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Common terms and definitions

A – C

Accountable Care Organization
A group of doctors, nurses, and other health care providers who work with you and your health plan to make all parts of your care work together.

Affordable Care Act (ACA)
A 2010 law that expands health insurance coverage for people living in the U.S.; also known as the Patient Protection and Affordable Care Act and Obamacare.

A professional trained to help you find and join a health insurance plan.

Allowed amount
The most a health insurance plan will pay for a covered service.

Annual deductible combined
The total amount a family has to pay out-of-pocket before their health plan starts to pay for care.

Annual Election Period (AEP)
The Annual Election Period is the time each year when Medicare beneficiaries can make their plan selection for the next plan year. Enrollment begins October 15 and ends December 7 for the January 1 effective date.

Annual limit
The total amount of money a health insurance plan will pay for benefits in one year.

A request for a review of a decision after a member was turned down for a benefit or payment.

Benefit year
A year of benefits coverage under an individual health insurance plan.

Health care services covered with some level of payment by an insurance plan.

A professional trained to help you find and enroll in a health insurance plan.

Bronze health plan
One of four plan groups known as "metal levels" Bronze plans typically have low monthly premiums but high costs when you get care. For Medicare plans, "metal levels" apply to Affordable Care Act (ACA) plans only.

A federal law that lets you buy health coverage if you lose a job, lose coverage as a dependent, or have another qualifying event. (See "Qualifying event")

Catastrophic health plan
Plans with low premiums and high deductibles. They're designed to protect you from the costs of a major illness or injury.

A request for payment that you or your health care provider send to your health insurer.

Centers for Medicare and Medicaid Services.

The percentage of costs you pay after you've paid your deductible.

Coordination of benefits
A way to figure out who makes the first payment when two or more health insurance plans are responsible for paying the same medical claim.

A fixed amount you pay for a covered health care service.

Your share of the cost for services covered by your insurance plan.

Covered services
Also called benefits, these are the services included in your health plan. You and your insurer share their cost. Most count toward your deductible and out-of-pocket maximum.

D – G

How much you pay each year for care before your insurance starts to pay.

A child, spouse, or disabled adult covered by your health plan.

Drug list
Also called a formulary, this is a list of prescription drugs covered by an insurance plan.

Durable medical equipment (DME)
Equipment and supplies like oxygen equipment, wheelchairs, crutches or diabetic blood testing strips that are ordered by a health care provider for long-term or everyday use.

Effective date
The day your insurance plan starts covering you.

Emergency room care
Health care services that can't wait. Patients go to the emergency department of a hospital for this type of care.

Excluded services
Health care services that your health insurance plan doesn't cover.

Flexible Spending Account (FSA)
An account set up through your employer that you can use to pay out-of-pocket medical expenses with tax-free dollars.

Also called a drug list. This is a list of prescription drugs that an insurance plan covers.

Generic drugs
A prescription drug with the same active-ingredient formula as a brand-name drug.

Gold health plan
One of four plan groups known as "metal levels." Gold plans usually have higher monthly premiums, but lower costs for care. For Medicare plans, "metal levels" apply to Affordable Care Act (ACA) plans only.

H – L

Health insurance
A contract that requires you to pay a premium while your health insurer agrees to pay some or all of your health care costs in exchange.

Health plan categories
Levels of health insurance plans, also described by their "metal level." They include Bronze, Silver, Gold, and Platinum. For Medicare plans, "metal levels" apply to Affordable Care Act (ACA) plans only. Each plan type balances your costs and risks differently.

Health Savings Account (HSA)
A special bank account that helps you set aside tax-free money for medical costs.

High-Deductible Health Plan (HDHP)
A plan with a lower monthly premium that requires you to pay higher health care costs before the insurance company starts to pay.

Hospital outpatient care
Care in a hospital that doesn't typically require an overnight stay.

Care that requires you to stay in a hospital.

Individual health insurance policy
Policies for people who aren't covered by employer-based coverage.

Inpatient care
Care that requires a patient to stay in a hospital, skilled nursing facility, and the like.

Lifetime limit
After you reach this limit, the insurance plan no longer pays for your health care costs.

Long-Term Care
Services for people who need help with basic daily living activities like dressing or bathing.

M – N

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.

Medically necessary
Services or supplies that meet accepted standards of medicine to diagnose or treat an illness, injury, condition, disease or its symptoms.

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.

Medicare Advantage (Medicare Part C)
A type of private Medicare health plan that administers your Part A and Part B benefits on behalf of Medicare and reduces your out-of-pocket costs.

Medicare Part D
The Medicare program that helps pay for your prescription drugs through private health plans.

The doctors, clinics, hospitals, pharmacies, and other providers that contract with your insurer to give you health care services.

Non-covered services
Services not included in your health plan (also called exclusions).

O – Q

Open Enrollment Period (OEP)
The time each year when you can enroll in a health insurance plan.

Open Enrollment Period (OEP) Medicare Advantage
A set time each year when members in a Medicare Advantage plan can cancel their plan enrollment and switch to another Medicare Advantage plan, or obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can also join a separate Medicare prescription drug plan at that time. The Medicare Advantage Open Enrollment Period is from January 1 until March 31, and is also available for a 3 month period after an individual is first eligible for Medicare.

Original Medicare
A fee-for-service health plan with two parts: Part A (hospital insurance) and Part B (medical insurance).

Out-of-pocket costs
Your medical costs like deductibles, coinsurance, and copayments for covered services. It also includes costs for services your insurance plan doesn't cover.

Out-of-pocket maximum
This is a limit on what you pay in a year for covered services. Deductibles, copays, and coinsurance count toward this amount. Premiums don't.

Plan year
Also called a policy year, this is the 12-month period of benefits coverage. It may not be the same as the calendar year.

Platinum health plan
One of four plan groups known as "metal levels." Platinum plans usually have the highest monthly premiums and pay the most when you get care. For Medicare plans, "metal levels" apply to Affordable Care Act (ACA) plans only.

Pre-existing condition
A health problem that began before health coverage starts. Insurance companies can't refuse to cover treatment or charge you extra if you have a pre-existing condition.

The amount of money you pay every month to keep your health insurance.

Premium tax credit
A tax credit you can use to lower your monthly insurance payment.

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

Primary care
Health services that cover prevention, wellness, and treatment for common illnesses.

Prior authorization
Approval that decides if a service, treatment plan, prescription drug, or durable medical equipment item is medically necessary.

Qualifying Life Event (QLE)
A change in your situation that makes you eligible to buy or change insurance in a Special Enrollment Period. The changes can include getting married, having a baby, or losing health coverage.

R – Z

A written order from your health care provider that tells you to see a specialist or get certain medical services.

Silver health plan
One of four plan groups known as "metal levels." Silver plans have moderate monthly premiums and moderate costs. For Medicare plans, "metal levels" apply to Affordable Care Act (ACA) plans only.

Skilled nursing care
Services from licensed nurses in a patient's home or nursing home.

Special Enrollment Period (SEP)
A time period outside open enrollment dates when you can buy an insurance plan or make changes to your current coverage. Special enrollment happens after a "qualifying life event" such as getting married or having a baby.

Subsidized coverage
Health coverage available at low or no cost for people with incomes below specific levels.

Summary of Benefits and Coverage (SBC)
A summary that helps you compare costs, benefits, coverage, and other health plan features. This is not applicable to Medicare members.

Urgent care
Care for an illness, injury, or condition that doesn't need emergency room care but is serious enough for you to get the care right away.

Wellness programs
Programs to help improve and promote health and fitness.

Last updated: March 2022