Understand health insurance definitions
Get clear answers so it’s easier to make decisions
Working with health insurance can be confusing. At times, you might feel like there’s a whole new language to learn. To make it easier, here’s a list of common terms and what they mean.
A health insurance reform law aimed at expanding health insurance coverage for people living in the U.S.
Learn more about the Affordable Care Act
Also known as: Patient Protection and Affordable Care Act, Obamacare, health care reform
A service, drug or item that your health insurance plan covers.
Benefits may include office visits, lab tests and procedures.
A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.
A federal law that requires group health plans to give continued health insurance coverage to certain employees and their dependents whose group coverage has ended.
Also known as: Consolidated Omnibus Budget Reconciliation Act of 1985
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) 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 copayment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Also known as: co-insurance
A process of figuring out which of two or more insurance policies has the main responsibility of processing or paying a claim and how much the other policies will contribute.
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: co-payment, copay, co-pay
The general term that refers to the share of costs for services covered by a plan or health insurance that you must pay out of your own pocket (sometimes called “out-of-pocket costs”).
Some examples of types of cost sharing include copayments, deductibles, and coinsurance. Other costs, including your premiums, penalties you may have to pay or the cost of care not covered by a plan or policy are usually not considered cost sharing.
A covered expense or service is the portion of a medical, dental or vision expense that your health insurance or plan has agreed to pay for or reimburse.
The amount you could owe during a coverage period (usually one year) for health care services your health insurance or plan covers before your health insurance or plan 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.
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.
Care you receive to help diagnose symptoms or risk factors you already have.
What this means for you:
Generally, diagnostic care is more expensive than preventive care. Many plans share costs with you for diagnostic care. Your care will either be coded and billed as a diagnostic or preventive care solution.
A 3-to-4 level tiered system that determines how each plan covers different types of prescription drugs. Each tier is typically assigned a cost you will pay for drugs listed in that tier.
What this means for you:
See what plans offer pharmacy benefits and review how their tier system covers the medications you need. Medications are placed in tiers that represent the cost you pay out-of-pocket. This makes it easier for you and your doctors to find options to save you money.
The date your insurance plan starts covering you.
A type of health insurance plan that requires members to get services from a network of health care providers that have a contract with the plan for services to be covered
An EPO plan is a type of managed care plan.
A set of 10 categories of services that most health insurance plans must cover under the ACA.
These include:
- Ambulatory (outpatient) care
- Emergency services (including emergency room care)
- Hospitalization
- Maternity and newborn care
- Mental health services and addiction treatment
- Prescription drugs
- Rehabilitation services
- Laboratory services
- Preventive care, wellness services, and chronic disease treatment
- Pediatric services (care for infants and children)
A document from your insurance company that describes what your health plan covers.
It also may give information about your deductibles, copayments, and the kinds of services or products your plan does not cover.
Also known as: explanation of coverage, COC, certificate of coverage, certificate of insurance, schedule of benefits
A list that you get after you've received a medical service, drug or item.
This list tells you the full price of the service, drug or item that you received. It also tells you how much you may need to pay for it.
A health care account that lets you put money aside, tax-free, to spend within the plan year to help pay for medical costs, child care, and other health services.
What this means for you:
Check with your employer or insurance to see which qualified health care expenses you can pay for with an FSA account, such as your portion of coinsurance and copays. This money is available to use throughout the plan year. With most FSAs, you lose any remaining money in the account at the end of the plan year.
A list of drugs your health insurance or plan covers.
A formulary may include how much you pay for each drug. If the plan uses “tiers” the formulary may list which drugs are in which tiers. For example, a formulary may include generic drug and brand name drug tiers.
Also known as: Prescription Drug List
A copy of a brand name drug
Generic drugs are required to have the same active ingredient, strength, dosage form, and route of administration as the brand name.
A resource where individuals, families, and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage.
The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children's Health Insurance Program (CHIP).
The Marketplace is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state. In others it is run by the federal government.
A network of physicians and other health care professionals that provides and coordinates an individual’s health care services.
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.
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.
A type of health plan that doesn't have a network of health care providers like other types of health plans.
This type of plan reimburses the member or provider after each billed charge.
Also known as: fee-for-service plan
A federal health insurance program for low-income families and children, eligible pregnant women, people with disabilities, and other adults.
The federal government pays for part of Medicaid and sets guidelines for the program. States pay for part of Medicaid and have choices in how they design their program.
Medicaid varies by state and may have a different name in your state.
A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
Eligible individuals can receive coverage for:
- Hospital services (Medicare Part A)
- Medical services (Medicare Part B)
- Prescription drugs (Medicare Part D)
Together, Medicare Parts A and B are known as Original Medicare.
Benefits can also be provided through a Medicare Advantage plan (Medicare Part C).
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A non-covered expense or service is the portion of a medical, dental or vision expense that is not paid for by your health insurance or plan.
FDA-approved brand name prescription drugs.
What this means for you:
Typically these drugs will cost you the most and there is often a lower priced, Tier 1 or Tier 2, alternative.
The time when you can choose to enroll in a health plan or re-enroll in a health plan you are already in.
You can usually do this without waiting periods or proof of insurance.
If you are eligible for Medicare, the open enrollment period is the time of year you can enroll or make changes to your Medicare coverage.
Also known as: annual enrollment period, annual election period
The health care providers (facilities, doctors, specialists, and suppliers) that are not contracted with your health insurer or plan to provide health care services.
What this means for you:
If you choose to receive out-of-network care, you may have higher costs. While some plans may cover out of network care, meaning they’ll pay part of the costs, other plans do not cover any costs for going out-of-network. Make sure you know what plans offer out-of-network coverage or not.
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% 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
Point of Service (POS) plans are a less-common hybrid of HMO and PPO plans that help you manage your care through a primary care physician, but also allow flexibility to go both in and out of network. These plans usually require you to pay a copay at the time of service instead of reaching a deductible amount.
What this means for you:
If your employer offers this type of plan, consider if it aligns with your coverage needs.
A health condition that exists before the date that new health coverage starts.
Under the ACA, health insurance companies can’t refuse to cover you or charge you more if you have a pre-existing condition.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
What this means for you:
Generally, if you are receiving services from network providers, you can rely on your network physician to obtain Prior Authorization. But when choosing out-of-network services, you will be responsible for obtaining Prior Authorization. Without this approval, you could be responsible for the full cost.
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 employer usually pay it monthly, quarterly or yearly.
FDA-approved brand name prescription drugs.
What this means for you:
Typically, these medications cost more than those in Tier 1 and less than those in Tier 3.
Financial help that lowers your taxes to help you and your family pay for private health insurance.
You can get this help if you get health insurance through the Marketplace and your income is below a certain level.
Advance payments of the tax credit can be used right away to lower your monthly premium costs.
Every plan with a pharmacy benefit contains a Prescription Drug List (PDL), also known as a formulary. The PDL lists the plan-approved drugs that your insurance will help pay for as well as how cost sharing works in each tier of drugs.
What this means for you:
Reviewing a plan’s PDL can help you anticipate costs for your medications.
Routine health care, including screenings, checkups, and patient counseling to prevent or discover illness, disease, or other health problems.
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.
A requirement from your health plan that some medications have additional coverage requirements which require approval from the health plan before you receive the medication.
What this means for you:
Certain medications may require approval from your plan to help cover costs before you receive the medication. Your Prescription Drug List (PDL) can tell you if your medication has this requirement.
A major life change that allows you to make changes to your health plan.
Some major changes include marriage, turning 26, divorce, the birth of a child or the loss of a job.
A written order from your primary care provider for you to see a specialist or get certain health care services.
In many health maintenance organizations (HMOs), you may need to get a referral before you can get health care services from anyone except your primary care provider. If you don't get a referral first, the plan or health insurance may not pay for the services.
When a covered person chooses to continue coverage under his or her 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.
A period of time where you can sign up for a health insurance plan outside of the normal time frame.
Most plans have a set time when you can join them. But you may need to change or join a plan at another time if you are in a special situation.
Your insurance plan decides what these special situations are. They may include marriage, turning 26, divorce, the birth of a child or the loss of a job. Check with your insurance to see what special situations they recognize.
Learn more about qualifying life events
Also known as: special circumstances, special enrollment period
A physician specialist focusing 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 who has special training in a specific area of health care.
A document that lists the plan's benefits.
It may make it easier to compare costs, benefits and coverage between different health plans.
Also known as: SBCS, benefits summary
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
