primary care physicians (PCP) notify the health plan, in advance, of plans for treatment 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.

Premium

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

Preventive Services

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

Primary Care Physician (PCP)

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

Provider

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



Q

Qualified Health Plan

An insurance plan that is certified by an exchange, provides essential health benefits, follows established limits on cost-sharing (deductibles, copayments, and out-of-pocket amounts) and meets other requirements.



T

Tax Credits

To help people afford health insurance, those eligible will receive tax credits to help with insurance costs. These credits are also known as premium tax credits, and will make it easier for millions of low- and middle-class Americans to pay for health insurance.

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