Healthcare Glossary

The Affordable Care Act (ACA), also known as Obamacare, is a healthcare reform law in the United States that aimed to increase access to affordable health insurance coverage. It implemented various provisions such as the creation of health insurance marketplaces, expansion of Medicaid eligibility, and the requirement for individuals to have insurance or pay a penalty.

A carrier refers to an insurance company or organization that offers health insurance plans to individuals or groups. Carriers are responsible for administering the insurance policies, collecting premiums, and paying out claims for covered medical expenses. They play a crucial role in providing access to healthcare coverage.

COBRA, short for Consolidated Omnibus Budget Reconciliation Act, is a federal law that allows individuals to continue their employer-sponsored health insurance coverage for a limited period after leaving their job, as long as they pay the full premium. This helps individuals maintain health insurance during job transitions or other qualifying events.

Coinsurance is a cost-sharing arrangement where the insured individual is responsible for paying a percentage of the covered healthcare services’ costs after meeting the deductible. For example, if the coinsurance is 20%, the insurance company pays 80% of the allowed amount, and the individual pays the remaining 20%.

A copayment, or copay, is a fixed amount that an insured individual pays at the time of receiving medical services or purchasing prescription drugs. It is a form of cost-sharing and typically varies based on the type of service or medication, such as a $20 copay for a doctor’s visit or a $10 copay for generic drugs.

Cost-sharing refers to the sharing of healthcare costs between the insurance provider and the insured individual. It includes expenses like copayments, coinsurance, and deductibles. Cost-sharing helps distribute the financial responsibility for healthcare services, ensuring that individuals contribute to the costs while still having insurance coverage.

The temporary limit on what your plan will cover for prescription drugs.

A deductible is the amount an insured individual must pay out of pocket for covered medical services before the insurance company starts contributing towards the costs. For example, if the deductible is $1,000, the individual is responsible for paying the first $1,000 of covered services, and then the insurance coverage begins. Deductibles can vary based on the insurance plan and are usually reset annually.

In healthcare, a dependent refers to an individual, such as a child or spouse, who relies on someone else for healthcare coverage. Dependents are typically eligible for coverage under a family member’s health insurance plan.

Eligibility refers to meeting the requirements or criteria to qualify for specific healthcare benefits or services. It can include factors such as income, age, citizenship, or employment status. Meeting eligibility criteria is crucial for accessing insurance coverage or government programs.

In the context of healthcare, an Eligible Professional refers to healthcare providers, such as doctors or other healthcare practitioners, who are eligible to participate in incentive programs established by the Centers for Medicare and Medicaid Services (CMS).

Essential Benefits are a set of services that health insurance plans must cover under the Affordable Care Act (ACA). These benefits include preventive care, hospitalization, prescription drugs, maternity care, mental health services, and more. The ACA ensures that health insurance plans offer comprehensive coverage by mandating these essential benefits.

A Health Savings Account is a tax-advantaged savings account that individuals can use to save money for qualified medical expenses. HSAs are typically paired with high-deductible health insurance plans and offer tax benefits, such as contributions being tax-deductible and withdrawals for medical expenses being tax-free.

HMO is a type of health insurance plan that requires individuals to choose a primary care physician (PCP) and receive referrals from the PCP to see specialists. HMOs generally have a network of providers and offer comprehensive care but limit coverage outside the network, except in emergencies.

Major Medical insurance refers to a type of health insurance that provides coverage for significant and costly medical expenses, such as hospital stays, surgeries, and treatments for serious conditions. It typically offers broad coverage for unexpected and high-cost healthcare needs.

Maximum out-of-pocket costs represent the highest amount an insured individual has to pay for covered healthcare services during a specific period, usually a year. Once this limit is reached, the insurance plan covers 100% of the remaining eligible expenses. This includes deductibles, copayments, and coinsurance.

Medicaid is a government-funded healthcare program in the United States that provides health coverage to low-income individuals and families. It offers a range of essential medical services, including doctor visits, hospital care, and prescription medications, to eligible individuals based on income and other criteria.

A medical cost sharing plan is an alternative to traditional health insurance where members contribute monthly payments that are pooled together to cover medical expenses. Members agree to share the costs of eligible medical services according to the terms of the plan. These plans are typically organized by faith-based or community organizations and operate under specific guidelines.

Medicare is a federal health insurance program in the United States primarily for individuals aged 65 and older, as well as certain younger individuals with disabilities. It consists of different parts (A, B, C, and D) that cover hospital care, medical services, prescription drugs, and additional options for more comprehensive coverage.

In the context of health insurance, a network refers to a group of healthcare providers, such as doctors, hospitals, and clinics, that have an agreement with an insurance company to provide services at negotiated rates. Staying within the network often results in lower out-of-pocket costs for the insured individual.

A network provider is a healthcare professional or facility that has contracted with an insurance company to offer medical services to insured individuals at negotiated rates. Insured individuals typically receive higher coverage and lower out-of-pocket costs when they choose network providers for their healthcare needs.

An office visit refers to a face-to-face appointment between a patient and a healthcare provider in a medical office or clinic setting. During an office visit, the patient can receive medical evaluation, diagnosis, treatment, and preventive care services from their healthcare provider.

Open enrollment is a specified period during which individuals can enroll in or make changes to their health insurance plans. It is an opportunity to sign up for coverage or switch plans, usually offered annually. Open enrollment periods provide individuals with the chance to review their options and select the best health insurance plan for their needs.

Out of network refers to healthcare providers or facilities that do not have a contract or agreement with a specific insurance company. Seeking medical care from out-of-network providers may result in higher out-of-pocket costs for the insured individual, as the insurance plan typically covers a lower percentage of the expenses or may not cover them at all.

A PCP, or primary care physician, is a healthcare provider who serves as the main point of contact for a patient’s general medical needs. The PCP provides routine healthcare, manages chronic conditions, and coordinates referrals to specialists when necessary. Having a designated PCP is often required in certain types of health insurance plans.

POS is a type of health insurance plan that combines features of both HMO and PPO plans. In a POS plan, individuals choose a primary care physician (PCP) and require referrals for specialist care. However, individuals also have the flexibility to seek care out-of-network, albeit at higher out-of-pocket costs.

PPO is a type of health insurance plan that offers a network of preferred healthcare providers, allowing individuals the freedom to choose any provider within or outside the network without requiring a referral. While there is greater flexibility, individuals typically receive higher coverage and lower costs when they use in-network providers.

A pre-existing condition refers to a health condition that an individual has before obtaining health insurance coverage. Prior to the implementation of the Affordable Care Act (ACA), insurance companies could deny coverage or charge higher premiums based on pre-existing conditions. However, the ACA prohibits such practices, ensuring that individuals with pre-existing conditions can obtain health insurance coverage.

A premium is the amount an individual pays to an insurance company for health insurance coverage. It is usually paid on a monthly basis. The premium is separate from other out-of-pocket costs, such as deductibles or copayments, and is necessary to maintain the insurance coverage.

Prescription drug coverage refers to the inclusion of medications as part of a health insurance plan. It provides coverage for prescription drugs, helping individuals afford the cost of necessary medications. Prescription drug coverage can vary based on the insurance plan and may include different tiers or formularies.

In healthcare, a provider refers to any individual or entity that delivers healthcare services, such as doctors, nurses, hospitals, clinics, and other healthcare professionals and facilities. Providers play a vital role in diagnosing, treating, and managing patients’ health conditions.

A qualifying life event is a significant life change that allows individuals to enroll in or make changes to their health insurance plans outside of the regular open enrollment period. Examples of qualifying life events include getting married, having a baby, losing health coverage, or moving to a new location. These events trigger a special enrollment period, giving individuals the opportunity to adjust their health insurance coverage to reflect their changed circumstances.

Short-term health insurance provides temporary coverage for a limited duration, typically ranging from a few months to a year. It is designed to bridge gaps in coverage during transitions, such as job changes or waiting periods for other health insurance options. Short-term plans often have more limited coverage and may not include all essential benefits.

A special enrollment period is a designated time outside of the regular open enrollment period during which individuals can enroll in or make changes to their health insurance plans. Special enrollment periods are triggered by certain life events, such as marriage, birth, adoption, or loss of other health coverage, allowing individuals to adjust their insurance coverage accordingly.

A subsidy is a financial assistance program that helps individuals or families afford health insurance coverage. It can come in the form of premium subsidies, which reduce the cost of monthly premiums, or cost-sharing subsidies, which lower out-of-pocket expenses like deductibles and copayments. Subsidies are based on factors such as income and family size.