Healthcare Professional Resources

Glossary

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Advanced Premium Tax Credits (APTC)

A tax credit you can take in advance to lower your monthly health insurance payment (or "Premium”). When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If you qualify for a Premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your Premium.

  • If at the end of the year you’ve taken more Premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return.
  • If you’ve taken less than you qualify for, you’ll get the difference back.

Affordable Care Act (ACA)

The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or "Obamacare").

The law has 3 primary goals:

  • Make affordable health insurance available to more people. The law provides consumers with subsidies ("Premium tax credits") that lower costs for households with incomes between 100% and 400% of the federal poverty level.
  • Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
  • Support innovative medical care delivery methods designed to lower the costs of health care generally.

Allowed Amount

The maximum amount a plan will pay for a covered health care service. May also be called "eligible expense," "payment allowance," or "negotiated rate."

If your provider charges more than the plan's allowed amount, you may have to pay the difference.

Annual Limit

A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. These caps are sometimes placed on particular 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 health care 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.

  • If you don't agree with a decision made by the Marketplace, you may be able to file an appeal. You can also appeal decisions by the SHOP Marketplace for small businesses.
  • If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
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Bronze, Silver, Gold, Platinum Health Plans

See Health Plan Categories.

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Catastrophic Health Plan

Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover any benefits other than 3 primary care visits per year before the plan's deductible is met. The Premium amount you pay each month for health care is generally lower than 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.

Claim

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Coinsurance

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

  • If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
  • If you haven't met your deductible: You pay the full allowed amount, $100.

Co-pay/Copayment

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.

  • If you've paid your deductible: You pay $20, usually at the time of the visit.
  • If you haven't met your deductible: You pay $100, the full allowable amount for the visit.

Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists. Generally plans with lower monthly Premiums have higher copayments. Plans with higher monthly Premiums usually have lower copayments.

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.

Cost Sharing Reduction (CSR)

A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. In the Health Insurance Marketplace, cost-sharing reductions are often called "extra savings." If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

  • When you fill out a Marketplace application, you'll find out if you qualify for Premium tax credits and extra savings. You can use a Premium tax credit for a plan in any metal category. But if you qualify for extra savings too, you'll get those savings only if you pick a Silver plan.
  • If you qualify for cost-sharing reductions, you also have a lower out-of-pocket maximum — the total amount you'd have to pay for covered medical services per year. When you reach your out-of-pocket maximum, your insurance plan covers 100% of all covered services.
  • If you're a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
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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.

  • Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details.
  • All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.
  • Some plans have separate deductibles for certain services, like prescription drugs.
  • Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.
  • Generally, plans with lower monthly Premiums have higher deductibles. Plans with higher monthly Premiums usually have lower deductibles.
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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.

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Health Insurance Marketplace

A service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.

The Health Insurance Marketplace (also known as the "Marketplace" or "exchange") provides health plan shopping and enrollment services through websites, call centers, and in-person help.

Small businesses can use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance for their employees.

When you apply for individual and family coverage through the Marketplace, you'll provide income and household information. You'll find out if you qualify for:

  • Premium tax credits and other savings that make insurance more affordable
  • Coverage through the Medicaid and Children's Health Insurance Program (CHIP) in your state

On HealthCare.gov, you may be asked to select your state or enter your ZIP code. If you live in a state that runs its own Marketplace, we'll send you to your state's Marketplace website.

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 Plan Categories

Levels of plans in the Health Insurance Marketplace: Bronze, Silver, Gold, Platinum. Categories (sometimes called "metal levels") are based on how you and your insurance plan split costs. Categories have nothing to do with quality of care. ("Catastrophic" plans are available to some people.)

For each plan category, you'll pay a different percentage of total yearly costs of your care, and your insurance company will pay the rest. Total costs include Premiums, deductibles, and out-of-pocket costs like copayments and coinsurance.

Each category may include several types of plans and provider networks, like health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

Health Reimbursement Accounts (HRA)

Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.

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. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP).

High-deductible plans usually have lower monthly Premiums than plans with lower deductibles. By using the untaxed funds in an HSA to pay for expenses before you reach your deductible and other out-of-pocket costs like copayments, you reduce your overall health care costs.

HSA funds roll over year to year if you don't spend them. An HSA may earn interest.

You can open an HSA through your bank or other financial institution.

High Deductible Health Plan (HDHP)

A plan with a higher deductible than a traditional insurance plan. The monthly Premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.

The IRS defines a high deductible health plan as any plan with a deductible of at least $1,300 for an individual or $2,600 for a family. An HDHP's total yearly out-of-pocket expenses (including deductibles, copayments, and coinsurance) can't be more than $6,550 for an individual or $13,100 for a family. (This limit doesn't apply to out-of-network services.)

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Medicaid

Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.

Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states.

You can apply anytime. If you qualify, your coverage can begin immediately, any time of year.

Medicare

A federal health insurance program for people 65 and 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 isn't part of the Health Insurance Marketplace. If you have Medicare coverage you don't have to make any changes. You're considered covered under the health care law.

Medicare Part D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

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Non-preferred Provider

A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.

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Open Enrollment Period

The yearly period when people can enroll in a health insurance plan. 2017 Open Enrollment ended January 31, 2017. 2018 Open Enrollment 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.

Out-of-Pocket Costs

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/Limit

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn't include your monthly Premiums. It also doesn't include anything you spend for services your plan doesn't cover.

  • For the 2017 plan year: The out-of-pocket limit for a Marketplace plan is $7,150 for an individual plan and $14,300 for a family plan.
  • For the 2016 plan year: The out-of-pocket limit for a 2016 Marketplace plan is $6,850 for an individual plan and $13,700 for a family plan.
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Plan

A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or planmay 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

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also "participating" providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

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 providers outside of the network for an additional cost.

Premium

The amount you pay for your health insurance every month. In addition to your Premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a Premiumtax credit.

When shopping for a plan, keep in mind that the plan with the lowest monthly Premium may not be the best match for you. If you need much health care, a plan with a slightly higher Premium but a lower deductible may save you a lot of money.

After you enroll in a plan, you must pay your first Premium directly to the insurance company – not to the Health Insurance Marketplace.

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

Preventive Services

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

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Prior Authorization

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

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Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services.  In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services.

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Special Enrollment Period

A time outside the yearly Open Enrollment Period when you can sign up for health insurance.

You qualify for a Special Enrollment Period if you've had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.

If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.

You can enroll in Medicaid and the Children's Health Insurance Program (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.

Job-based plans must provide a special enrollment period of at least 30 days.

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TRICARE

A health care program for active-duty and retired uniformed services members and their families.

Reference: Glossary. HealthCare.gov web site. https://www.healthcare.gov/glossary/. Accessed September 1, 2017.

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