Glossary of Terms
Here’s a glossary of terms that consumers should be familiar with to make informed decisions about the best health coverage for themselves.
A
A measure of the percentage of total healthcare costs that a health insurance plan is expected to cover for a standard population.
A legal document that outlines an individual’s healthcare preferences, such as resuscitation and life support, if they cannot make decisions.
Financial assistance provided under the ACA to help lower-income individuals and families afford health insurance premiums in the Health Insurance Marketplace.
An undesirable or unexpected medical occurrence during treatment, such as a side effect of medication.
A situation where sicker individuals are more likely to enroll in and utilize healthcare coverage, potentially causing increased costs for insurance plans.
B
The practice of a healthcare provider billing a patient for the difference between what the provider charges and what the insurance plan pays.
The requirement that health insurance plans provide equal coverage for mental health and substance abuse treatment as they do for physical health services.
The branch of healthcare that focuses on mental health and substance abuse treatment.
A reference health insurance plan used to determine subsidies and establish minimum essential coverage under the ACA.
A person eligible for and receiving healthcare benefits from a health insurance plan, such as Medicare or Medicaid.
The 12-month period during which a health insurance plan provides coverage to the insured.
C
Legislation that extended funding for the Children’s Health Insurance Program (CHIP) and made other improvements to the program.
A state and federally-funded program that provides health coverage to eligible low-income children.
A federal law that allows individuals to continue their employer-sponsored health insurance coverage for a limited time after leaving their job.
A system in which health insurance premiums are based on geographic areas or the entire community rather than individual health status.
Efforts to protect and represent the interests of healthcare consumers in areas like access to care and quality of care.
State-funded programs that provide assistance and information to consumers navigating the health insurance system.
Health insurance plans that encourage consumers to make informed healthcare decisions and offer tools like Health Savings Accounts (HSAs).
The fixed amount that a healthcare consumer must pay for a specific medical service or prescription drug in addition to what the insurance plan covers.
D
A term used in the past to describe false claims about rationing healthcare services under the ACA.
The amount a healthcare consumer must pay out-of-pocket for covered medical services before their insurance plan begins to pay.
Dental benefits are provided to children as part of their health insurance plans, often required by the ACA.
The age at which children can no longer be covered as dependents on their parents’ health insurance plans, typically 26 under the ACA.
Health insurance coverage provided to family members of the primary policyholder, such as spouses and children.
The status of eligible individuals for both Medicare and Medicaid, often indicating low income and special healthcare needs.
E
A federal law that requires hospitals to provide emergency medical treatment regardless of a patient’s ability to pay.
Healthcare providers serving predominantly low-income and medically underserved communities are often included in network directories.
A set of benefits that all health insurance plans, including those under the Affordable Care Act (ACA), are required to cover.
An insurance company statement explaining how a medical claim was processed and what costs the patient is responsible for.
F
A tax form provided by the Health Insurance Marketplace (Exchange) to report information about insurance coverage.
A list of prescription drugs covered by a health insurance plan, often organized into tiers with varying co-payment amounts.
G
A primary care physician or healthcare provider manages a patient’s access to specialists and certain medical services within a managed care plan.
A health plan that existed before the ACA was enacted and is exempt from specific law provisions.
A requirement that health insurance plans must accept all applicants, regardless of their health status.
A provision ensuring that the insurer cannot cancel health insurance plans as long as the policyholder pays premiums.
H
A tax-advantaged savings account that allows consumers to set aside money for eligible medical expenses.
A legal document that designates a person to make healthcare decisions on behalf of an individual who cannot do so.
Federal legislation that protects the privacy and security of individuals’ health information.
I
Information that can be used to identify a specific patient, subject to privacy and security protections under HIPAA.
Permission given by a patient or their legal representative after understanding a medical procedure’s risks, benefits, and alternatives.
Healthcare providers and facilities with contracts with a specific insurance plan offer services at a lower cost to plan members.
J
Low-cost insurance plans that offer limited coverage and may not meet essential healthcare needs.
M
Metal levels categorize health insurance plans (Bronze, Silver, Gold, and Platinum), indicating coverage quality and cost-sharing.
An online platform where individuals and families can shop for and purchase health insurance plans, often associated with the Health Insurance Marketplace established under the ACA.
A state and federally-funded program that provides health coverage for low-income individuals and families.
The percentage of premium dollars an insurance company spends on healthcare services and quality improvement activities.
Healthcare services or treatments that are required to diagnose or treat a medical condition and are supported by clinical evidence.
Limits established by Medicare on the number of units of a medical service that can be provided to a patient on a single date of service.
A federal health insurance program primarily for seniors aged 65 and older and certain younger individuals with disabilities.
N
A person or organization that provides assistance to individuals in enrolling in health insurance plans, often in the Health Insurance Marketplace.
A list of healthcare providers, hospitals, and facilities that are contracted with a specific insurance plan to provide medical services to plan members.
O
The timeframe during which individuals can enroll in or make changes to their health insurance plans for the upcoming coverage year.
The annual period during which individuals can enroll in or make changes to their Medicare Advantage or Medicare Part D prescription drug plans.
Healthcare providers and facilities that do not have contracts with a specific insurance plan and may result in higher out-of-pocket costs for plan members.
The expenses paid by consumers for healthcare services, including deductibles, co-pays, and co-insurance.
The maximum amount a consumer is required to pay for covered medical services during a plan year.
The highest amount an insured individual is required to pay for covered medical services during a plan year.
P
An online platform that allows patients to access their medical records, schedule appointments, and communicate with their healthcare providers.
A comprehensive healthcare reform law passed in 2010, also known as Obamacare, that significantly changed the U.S. healthcare system.
Individuals’ rights and protections when receiving healthcare services, including the right to informed consent and privacy.
A model of healthcare that emphasizes a partnership between patients and healthcare providers, considering patients’ values and preferences.
A nonprofit organization established under the ACA to research healthcare outcomes and provide information to help consumers make informed healthcare decisions.
The regular monthly payment to an insurance company for health coverage.
A list of healthcare providers and facilities available to plan members within a health insurance network.
The group of healthcare providers and facilities participating in a specific health insurance plan.
The payment made by an insurance company to a healthcare provider for the services rendered to a patient, often subject to negotiated rates.
Q
Health insurance plans that meet the requirements and standards established under the Affordable Care Act (ACA).
Groups that work to improve healthcare quality and patient care for Medicare beneficiaries.
Ratings or scores provided by the government or independent organizations that assess the quality and performance of health insurance plans.
R
The retroactive cancellation of a health insurance policy, often due to fraud or misrepresentation on the application.
An additional document added to an insurance policy to modify or exclude specific coverage.
A mechanism used in health insurance to balance the costs of covering individuals with varying health risks, preventing insurers from avoiding high-risk individuals.
A grouping of individuals within an insurance plan who share similar characteristics and health risks, which can impact premium costs.
A strategy insurance companies use to spread the risk of covering high-cost medical claims across a larger group of policyholders.
S
A period during which individuals can enroll in or make changes to their health insurance plan outside of the regular open enrollment period, often due to qualifying life events.
A healthcare provider with specialized training and expertise in a specific area of medicine, such as cardiology or dermatology.
A state and federally-funded program that provides health insurance to low-income children and some adults who do not qualify for Medicaid.
Health insurance plans that receive financial support from the government, reducing the cost of coverage for consumers.
Financial assistance the government provides to help lower-income individuals and families afford health insurance.
A federal agency focused on improving behavioral health in the United States.
T
The practice of providing medical services remotely through video, phone, or online communication.
U
A situation where an individual’s health insurance coverage does not adequately meet their healthcare needs, often due to high deductibles or co-pays.
A healthcare system where all residents have access to medical services and are required to have health insurance.
A requirement that all individuals have health insurance, often enforced through penalties or taxes for non-compliance.
A healthcare system where all residents have access to medical services, often funded through taxes.
The process of evaluating the medical necessity and efficiency of healthcare services provided to patients.
V
A healthcare delivery model focused on providing high-quality care while controlling costs.
A healthcare model that adjusts patient cost-sharing to encourage high-value healthcare services and discourage low-value services.
W
The period of time an individual must wait before becoming eligible for coverage under a health insurance plan.
A financial or non-financial reward offered to individuals who participate in wellness programs or meet specific health-related goals.
Programs offered by employers or insurers to encourage individuals to adopt healthy behaviors and engage in wellness activities.
Initiatives offered by employers or health plans to encourage healthy behaviors and improve overall well-being.
Health assessments and tests that evaluate an individual’s risk for various diseases and conditions, often offered as preventive services.
A preventive healthcare appointment that promotes health and well-being is often covered without cost-sharing under the ACA.
X
A medical imaging technique that uses electromagnetic radiation to produce images of the inside of the body.
Y
A designated time each year when individuals can enroll in or make changes to their health insurance plans.
A term referring to young adults who believe they are less likely to need health insurance due to their perceived good health.
A term used to describe young, healthy individuals who may choose to go without health insurance due to perceived low healthcare needs.
Z
A health insurance plan in which no deductible applies, meaning that insurance coverage begins immediately without out-of-pocket costs.
Healthcare services fully covered by insurance plans and do not require cost-sharing from consumers.
Differences in healthcare access and outcomes based on geographical location, often due to socioeconomic factors.