Insurance terms

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All

ACA-Compliant Coverage

Also called Obamacare plans, these are health insurance policies that meet all the coverage requirements laid out in the 2010 Affordable Care Act. This sweeping health reform law set new standards for insurance to better protect consumers. All ACA plans must offer essential health benefits, cover preexisting conditions, have no annual/lifetime dollar limits, and meet other requirements. This improved-quality coverage comes with an individual mandate to have insurance or face a tax penalty.

Accident Insurance

Supplemental insurance that covers expenses if you suffer an unexpected injury from an accident, such as broken bones from a bike crash, concussions on the basketball court, burns from a cooking mishap, and more. Accident insurance helps cover costly medical bills, ambulance fees, or unpaid time off work to recover that your regular medical insurance may not address.

Accountable Care Organization

These are healthcare teams that work together to provide coordinated care, aiming to improve quality and cut costs by sharing responsibilities and rewards.

Actuary

These professionals use statistics and analytics to calculate risk and forecast future costs. Health insurance companies rely on actuaries to crunch the numbers on historical claims data and health trends to accurately predict future expenses. This guides pricing and ensures enough premium payment is collected upfront to cover upcoming medical bills that could randomly hit.

Adjuster

An insurance claims adjuster is someone charged with evaluating an insurance claim to determine if and how much an insurance company must pay for the claim under review. An adjuster may be a representative of the insurance company or they may be independent. A claimant can also hire a public adjuster to do their own investigation on the claim, apart from the insurance company.

Admitting Privilege

This is an agreement between doctors and hospitals that allows physicians to admit patients to that hospital for medical treatment or care.

Advance Care Planning Consultations

These discussions take place between healthcare providers and individuals to determine preferences for future medical care. It includes conversations about end-of-life care wishes, ensuring that healthcare aligns with a person’s values and desires.

Advance Directive

An advance directive is a legal document allowing individuals to spell out their healthcare wishes. It may include instructions about life-sustaining treatments and appointing someone to make healthcare decisions on their behalf if they cannot communicate.

Advance Insurance Premium Payment

This can be the first or binder payment of an insurance policy, or it may be a payment made before the scheduled first payment for a policy that the insurance company makes available to the policyholder, typically, for a discount or as part of a promotion.

Advance Premium Tax Credit

This government subsidy helps reduce the cost of health insurance premiums for eligible individuals or families with lower incomes.

Adverse Determination

With respect to health insurance, an adverse benefit determination refers to a situation where the insurance company denies a benefit, refuses payment for a service already received, or rescinds health coverage.

Adverse Selection

Adverse selection is a situation in which those who expect to need more healthcare services are the ones signing up for insurance. It can lead to imbalanced risk pools and potentially higher costs for insurers, affecting the stability of insurance plans.

Affordable Care Act (ACA)

The ACA is a comprehensive healthcare reform law aimed to improve healthcare accessibility, affordability, and quality in the United States. Sometimes known as Obamacare, it introduced measures such as health insurance marketplaces, subsidies, and protections against insurance denials due to preexisting conditions.

Agent

In healthcare, an agent is a licensed individual who assists in finding and purchasing health insurance plans that match a person's needs. They help buyers navigate the various insurance options available in the market.

Allowed Amount

This is the maximum dollar amount a health insurer agrees to pay for any medical service, treatment, test, etc. Anything above this agreed rate will be billed to patients as "balance billing." Rate negotiations between health providers and insurance carriers establish allowed amounts for every covered service, from a 15-minute doctor visit to an organ transplant surgery.

American Rescue Plan

This legislative package provided economic relief during the COVID-19 pandemic. It included measures to expand and increase subsidies for health insurance plans under the ACA, reducing costs for many individuals and families.

Annual Limit

This refers to the maximum amount an insurance plan will pay for covered services in one year. The ACA prohibited most health insurance plans from imposing annual limits on essential health benefits to ensure adequate coverage for individuals.

Appeal

If a claim is denied by the insurance company, the insured person can request they take a second look and reconsider covering it. Submitting a formal appeal with evidence from your doctor allows you to contest your insurer's decision. Health plans must outline the appeals process, which starts with an internal review and can escalate to external third parties or a court. Appeals allow you to stand up for your right to fair coverage.

Application (App)

With respect to health insurance, an application is a form providing the insurer with certain information necessary to underwrite one’s health risks. It is typically attached to the insurance contract as part of the “entire contract.”

Association Health Plan

These plans allow small businesses or self-employed individuals to join together to purchase health insurance. It aims to give them access to more affordable coverage by leveraging the buying power of a larger group.

Authorized Representative

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

Balance Billing

This is the amount a healthcare provider charges a patient for the difference between what their insurance covers and the cost of the services rendered.

Benchmark Plan

This is a plan that is used as a reference point for determining the level of coverage and costs for health insurance offered in a particular area.

Beneficiary

Beneficiaries receive advantages or payments from an insurance policy, as in the case of a person covered by a health insurance plan. Beneficiaries can have any health insurance, including Medicare, Medicaid, or private coverage.

Benefit Cap

Some plans limit coverage for health treatments or services by capping the number of visits or dollar amount they'll shell out for them in a year. For example, an insured person may encounter a hard cutoff after 20 chiropractor sessions or 30 physical therapy appointments annually. Other caps could restrict how much the plan covers for high-cost infertility treatments. While benefit caps aim to prevent overutilization, knowing which critical services have limits can help buyers choose the best insurance policy.

Benefits Year

Unlike the calendar year, which starts fresh on January 1, a benefit year is based on the date when a plan began. This 12-month cycle serves as the basis for all the elements of a policy, from deductibles, out-of-pocket maximums, and covered drugs to in-network providers and more. It's essentially how insurance companies keep track of a person’s accumulating costs and enrollment specifics over time. Switching plans mid-year? Understanding the benefit year provided insight into upcoming changes to expect.

Book of Business

A book of business, in the context of insurance, is a database or “book” that lists all of the insurance policies the insurance company has written or completed.

Brand-Name Drugs

These are medications with exclusive patent-protected names, like Vyvanse for treating ADHD or Keytruda for different types of cancer. Despite high price tags, they advertise directly to patients because no generic equivalents exist yet to compete with them. Being the only one on the shelves gives brand-name drugs the leverage to charge more and maximize profits during the patent protection period. This contributes to rising insurance premiums. If you prefer brand names over generics, be prepared to pay hefty coinsurance costs or copays.

Broker

Brokers are like the matchmakers of insurance. They help buyers find and enroll in the right insurance plan to suit their needs.

Bronze Plan

This is one of the tiers of health insurance plans under the ACA and usually offers lower monthly premiums but higher out-of-pocket costs for healthcare services.

Bundled Plan

Bundled plans combine different types of insurance coverage, like health, dental, and vision, into one convenient plan.

CO-OP

The Consumer Operated and Oriented Plan program, or CO-OP, is designed to provide nonprofit, member-governed health insurance options.

COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families to continue their employer-sponsored health insurance coverage temporarily after leaving a job, usually at a higher cost.

Cancelation

With respect to health insurance, a cancellation refers to the termination of the insurance policy or coverage either by the insurance company or the insured person before the end of the period of coverage.

Cancer Insurance Policy

This type of insurance provides financial support if someone is diagnosed with cancer. It helps cover treatment costs, including medical bills, medications, and other related expenses.

Capitation

This alternative payment model is like a flat-rate subscription for healthcare services. Capitation is a payment method in which healthcare providers receive a fixed amount per patient to cover all necessary medical services. Primary care physicians or integrated hospital-insurer networks will manage total care for a large patient group under an agreed-upon capitated rate paid upfront on a monthly basis by associated health plans. This prepaid lump sum remains the same per member regardless of utilization levels or whether they are healthy versus battling complex diseases. By prepaying for expected care expenses based on large-scale projections, this system incentivizes efficient preventative services over costly acute treatments.

Carrier

A carrier is another name for an insurance company that offers insurance coverage, manages policies, and pays for covered services.

Case Management

When prolonged hospitalizations or complex chronic illnesses lead to intensive ongoing care needs, case management helps coordinate treatments with medical teams, health plan administrators, patients, and family caregivers. These patient-centered services aim to optimize recovery outcomes and quality of life while managing the runaway costs of ambulant visits, home therapies, community care referrals, special equipment acquisition, etc. Case managers help enhance continuity and reduce duplication and contradictions across multi-specialist providers.

Catastrophic Plan

These are high-deductible health plans designed for young or healthy individuals, offering minimal coverage but protection in cases of severe medical emergencies or accidents.

Centers for Medicare and Medicaid Services (CMS)

CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

Certificate of Creditable Coverage

Proof of a person’s current or most recent insurance policy details will come via this official document, usually provided when coverage ends or changes. It provides evidence that legally entitles you to enroll in another individual or group health plan without exclusions or waiting periods imposed based on preexisting conditions. Certificates list the start and end dates, covered dependents, prior payer contact info, policy numbers, etc.

Certificate of Insurance

Think of this as the membership card for an insurance policy. It is a document that confirms your coverage details, such as the type of insurance, coverage period, and benefits included.

Children's Health Insurance Program (CHIP)

CHIP provides low-cost health coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance.

Claim

The claim is a request for payment submitted by a healthcare provider to an insurance company for services provided to a patient.

Clause

Since health insurance is a contract, it includes clauses. A clause in this context refers to the financial responsibility of the insurance company to the policyholder as stipulated in the contract.

Closed Formulary

A list of medications (formulary) which may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.

Coinsurance

Think of this as cost-sharing in a joint venture. It is the percentage of healthcare costs you share with your insurance company after you have paid your deductible.

Commission

In terms of insurance, a commission is a fee in a percentage of the premium that an insurance company pays an insurance agent in exchange for soliciting applications for insurance for the company.

Community Rating

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

Composite Rate

A composite rate is an insurance premium based on the average risk profile of a group rather than the risk profile of an individual policyholder. A composite rate implies that all members of a particular group pay the same insurance premium for coverage.

Comprehensive Coverage

Comprehensive coverage includes a wide range of healthcare services and treatments, offering extensive protection against various health issues.

Coordination of Benefits

Coordination of Benefits (COB) refers to the rules that determine the primary plan and the secondary plan when an insured has two or more policies covering the same risks. It prevents insurers from overpaying for claims.

Copayment

Copayments are fixed amounts paid for specific services covered by insurance, often due at the time of service.

Cost Sharing

This involves sharing expenses between an insured person and their insurance company, including deductibles, copayments, and coinsurance.

Cost-Sharing Reduction

A subsidy for eligible individuals or families to reduce out-of-pocket costs such as deductibles, copayments, and coinsurance. If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

Coverage Exclusions

Every policy will list exclusions, or services they don’t cover. Certain prescription meds, alternative treatments, extremely high-cost new therapies, or experimental procedures will almost never be included. Say you want LASIK eye surgery? Most health plans strongly resist covering these vision enhancements as a "non-essential benefit.” Digging through exclusions upfront helps avoid unpleasant surprise bills later.

Covered Services

This term refers to the comprehensive list of medical care, tests, treatments, therapies, and services covered by your health insurance. Everything from preventive scans to complex surgery may fall under this umbrella, as long as it's deemed medically necessary.

Critical Illness Plan

Like a safety net for tough times, this insurance policy pays a lump sum or provides a benefit if the insured person is diagnosed with a serious illness such as cancer, stroke, or heart attack.

Deductible

A deductible is an out-of-pocket fee that an insured needs to pay as part of their insurance coverage. If an insured has a loss, they need to pay up to their deductible limit first before their insurance policy will cover the rest of the damages.

Defined-Benefit Plan

This is a retirement plan in which an employer promises specific benefits upon retirement, often including healthcare coverage.

Denial of Claim

A claim denial occurs when an insurance company refuses to pay for specific services or treatments outlined in a claim.

Dental Discount Plan

This program offers discounts on dental services for an annual fee but does not provide insurance coverage.

Dental Insurance

Because dental care is usually not included in primary health insurance, purchasing supplemental insurance, such as a dental plan, is necessary. It helps cover the cost of dental care and treatments, including routine check-ups, cleanings, fillings, and more.

Dependent

These are like the plus-ones on an insurance plan. Dependents, such as children or spouses, are covered by someone else's health insurance policy.

Digital Medicine Cabinet

This term refers to one of the features available to all members of HealthBird. The digital medicine cabinet is a feature that allows our members to search, add, and keep track of their prescriptions, medications and supplements.

Direct Primary Care

This is a healthcare model in which patients pay a monthly fee directly to a primary care physician for comprehensive primary healthcare services without involving insurance companies.

Earned Premium

Policyholders usually pay their premiums in advance. However, insurance companies do not immediately account for these premiums in their earnings. Rather, they earn the premium at even rates throughout the term of the policy. Therefore, the portion of premium that applies to the expired portion of the policy becomes the earned premium. Similarly, the portion of premium received that applies to the remaining term of the policy becomes the unearned premium reserve.

Easy Enrollment Program

Think of this as the express lane for insurance sign-up. It's a simplified process that makes it easier for individuals to enroll in health insurance plans without complex paperwork or hurdles.

Easy Pricing

Easy pricing refers to transparent and straightforward pricing structures for healthcare services or insurance plans, helping consumers understand costs easily.

Effective Date

This is the start date for a person’s insurance coverage. It's the date when your insurance policy becomes active and starts providing coverage for healthcare services.

Effectuated Enrollment

This refers to the number of individuals who have successfully enrolled in a health insurance plan and have active coverage.

Electronic Health Record (EHR)

EHRs are electronic versions of patients' medical records containing information about their health history, treatments, medications, and more. They are accessible to healthcare providers.

Electronic Medical Record (EMR)

EMRs contain patients' medical information as recorded by a specific healthcare provider or facility, aiding patient care within that practice or institution.

Eligibility

Eligibility requirements, in the context of insurance, are requirements that an individual must meet in order to qualify for an insurance policy.

Eligibility Period

An eligibility period is the time frame following the eligibility date, usually 31 days, during which potential members of a group may enroll in a benefits program, e.g. health insurance, life insurance, or disability insurance, without evidence of insurability.

Embedded Deductible

An embedded deductible is a feature in family health insurance plans that allows each member to have their own individual deductible within the overall family deductible.

Emergency Room

Both urgent care and emergency rooms provide medical care, but they serve different levels of urgency. The emergency room is for life-threatening emergencies that require immediate medical attention, such as chest pain, difficulty breathing, severe bleeding, broken bones, head injuries, seizures, and poisoning. It provides a wider range of services than urgent care, including CT scans, MRIs, surgery, and intensive care, but has longer wait times and higher costs. The emergency room is open 24/7.

Employer Mandate

It's a provision under the ACA that requires certain employers to provide health insurance coverage to their employees or face penalties.

Employer Shared-Responsibility Payment

This is a penalty imposed on certain large employers if they fail to provide their employees with affordable health insurance that meets minimum coverage standards.

Employer Shared-Responsibility Provision

This is like a rulebook for employers regarding health insurance. It outlines the obligations and requirements for certain large employers under the Affordable Care Act to offer health insurance to their employees.

Employer Tax Credits

Tax credits are available to small businesses that provide health insurance coverage to their employees, helping offset the costs.

Employer-Sponsored Health Insurance

This refers to employers' health insurance plans, which typically provide group coverage at more affordable rates.

Employer-Sponsored Health Plans

These are health insurance plans employers offer their employees, sometimes with multiple options based on individual needs.

Enrollment Period

An enrollment period is a specific time period during which a person can get health insurance, make changes in their policy, or qualify and apply for government subsidies.

Essential Health Benefits

Essential health benefits are a set of services that health insurance plans must cover, including preventive care, prescription drugs, and maternity care, as required by the ACA.

Exclusion

An exclusion refers to specific medical conditions, services, or treatments not covered by an insurance policy.

Explanation of Benefits (EOB)

This is a statement sent by an insurance company to the insured person explaining the healthcare services provided, the amount paid by the insurance, and any remaining costs the patient owes.

Family Glitch

The family glitch is a rule that prevents some families with employer-sponsored health insurance from receiving financial assistance for marketplace coverage. It happens when the employer's coverage is considered "affordable" for the employee, even if it's not affordable for the entire family. This makes marketplace coverage too expensive for many families, leaving them with limited options.

Federal Poverty Level (FPL)

The FPL sets income thresholds used to determine eligibility for various healthcare programs under the Affordable Care Act (ACA). It helps decide who qualifies for subsidies, Medicaid, or CHIP by comparing household income to these set levels. In 2023, 400% above the FPL represents an income of $111K for one person or $228K for a family of four.

Federally Facilitated Marketplace (FFM)

The FFM is an online platform the federal government runs where individuals and families can compare, shop for, and enroll in health insurance plans. It serves as a marketplace for different insurance options.

Fee-for-Service

This is a payment model in which healthcare providers charge for each service or treatment they provide.

Fiduciary

A fiduciary is a person who holds a legal or ethical relationship of trust with one or more other parties. Fiduciaries are persons or organizations that act on behalf of others and are required to put the clients’ interests ahead of their own.

Final Adverse Benefit Determination

A final internal adverse benefit determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility.

Flexible Spending Account (FSA)

An FSA is a savings account you can contribute to from your paycheck before taxes. You can use this money for qualified medical costs like copayments, deductibles, and some over-the-counter items. Notably, FSAs are tax-free.

Formulary

A drug formulary is a list of drugs approved by a health insurance provider, categorized by cost.

Free Look Period

The Free Look Period allows you to review your insurance policy after purchasing it. If you change your mind within this period, you can cancel the policy and get a refund without penalties.

Full-Time Equivalent (FTE)

This is a measure employers use to determine whether they're required to offer health insurance under specific laws. It's calculated by adding up all the hours part-time employees work and converting them into the equivalent of full-time employees.

Gatekeeper

A gatekeeper is a healthcare provider who is the first point of contact for patients, and who decides what level of care the patient will get next. Oftentimes, primary care physicians are gatekeepers in the healthcare system.

General Agent

General agents are insurance agents who sell insurance products to other insurance agents or brokers. The other insurance agents and brokers then sell these products to the people or companies who will be using the insurance. General agents act as insurance wholesalers as opposed to insurance retailers.

Generic Drug

Once a brand-name drug's patent expires, other companies can offer the same medication at a lower cost as a generic drug. These alternative versions contain the same active ingredients and work just as effectively but without the hefty brand-name price tag. Choosing generic drugs is a smart way to manage your healthcare expenses while still getting the necessary medication.
A

ACA-Compliant Coverage

Also called Obamacare plans, these are health insurance policies that meet all the coverage requirements laid out in the 2010 Affordable Care Act. This sweeping health reform law set new standards for insurance to better protect consumers. All ACA plans must offer essential health benefits, cover preexisting conditions, have no annual/lifetime dollar limits, and meet other requirements. This improved-quality coverage comes with an individual mandate to have insurance or face a tax penalty.

Accident Insurance

Supplemental insurance that covers expenses if you suffer an unexpected injury from an accident, such as broken bones from a bike crash, concussions on the basketball court, burns from a cooking mishap, and more. Accident insurance helps cover costly medical bills, ambulance fees, or unpaid time off work to recover that your regular medical insurance may not address.

Accountable Care Organization

These are healthcare teams that work together to provide coordinated care, aiming to improve quality and cut costs by sharing responsibilities and rewards.

Actuary

These professionals use statistics and analytics to calculate risk and forecast future costs. Health insurance companies rely on actuaries to crunch the numbers on historical claims data and health trends to accurately predict future expenses. This guides pricing and ensures enough premium payment is collected upfront to cover upcoming medical bills that could randomly hit.

Admitting Privilege

This is an agreement between doctors and hospitals that allows physicians to admit patients to that hospital for medical treatment or care.

Adjuster

An insurance claims adjuster is someone charged with evaluating an insurance claim to determine if and how much an insurance company must pay for the claim under review. An adjuster may be a representative of the insurance company or they may be independent. A claimant can also hire a public adjuster to do their own investigation on the claim, apart from the insurance company.

Advance Care Planning Consultations

These discussions take place between healthcare providers and individuals to determine preferences for future medical care. It includes conversations about end-of-life care wishes, ensuring that healthcare aligns with a person’s values and desires.

Advance Directive

An advance directive is a legal document allowing individuals to spell out their healthcare wishes. It may include instructions about life-sustaining treatments and appointing someone to make healthcare decisions on their behalf if they cannot communicate.

Advance Insurance Premium Payment

This can be the first or binder payment of an insurance policy, or it may be a payment made before the scheduled first payment for a policy that the insurance company makes available to the policyholder, typically, for a discount or as part of a promotion.

Advance Premium Tax Credit

This government subsidy helps reduce the cost of health insurance premiums for eligible individuals or families with lower incomes.

Adverse Determination

With respect to health insurance, an adverse benefit determination refers to a situation where the insurance company denies a benefit, refuses payment for a service already received, or rescinds health coverage.

Adverse Selection

Adverse selection is a situation in which those who expect to need more healthcare services are the ones signing up for insurance. It can lead to imbalanced risk pools and potentially higher costs for insurers, affecting the stability of insurance plans.

Affordable Care Act (ACA)

The ACA is a comprehensive healthcare reform law aimed to improve healthcare accessibility, affordability, and quality in the United States. Sometimes known as Obamacare, it introduced measures such as health insurance marketplaces, subsidies, and protections against insurance denials due to preexisting conditions.

Agent

In healthcare, an agent is a licensed individual who assists in finding and purchasing health insurance plans that match a person's needs. They help buyers navigate the various insurance options available in the market.

Allowed Amount

This is the maximum dollar amount a health insurer agrees to pay for any medical service, treatment, test, etc. Anything above this agreed rate will be billed to patients as "balance billing." Rate negotiations between health providers and insurance carriers establish allowed amounts for every covered service, from a 15-minute doctor visit to an organ transplant surgery.

American Rescue Plan

This legislative package provided economic relief during the COVID-19 pandemic. It included measures to expand and increase subsidies for health insurance plans under the ACA, reducing costs for many individuals and families.

Annual Limit

This refers to the maximum amount an insurance plan will pay for covered services in one year. The ACA prohibited most health insurance plans from imposing annual limits on essential health benefits to ensure adequate coverage for individuals.

Appeal

If a claim is denied by the insurance company, the insured person can request they take a second look and reconsider covering it. Submitting a formal appeal with evidence from your doctor allows you to contest your insurer's decision. Health plans must outline the appeals process, which starts with an internal review and can escalate to external third parties or a court. Appeals allow you to stand up for your right to fair coverage.

Application (App)

With respect to health insurance, an application is a form providing the insurer with certain information necessary to underwrite one’s health risks. It is typically attached to the insurance contract as part of the “entire contract.”

Association Health Plan

These plans allow small businesses or self-employed individuals to join together to purchase health insurance. It aims to give them access to more affordable coverage by leveraging the buying power of a larger group.

Authorized Representative

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
B

Balance Billing

This is the amount a healthcare provider charges a patient for the difference between what their insurance covers and the cost of the services rendered.

Benchmark Plan

This is a plan that is used as a reference point for determining the level of coverage and costs for health insurance offered in a particular area.

Beneficiary

Beneficiaries receive advantages or payments from an insurance policy, as in the case of a person covered by a health insurance plan. Beneficiaries can have any health insurance, including Medicare, Medicaid, or private coverage.

Benefit Cap

Some plans limit coverage for health treatments or services by capping the number of visits or dollar amount they'll shell out for them in a year. For example, an insured person may encounter a hard cutoff after 20 chiropractor sessions or 30 physical therapy appointments annually. Other caps could restrict how much the plan covers for high-cost infertility treatments. While benefit caps aim to prevent overutilization, knowing which critical services have limits can help buyers choose the best insurance policy.

Benefits Year

Unlike the calendar year, which starts fresh on January 1, a benefit year is based on the date when a plan began. This 12-month cycle serves as the basis for all the elements of a policy, from deductibles, out-of-pocket maximums, and covered drugs to in-network providers and more. It's essentially how insurance companies keep track of a person’s accumulating costs and enrollment specifics over time. Switching plans mid-year? Understanding the benefit year provided insight into upcoming changes to expect.

Book of Business

A book of business, in the context of insurance, is a database or “book” that lists all of the insurance policies the insurance company has written or completed.

Brand-Name Drugs

These are medications with exclusive patent-protected names, like Vyvanse for treating ADHD or Keytruda for different types of cancer. Despite high price tags, they advertise directly to patients because no generic equivalents exist yet to compete with them. Being the only one on the shelves gives brand-name drugs the leverage to charge more and maximize profits during the patent protection period. This contributes to rising insurance premiums. If you prefer brand names over generics, be prepared to pay hefty coinsurance costs or copays.

Broker

Brokers are like the matchmakers of insurance. They help buyers find and enroll in the right insurance plan to suit their needs.

Bronze Plan

This is one of the tiers of health insurance plans under the ACA and usually offers lower monthly premiums but higher out-of-pocket costs for healthcare services.

Bundled Plan

Bundled plans combine different types of insurance coverage, like health, dental, and vision, into one convenient plan.
C

Cancelation

With respect to health insurance, a cancellation refers to the termination of the insurance policy or coverage either by the insurance company or the insured person before the end of the period of coverage.

Cancer Insurance Policy

This type of insurance provides financial support if someone is diagnosed with cancer. It helps cover treatment costs, including medical bills, medications, and other related expenses.

Capitation

This alternative payment model is like a flat-rate subscription for healthcare services. Capitation is a payment method in which healthcare providers receive a fixed amount per patient to cover all necessary medical services. Primary care physicians or integrated hospital-insurer networks will manage total care for a large patient group under an agreed-upon capitated rate paid upfront on a monthly basis by associated health plans. This prepaid lump sum remains the same per member regardless of utilization levels or whether they are healthy versus battling complex diseases. By prepaying for expected care expenses based on large-scale projections, this system incentivizes efficient preventative services over costly acute treatments.

Case Management

When prolonged hospitalizations or complex chronic illnesses lead to intensive ongoing care needs, case management helps coordinate treatments with medical teams, health plan administrators, patients, and family caregivers. These patient-centered services aim to optimize recovery outcomes and quality of life while managing the runaway costs of ambulant visits, home therapies, community care referrals, special equipment acquisition, etc. Case managers help enhance continuity and reduce duplication and contradictions across multi-specialist providers.

Carrier

A carrier is another name for an insurance company that offers insurance coverage, manages policies, and pays for covered services.

Catastrophic Plan

These are high-deductible health plans designed for young or healthy individuals, offering minimal coverage but protection in cases of severe medical emergencies or accidents.

Centers for Medicare and Medicaid Services (CMS)

CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

Certificate of Insurance

Think of this as the membership card for an insurance policy. It is a document that confirms your coverage details, such as the type of insurance, coverage period, and benefits included.

Certificate of Creditable Coverage

Proof of a person’s current or most recent insurance policy details will come via this official document, usually provided when coverage ends or changes. It provides evidence that legally entitles you to enroll in another individual or group health plan without exclusions or waiting periods imposed based on preexisting conditions. Certificates list the start and end dates, covered dependents, prior payer contact info, policy numbers, etc.

Children's Health Insurance Program (CHIP)

CHIP provides low-cost health coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance.

Claim

The claim is a request for payment submitted by a healthcare provider to an insurance company for services provided to a patient.

Clause

Since health insurance is a contract, it includes clauses. A clause in this context refers to the financial responsibility of the insurance company to the policyholder as stipulated in the contract.

Closed Formulary

A list of medications (formulary) which may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.

CO-OP

The Consumer Operated and Oriented Plan program, or CO-OP, is designed to provide nonprofit, member-governed health insurance options.

COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families to continue their employer-sponsored health insurance coverage temporarily after leaving a job, usually at a higher cost.

Coinsurance

Think of this as cost-sharing in a joint venture. It is the percentage of healthcare costs you share with your insurance company after you have paid your deductible.

Commission

In terms of insurance, a commission is a fee in a percentage of the premium that an insurance company pays an insurance agent in exchange for soliciting applications for insurance for the company.

Community Rating

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

Composite Rate

A composite rate is an insurance premium based on the average risk profile of a group rather than the risk profile of an individual policyholder. A composite rate implies that all members of a particular group pay the same insurance premium for coverage.

Comprehensive Coverage

Comprehensive coverage includes a wide range of healthcare services and treatments, offering extensive protection against various health issues.

Coordination of Benefits

Coordination of Benefits (COB) refers to the rules that determine the primary plan and the secondary plan when an insured has two or more policies covering the same risks. It prevents insurers from overpaying for claims.

Copayment

Copayments are fixed amounts paid for specific services covered by insurance, often due at the time of service.

Cost Sharing

This involves sharing expenses between an insured person and their insurance company, including deductibles, copayments, and coinsurance.

Cost-Sharing Reduction

A subsidy for eligible individuals or families to reduce out-of-pocket costs such as deductibles, copayments, and coinsurance. If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

Critical Illness Plan

Like a safety net for tough times, this insurance policy pays a lump sum or provides a benefit if the insured person is diagnosed with a serious illness such as cancer, stroke, or heart attack.

Coverage Exclusions

Every policy will list exclusions, or services they don’t cover. Certain prescription meds, alternative treatments, extremely high-cost new therapies, or experimental procedures will almost never be included. Say you want LASIK eye surgery? Most health plans strongly resist covering these vision enhancements as a "non-essential benefit.” Digging through exclusions upfront helps avoid unpleasant surprise bills later.

Covered Services

This term refers to the comprehensive list of medical care, tests, treatments, therapies, and services covered by your health insurance. Everything from preventive scans to complex surgery may fall under this umbrella, as long as it's deemed medically necessary.
D

Deductible

A deductible is an out-of-pocket fee that an insured needs to pay as part of their insurance coverage. If an insured has a loss, they need to pay up to their deductible limit first before their insurance policy will cover the rest of the damages.

Defined-Benefit Plan

This is a retirement plan in which an employer promises specific benefits upon retirement, often including healthcare coverage.

Denial of Claim

A claim denial occurs when an insurance company refuses to pay for specific services or treatments outlined in a claim.

Dental Discount Plan

This program offers discounts on dental services for an annual fee but does not provide insurance coverage.

Dental Insurance

Because dental care is usually not included in primary health insurance, purchasing supplemental insurance, such as a dental plan, is necessary. It helps cover the cost of dental care and treatments, including routine check-ups, cleanings, fillings, and more.

Dependent

These are like the plus-ones on an insurance plan. Dependents, such as children or spouses, are covered by someone else's health insurance policy.

Digital Medicine Cabinet

This term refers to one of the features available to all members of HealthBird. The digital medicine cabinet is a feature that allows our members to search, add, and keep track of their prescriptions, medications and supplements.

Direct Primary Care

This is a healthcare model in which patients pay a monthly fee directly to a primary care physician for comprehensive primary healthcare services without involving insurance companies.
E

Earned Premium

Policyholders usually pay their premiums in advance. However, insurance companies do not immediately account for these premiums in their earnings. Rather, they earn the premium at even rates throughout the term of the policy. Therefore, the portion of premium that applies to the expired portion of the policy becomes the earned premium. Similarly, the portion of premium received that applies to the remaining term of the policy becomes the unearned premium reserve.

Easy Enrollment Program

Think of this as the express lane for insurance sign-up. It's a simplified process that makes it easier for individuals to enroll in health insurance plans without complex paperwork or hurdles.

Easy Pricing

Easy pricing refers to transparent and straightforward pricing structures for healthcare services or insurance plans, helping consumers understand costs easily.

Eligibility

Eligibility requirements, in the context of insurance, are requirements that an individual must meet in order to qualify for an insurance policy.

Eligibility Period

An eligibility period is the time frame following the eligibility date, usually 31 days, during which potential members of a group may enroll in a benefits program, e.g. health insurance, life insurance, or disability insurance, without evidence of insurability.

Effective Date

This is the start date for a person’s insurance coverage. It's the date when your insurance policy becomes active and starts providing coverage for healthcare services.

Effectuated Enrollment

This refers to the number of individuals who have successfully enrolled in a health insurance plan and have active coverage.

Electronic Health Record (EHR)

EHRs are electronic versions of patients' medical records containing information about their health history, treatments, medications, and more. They are accessible to healthcare providers.

Electronic Medical Record (EMR)

EMRs contain patients' medical information as recorded by a specific healthcare provider or facility, aiding patient care within that practice or institution.

Embedded Deductible

An embedded deductible is a feature in family health insurance plans that allows each member to have their own individual deductible within the overall family deductible.

Emergency Room

Both urgent care and emergency rooms provide medical care, but they serve different levels of urgency. The emergency room is for life-threatening emergencies that require immediate medical attention, such as chest pain, difficulty breathing, severe bleeding, broken bones, head injuries, seizures, and poisoning. It provides a wider range of services than urgent care, including CT scans, MRIs, surgery, and intensive care, but has longer wait times and higher costs. The emergency room is open 24/7.

Employer Mandate

It's a provision under the ACA that requires certain employers to provide health insurance coverage to their employees or face penalties.

Employer Shared-Responsibility Payment

This is a penalty imposed on certain large employers if they fail to provide their employees with affordable health insurance that meets minimum coverage standards.

Employer Shared-Responsibility Provision

This is like a rulebook for employers regarding health insurance. It outlines the obligations and requirements for certain large employers under the Affordable Care Act to offer health insurance to their employees.

Employer Tax Credits

Tax credits are available to small businesses that provide health insurance coverage to their employees, helping offset the costs.

Employer-Sponsored Health Insurance

This refers to employers' health insurance plans, which typically provide group coverage at more affordable rates.

Employer-Sponsored Health Plans

These are health insurance plans employers offer their employees, sometimes with multiple options based on individual needs.

Enrollment Period

An enrollment period is a specific time period during which a person can get health insurance, make changes in their policy, or qualify and apply for government subsidies.

Essential Health Benefits

Essential health benefits are a set of services that health insurance plans must cover, including preventive care, prescription drugs, and maternity care, as required by the ACA.

Exclusion

An exclusion refers to specific medical conditions, services, or treatments not covered by an insurance policy.

Explanation of Benefits (EOB)

This is a statement sent by an insurance company to the insured person explaining the healthcare services provided, the amount paid by the insurance, and any remaining costs the patient owes.
F

Family Glitch

The family glitch is a rule that prevents some families with employer-sponsored health insurance from receiving financial assistance for marketplace coverage. It happens when the employer's coverage is considered "affordable" for the employee, even if it's not affordable for the entire family. This makes marketplace coverage too expensive for many families, leaving them with limited options.

Federal Poverty Level (FPL)

The FPL sets income thresholds used to determine eligibility for various healthcare programs under the Affordable Care Act (ACA). It helps decide who qualifies for subsidies, Medicaid, or CHIP by comparing household income to these set levels. In 2023, 400% above the FPL represents an income of $111K for one person or $228K for a family of four.

Federally Facilitated Marketplace (FFM)

The FFM is an online platform the federal government runs where individuals and families can compare, shop for, and enroll in health insurance plans. It serves as a marketplace for different insurance options.

Fee-for-Service

This is a payment model in which healthcare providers charge for each service or treatment they provide.

Fiduciary

A fiduciary is a person who holds a legal or ethical relationship of trust with one or more other parties. Fiduciaries are persons or organizations that act on behalf of others and are required to put the clients’ interests ahead of their own.

Final Adverse Benefit Determination

A final internal adverse benefit determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility.

Flexible Spending Account (FSA)

An FSA is a savings account you can contribute to from your paycheck before taxes. You can use this money for qualified medical costs like copayments, deductibles, and some over-the-counter items. Notably, FSAs are tax-free.

Formulary

A drug formulary is a list of drugs approved by a health insurance provider, categorized by cost.

Free Look Period

The Free Look Period allows you to review your insurance policy after purchasing it. If you change your mind within this period, you can cancel the policy and get a refund without penalties.

Full-Time Equivalent (FTE)

This is a measure employers use to determine whether they're required to offer health insurance under specific laws. It's calculated by adding up all the hours part-time employees work and converting them into the equivalent of full-time employees.
G

Gatekeeper

A gatekeeper is a healthcare provider who is the first point of contact for patients, and who decides what level of care the patient will get next. Oftentimes, primary care physicians are gatekeepers in the healthcare system.

General Agent

General agents are insurance agents who sell insurance products to other insurance agents or brokers. The other insurance agents and brokers then sell these products to the people or companies who will be using the insurance. General agents act as insurance wholesalers as opposed to insurance retailers.

Generic Drug

Once a brand-name drug's patent expires, other companies can offer the same medication at a lower cost as a generic drug. These alternative versions contain the same active ingredients and work just as effectively but without the hefty brand-name price tag. Choosing generic drugs is a smart way to manage your healthcare expenses while still getting the necessary medication.

Gold Plan

Under the Affordable Care Act (ACA), health plans covering ~80% of medical costs (after premiums) have a gold medal designation. This type of plan includes moderate out-of-pocket costs for enhanced benefits.

Grace Period

A grace period is a window after your insurance premium due date when coverage remains active, even if the payment is late. It's like getting an extension on a deadline without penalties — giving you time to catch up without losing coverage.

Grandfathered Plan

A grandfathered plan is an existing health insurance policy in place before the Affordable Care Act (ACA) was enacted in March 2010. These plans are exempt from some ACA requirements, allowing them to keep certain features that newer plans might not have.

Group Contract

A group contract is a health or life insurance contract that covers a group of people, typically employees of the same company.

Group Health Insurance

Group health insurance is coverage an employer or organization provides to its employees or members as a collective group. It offers benefits like medical, dental, or vision coverage to eligible members, often at more affordable rates than individual plans.

Guaranteed Issue

Guaranteed issue is a type of life insurance that is issued without requiring the applicant to answer medical questions or undergo a medical examination.
H

Healthcare Provider

A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices.

Healthcare Service Contractor

Health care service contractor means any corporation, cooperative group, or association, which is sponsored by or otherwise intimately connected with a provider or group of providers.

Healthcare Common Procedure Coding System (HCPCS)

HCPCS is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.

Health Coverage

Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).

Health Insurance Premium

The upfront monthly or annual amount you have to pay to maintain enrollment access to coverage benefits through private insurance plans or state marketplaces.

Health Maintenance Organization (HMO)

An HMO is a type of health insurance plan that requires you to choose a primary care physician (PCP) and get referrals from them to see specialists. It focuses on preventive care and often has a network of doctors and hospitals you must use for coverage.

HIPAA

HIPAA stands for Health Insurance Portability and Accountability Act. In a nutshell, it's a law in the United States that protects your medical privacy and ensures you can keep your health insurance even if you change jobs or lose your job.

HSA (Health Savings Account)

An HSA is a savings account specifically for medical expenses. It allows individuals with high-deductible health plans to contribute pre-tax income, and withdrawals for qualified medical expenses are tax-free. Plus, the money rolls over year after year.

High-Deductible Health Plan (HDHP)

An HDHP is a health insurance plan with a higher deductible than traditional plans. It often comes with lower premiums but requires higher out-of-pocket costs before insurance coverage kicks in.

Health Insurance Marketplace

The Health Insurance Marketplace, established by the ACA, is an online platform where individuals, families, and small businesses can compare, shop for, and enroll in health insurance plans. It offers a range of options and helps individuals find coverage that meets their needs and budget.

Healthcare.gov

Healthcare.gov is the official website created by the federal government, where people can enroll in health insurance plans through the Health Insurance Marketplace. It provides information about available plans, subsidies, and enrollment assistance.
I

Independent Review Organization

Within the healthcare industry, an independent review organization (IRO) acts as a third-party medical review resource which provides objective, unbiased medical determinations that support effective decision making, based only on medical evidence.

Individual Mandate

The Individual Mandate, a key provision of the Affordable Care Act (ACA), required most Americans to have health insurance coverage or pay a penalty. It aimed to increase the number of people with health insurance to balance risk pools and keep premiums affordable.

Individual Market

Often referred to simply as the “Marketplace” or the “Exchange,” this service helps you shop for and enroll in health insurance for you and your family through websites, call centers and in-person help.

In-Network

In-network refers to healthcare providers (doctors, hospitals, etc.) contracted with your insurance company to provide services at negotiated rates. Using in-network providers, who are included in your plan, often results in lower out-of-pocket costs for insured individuals.

Insurer

An insurer is the insurance company or the party that agrees to compensate people, companies or other organizations for specific financial losses. In the case of health insurance, the insurer is the party that agrees to cover some or all of the costs for covered health care services in exchange for a premium.

Insurance

Insurance is a contract, represented by a policy, in which a policyholder receives financial protection or reimbursement against losses from an insurance company.

Insurance Commissioner

An insurance commissioner is a public official in the executive branch of a state or territory in the United States who, along with their office, regulates the insurance industry.

Insurance Policy

A document detailing the terms and conditions of a contract of insurance.

Insured

An insured is a party who is insured against specific perils by either being the holder of an insurance policy or by otherwise being covered.

Insurance Premium

Like a subscription fee, an insurance premium is the amount you pay, often monthly, to your insurance company to maintain your health coverage. It's the cost of having an insurance policy regardless of whether you use healthcare services.
L

Lapse

A lapse is when certain privileges cease to be in effect. In the context of insurance, it usually refers to a cessation of coverage. A lapse of coverage can occur if a policyholder fails to pay the premiums that they owe to the insurer.

Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance company.

Lifetime Maximum

This is a cap on the total dollar amount your medical insurance contributes over the entire enrollment span. It could hit limits for pricey care like transplants or gene therapy.

Life Event

Qualifying event refers to a change in a person’s life that affects their insurance coverage. A proof of this change can make that person enroll for coverage suited to their new life in the government-sponsored insurance department in the United States.

Limitations

Limitations are the maximum amount of money that an insurance company will pay out for a claim in a policy period. These amounts are typically specified on the insurance policy.

Limit of Liability

A limit of liability is the most an insurance company would pay a policyholder who loses a lawsuit. The policy terms explain exactly how much. In case the policyholder is sued and owes more than the limit of liability provided in the coverage, they would need to pay the rest for the damages out-of-pocket.

Long-Term Care Insurance

These are extra policies that reimburse people for things like nursing home care, assisted living, or home health care, typically for aging or disabilities requiring custodial help/supervision.

Loss Ratio

The loss ratio method is a way to calculate how much money an insurance company makes relative to the benefits that it has to pay out. It is used to determine an insurance company’s financial health.
The loss ratio equation is as follows:
Loss ratio = (Benefits paid out + Adjustment expenses) / Premiums collected
M

Managed Care

A cost-cutting approach that involves reviewing and controlling the types and frequency of patient medical care through HMOs and preferred provider networks.

Medicaid

Like a safety net for low-income individuals and families, Medicaid is a joint federal and state program that provides health coverage to eligible individuals, offering comprehensive benefits including doctor visits, hospital stays, and long-term care.

Medicare

Medicare is a federal health insurance program primarily for people aged 65 and older, but also certain younger individuals with disabilities or specific health conditions.

Metal Plans

This term refers to the four tiers of coverage under the ACA marketplace, which determine premium and out-of-pocket expense ratios: Bronze, Silver, Gold, and Platinum.
N

Navigator

Navigators are experts trained to help people understand the complexities of insurance plans. They can assist in finding the right plan to fit a person’s needs and budget.

Network

Think of this as the circle of healthcare providers in a given insurance plan. A network is a group of doctors, hospitals, and other healthcare providers contracted with an insurance company to provide services to policyholders at negotiated rates.

No Surprises Act

This act protects people from surprise bills when they unintentionally get care from out-of-network providers, especially during emergencies. It ensures you're not hit with unexpected bills for in-network care from out-of-network providers.

Non-Qualified Health Plan

These plans don't meet all the Affordable Care Act (ACA) standards, meaning they might not offer all the benefits or protections you'd get from ACA-compliant plans.
O

Obamacare

This is another name for the Affordable Care Act (ACA), which aimed to make healthcare more accessible and affordable. It introduced features like marketplaces, subsidies, and protections against denial based on pre-existing conditions.

Obamacare Metal Plans

These plans come in different tiers — bronze, silver, gold, and platinum — each with varying costs and coverage levels. Bronze plans usually have lower premiums but higher out-of-pocket costs, while platinum plans have higher premiums but lower out-of-pocket expenses.

Off-Exchange Health Insurance Plan

These are health plans bought directly from insurance companies or brokers outside the official Health Insurance Marketplace. They might offer similar coverage but without marketplace perks like tax credits.

Open Access Plan

With these plans, you don't need a referral to see specialists; you can directly access them within your network.

Open Enrollment

This is the window of opportunity for you to get insurance and receive subsidies. Open Enrollment is when individuals can enroll in or change health insurance plans. It's a designated time frame each year to sign up for coverage through the Health Insurance Marketplace or employer-sponsored plans.

Out-of-Area Coverage

This coverage helps when you're away from your usual network area. It ensures you're still covered when you are traveling.

Out-of-Network

Out-of-network refers to healthcare providers who don't have agreements with your insurance company. Getting services from out-of-network providers may result in higher costs or lower coverage except in the case of specific emergencies. You trade higher costs for flexibility.

Out-of-Network (Out-of-Plan)

These are healthcare providers who are not in the network of your insurance plan. Seeing them might mean paying more from your own pocket, since they don't have agreements with your insurer for discounted rates.

Out-of-Pocket Costs

These are your expenses beyond the premium you pay. Out-of-pocket costs are the expenses you pay for healthcare services not covered by insurance. This includes deductibles, copayments, and coinsurance and can have limits like an out-of-pocket maximum.

Out-of-pocket Maximum

This refers to the most you will pay for covered health care in a year. After you hit this limit, your insurance covers 100% of costs.

Outpatient

These are any healthcare services or treatments that don't require you to stay overnight in a hospital.

Over-the-Counter (OTC) Drugs

These are medications you can buy without a prescription. They are available at pharmacies or online for common health issues such as headaches or colds. Whether your health insurance covers the cost of over-the-counter medications depends on several factors, like the type of health insurance plan, the type of OTC drug, and whether a doctor prescribes the medicine. Ultimately, the best way to determine whether your health insurance plan covers OTC medications is to contact your insurance company directly.
P

Patient Protection and Affordable Care Act (PPACA)

This is the formal name for the healthcare makeover law, also known as Obamacare. It aimed to make healthcare more affordable and accessible by introducing new rules for insurance companies, offering subsidies, and protecting against unfair insurance practices.

Platinum Plan

These plans come in dPlatinum plans, one of the tiers of health insurance plans under the ACA, have higher monthly premiums but lower out-of-pocket costs when you need healthcare services.ifferent tiers — bronze, silver, gold, and platinum — each with varying costs and coverage levels. Bronze plans usually have lower premiums but higher out-of-pocket costs, while platinum plans have higher premiums but lower out-of-pocket expenses.

Pre-Admission Certification

Before getting admitted, your doctor might need to certify or confirm that your hospital stay is necessary for your treatment. This step ensures your insurance covers those costs.

Pre-Existing Condition

Conditions or illnesses you had before getting insurance coverage are pre-existing conditions. Under the ACA, insurers can't deny coverage or charge more due to these conditions.

Preferred Provider Organization (PPO)

In PPO plans, you can see any doctor or specialist within the network without needing a referral. Going outside the network might cost you more, but staying in brings more savings.

Premium

A premium is the amount you pay, typically monthly, to your insurance company to maintain coverage. It's the insurance policy's cost, regardless of whether you use healthcare services.

Premium Subsidies

Financial help from the government to lower your monthly health insurance costs, calculated based on income levels. For example, if you earn $40,000 per year, you might qualify for a premium subsidy that reduces your monthly premium from $200 to $10.

Premium Tax Credit

This tax break is designed to help lower-income people afford health insurance. It's like getting some money back during tax season to help cover the cost of your monthly health insurance premiums.

Primary Care Provider (PCP)

Your primary care provider is your go-to doctor for routine check-ups, coordinating your care, and referring you to specialists if needed.

Prior Authorization

Before your insurance approves coverage for particular services or drugs, your doctor might need prior authorization to ensure they're medically necessary.

Private Exchange

This is a platform where individuals or businesses can shop for health insurance plans outside the official Health Insurance Marketplace.

Private health insurance

Health insurance purchased directly from a private insurance company rather than through a government program. Benefits of private health insurance include a wider choice of doctors and hospitals, more flexibility in coverage, and some services that are not covered by government programs. Drawbacks are that it can be more expensive than government programs, may not cover pre-existing conditions, and may have higher deductibles and copays.

Provider

Providers are healthcare professionals who offer medical services. They include doctors, hospitals, clinics, and other healthcare entities providing care and services.

Public Exchange

This is where individuals, families, and small businesses can shop for health insurance, often facilitated by the government.
Q

Quality Assurance

A process that looks at activities or products on a regular basis to make sure they are being done at the required level of excellence.

Qualified Health Plan (QHP)

A QHP is a health insurance plan that meets the Affordable Care Act (ACA) standards, offering essential health benefits and consumer protections and meeting certification requirements to be sold on the health insurance marketplace.

Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)

This is a benefit that businesses with fewer than 50 employees can offer to help their workers pay for qualified medical expenses, including health insurance premiums.

Qualifying Coverage

This refers to health insurance coverage that meets the minimum standards set by the ACA, ensuring individuals comply with the law's requirement of having health insurance.

Qualifying Event

Under the Affordable Care Act (ACA), a qualifying event refers to a significant life change that allows individuals to enroll in or change their health insurance plans outside the regular enrollment period (OEP). These events might include getting married, having a baby, adopting a child, losing existing health coverage due to reasons like job loss, or experiencing a change in household composition due to divorce or death. Additionally, moving to a new area that offers different health plan options can also be considered a qualifying event.
Qualifying events trigger a Special Enrollment Period (SEP), allowing individuals to adjust their health insurance coverage to accommodate the new circumstances. It allows affected individuals and their families to access healthcare coverage or change their existing plans to suit their needs better. The Special Enrollment Period typically lasts for a limited time after the qualifying event, allowing individuals to secure adequate healthcare coverage during these critical life transitions.
R

Reasonable and Customary Fees

Reasonable and customary fees refer to the standard charges accepted by healthcare providers in a specific geographic area for certain medical services or treatments. These fees are determined based on what healthcare professionals in the region typically charge for similar services, considering factors like the type of service, location, and prevailing market rates. Insurance companies often use these fees as a benchmark to establish the maximum amount they will cover for specific medical procedures or treatments. When a provider's fees exceed the reasonable and customary amount, the patient may be responsible for paying the difference out-of-pocket unless covered by specific insurance arrangements or agreements.

Reinsurance

Think of reinsurance as a safety net for insurance companies. It's a way for insurers to protect themselves against excessive losses by transferring some risk to another insurer.

Rescission

This is the cancellation of an insurance policy retroactively, often due to the insurer claiming misinformation or non-disclosure of important health information by the insured.
S

Self-Insured Health Plan

These are health plans in which an employer assumes the financial risk of providing healthcare benefits to its employees instead of purchasing a traditional insurance plan.

Short-Term Health Insurance

These plans offer temporary coverage for a limited period, often used as a bridge between more comprehensive plans or during temporary gaps in coverage.

Silver Plan

Silver plans, one of the tiers of health insurance plans under the ACA, offer a moderate balance between monthly premiums and out-of-pocket costs. They're the middle-ground option for those seeking decent coverage without paying the highest premiums.

Single-Payer system

This is a healthcare system in which a single entity, typically the government, is responsible for financing healthcare services for all citizens.

Small-Group Health Insurance

These are health insurance plans designed for businesses with few employees. They often offer group coverage with different options for the employees.

Socialized Medicine

This is a healthcare system in which the government owns or heavily regulates healthcare facilities and pays for medical services, aiming to provide universal healthcare coverage for all citizens.

Special Enrollment Period (SEP)

This is a bonus chance to sign up for health insurance or change your plan outside the usual enrollment period. You can enroll in health insurance if you've had certain qualifying life events, such as losing health coverage, moving to a new area, getting married, having a baby, adopting a child, or experiencing a significant change in income. The Special Enrollment Period typically lasts for a limited time after the qualifying event, allowing individuals to secure adequate healthcare coverage during critical life transitions.

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider with more training in a specific area of health care.

Specialty Drug

These are medications specifically designed to treat complex or chronic conditions. They often require special handling, administration, or monitoring and can be more expensive than typical medications.

Student Health Insurance

These are health insurance plans specifically tailored for students, often offered by colleges or universities to cover medical needs while studying. Even if you can access a student healthcare plan, you can apply for coverage (or stay covered) through the Health Insurance Marketplace.

Subsidies

Subsidies refer to financial assistance from the government to lower the cost of health insurance premiums for eligible individuals and families and make health coverage more affordable. Subsidies are based on income, meaning eligibility and subsidy amount depend on your household earnings, and feature reduced premiums that help make monthly payments more manageable. Subsidies are available through government-run health insurance marketplaces and may vary by state.

Supplemental Insurance

These are policies for very specific health coverage, such as dental, vision, or hospitalization, which supplement your health insurance coverage in areas where you need additional support. There are many of these types of policies available, including for hearing care, cancer treatments, hospital expenses, and even final expenses in the event of death.
T

Telemedicine

Telehealth — sometimes called telemedicine — lets your healthcare provider care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. It allows patients to consult with doctors or healthcare professionals remotely using technology, like video calls or phone calls, for diagnosis, treatment, or advice.

Travel Insurance

This insurance covers medical expenses, trip cancellations, lost luggage, and other unexpected mishaps while traveling, offering peace of mind during a trip.
U

Underwriter

Underwriters are the people who evaluate the risks and decide whether to approve an insurance application, setting the terms, conditions, and premiums for coverage.

Urgent Care

Both urgent care and emergency rooms provide medical care, but they serve different levels of urgency. People should go to urgent care for non-life-threatening injuries and illnesses that require prompt attention, such as sprains and strains, minor cuts and burns, fevers and infections, allergies, earaches and sore throats, urinary tract infections, and minor eye problems. Urgent care offers services like X-rays, lab tests, and stitches and usually has shorter wait times and lower costs than the emergency room. Choosing the right place for your medical needs is important. If you are unsure, always seek professional medical advice.
V

Veterans Aid and Attendance Assistance

These are specific benefits for those who served. Veterans Aid and Attendance programs provide benefits and support, including healthcare, to eligible veterans and their families through the Department of Veterans Affairs (VA).

Voluntary Accident Insurance

This is an extra protection for unexpected events. Voluntary Accident Insurance provides coverage for medical expenses resulting from accidents, complementing primary health insurance by offering specific accident-related financial benefits. It is a supplemental benefit provided by some employers that helps cover out-of-pocket medical costs associated with accidents that occur outside of work.
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