Like any type of business, health care has its own special terms. Here are some of the top ones you may come across – along with quick definitions.
Affordable Care Act (ACA)
A health insurance reform law aimed at expanding health insurance coverage for people living in the United States.
Also known as: Patient Protection and Affordable Care Act, health reform
The maximum amount a health care plan will pay for a covered health plan service.
If your provider charges more than the allowed amount, you may have to pay the difference.
Also known as: eligible expense, payment allowance, negotiated rate, allowable charge
A service, drug or item that your health plan covers. Benefits may include office visits, lab tests and procedures.
A federal law that requires group health plans to offer continued health insurance coverage to certain employees and their dependents whose group coverage has ended.
Also known as: Consolidated Omnibus Budget Reconciliation Act
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service.
You generally pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20 percent would be $20. The health insurance or plan pays the rest of the allowed amount.
A way that health insurance companies price insurance. Within an area, all policyholders pay the same premium regardless of health status, age or other considerations.
Consumer-driven Health Plan (CDHP)
A type of health insurance plan that encourages members to take more responsibility for their health care costs.
A CDHP usually has a high deductible and includes a pretax spending account to help pay for health care costs.
Examples of these accounts include the health reimbursement account (HRA), health savings account (HSA) and medical savings account (MSA).
Also known as: CDH, consumer-directed health plan
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service.
The amount can vary by the type of covered health care service.
Also known as: copayment
A child, disabled adult or spouse covered by your health plan.
A person may need to be a certain age or meet other conditions to qualify as a dependent under your plan.
The amount you could owe during a coverage period (usually one year) for health care services your health insurance or plan covers before it begins to pay.
For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
The money an employer pays for employees to have health insurance and other benefits.
Exclusive Provider Organization (EPO)
A type of health insurance plan that only pays for services if your employees go to doctors, specialists or hospitals in the plan’s network – except for emergencies.
Flexible Spending Account (FSA)
A special account employees can put money into that can be used for copayments, deductibles, some drugs and other health care costs. This money is not taxed and cannot be carried over into the next year.
Employers may make contributions to FSAs, but this isn’t required.
Group Health Plan
Health insurance provided through a group, such as an employer or union.
Health Maintenance Organization (HMO)
A network of physicians and other health care professionals that provides and coordinates an individual’s health care services.
Health Reimbursement Account (HRA)
An account employers fund for covered or retired workers. Show More...The IRS does not tax this money. Any funds left in these accounts at year-end can roll over to the next year.
Health Savings Account (HSA)
A bank account that lets people put money aside, tax-free, to save and pay for health care expenses.
The Internal Revenue Service (IRS) limits who can open and put money into an HSA.
High-deductible Health Plan (HDHP)
A type of health plan with higher deductibles and lower premiums than most other health plans.
This type of plan may also let you open an HSA.
Managed Care Plan
A type of health insurance plan that tries to lower health care costs and improve quality. Common managed care plans include PPO, HMO, EPO and POS plans.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit, the plan will usually pay 100 percent of the allowed amount.
This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.
Also known as: out-of-pocket maximum, out-of-pocket threshold
A type of health insurance plan that lets members use any health care provider. The plan will usually pay more of the member's health care costs when they get services from network providers that have a contract with the plan.
A POS plan is a type of managed care plan.
Also known as: point-of-service plan
Preferred Provider Organization (PPO)
A network of medical doctors, hospitals and other health care providers who work with a health insurance plan to give care at a lower cost.
The amount that must be paid for your health insurance or plan.
You and/or your employees usually pay it monthly, quarterly or yearly.
Primary Care Provider (PCP)
A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law and the terms of the plan who provides, coordinates or helps you access a range of health care services.
When your business or organization chooses to continue coverage under your current health insurance plan.
Renewal usually occurs once a year. If you pay your premium, your health insurance company may accept that as your request to renew coverage.
Self-funded Health Plan
A type of plan where an employer is responsible to pay for medical claims of workers.
Also known as: self-insured health plan
Levels or ranks used to show how you and your health plan share costs.
Also known as: metal level, coverage level