Health Insurance

Health Insurance terms

1. Access Fee An ”access fee” is a specific amount that a person covered under the policy must pay each time certain services are used or received.
2. Accountable Care Organization A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get.
3. Accreditation If a Marketplace health plan is approved, this is the “seal of approval” given to the plan by an independent organization to show that the plan meets…
4. Actuarial justification The demonstration by an insurer that the premiums collected are reasonable, given the benefits provided under the plan or that the distribution of…
5. Actuarial Value The percentage of total average costs for covered benefits that a plan will cover.
6. Acute Care Facility One step below a hospital, an acute care facility gives advanced medical and nursing services to bring you back to health.
7. Adjusted community rating A way of pricing insurance where premiums are not based upon a policyholder's health status, but may be based upon other factors, such as age and…
8. Advanced Premium Tax Credit The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace.
9. Affordable Care Act The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was…
10. Affordable Care Act (ACA) (ACA) This is the title usually given to the federal health reform passed in March 2010 and collectively refers to the provisions of the Patient Protection and…
11. Affordable coverage (as it relates to APTC) Employer coverage is considered affordable - as it relates to the Advanced Premium Tax Credit (APTC) - if the employee’s share of the annual premium for…
12. Age Rating Varying premiums based on age. The ACA will cap the maximum variation for age at 3:1.
13. Agent Agent means any individual, other than a broker-dealer, who represents a broker-dealer or issuer in effecting or attempting to effect purchases or sales…
14. Alimony Alimony is money you get from a spouse with whom you no longer live, or a former spouse, if paid to you as part of a divorce agreement, separation…
15. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated…
16. Annual Deductible Combined Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or…
17. Annual Household Income The total income for a family in a calendar year.
18. Annual Limit A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan.
19. Appeal To call for a review of an IRS decision or proposed adjustment.
20. Assignment Assignment occurs when someone who has written, or sold, a listed option receives a notice that the option has been exercised and he or she must fulfill…
21. Assisted Living See board and care facility.
22. Assisters Assisters deliver in-person outreach, education and enrollment in public insurance coverage options only.
23. Attest/Attestation When you apply for health coverage through the Marketplace, you're required to agree (or "attest") to the truth of the information provided by signing the…
24. Authorized Representative Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.
25. Balance Billing When a provider bills you for the difference between the provider’s charge and the allowed amount.
26. Banding Organizing people together by age groups to calculate premiums.
27. Benefit Level A benefit level is a group of plans that have similar value. The groupings help you compare plans with similar covered benefits and costs to determine the…
28. Benefits The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's…
29. Biosimilar Biological Products The generic version of more complicated medications.
30. Board and Care Facility (Long Term) A board and care facility offers no nursing services. It is designed for people who are unable to take care of their day-to-day feeding, hygiene, and/or…
31. Brand Name (Drugs) A drug sold by a drug company under a specific name or trademark and that is protected by a patent.
32. Broker An agent who handles the public's orders to buy and sell securities, commodities or other property. A commission is generally charged for this service.
33. Brokers Insurance agents or brokers who have been certified by Maryland Health Connection can help you select and purchase health coverage.
34. Bronze Health Plan See Health Plan Categories
35. Business Day Any day on which offices of a bank are open to the public for carrying on substantially all of the bank's business.
36. Calendar Day Every day of the calendar month, which includes Saturday, Sunday, and state and federal holidays.
37. Cancelled Debts If you incurred a debt from a loan or from buying something on credit and a portion of the amount you owe is discharged or forgiven ("cancelled"), the…
38. Capital Gains A capital gain is the amount you get from selling property, like stock or a house.
39. Capitation A flat per patient fee paid to providers no matter how many services they have provided.
40. Care Coordination The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to…
41. Carriers A company that provides health insurance plans.
42. Catastrophic Health Insurance Catastrophic health insurance is a type of health insurance that typically has very high deductibles.
43. Catastrophic Health Plan Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover any benefits other than 3 primary…
44. Catastrophic Plan A catastrophic plan covers an individual or family in the event of a major medical emergency.
45. Centers for Medicare & Medicaid Services (CMS) (CMS) The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace.
46. Certificate of Coverage A document issued to a member of a group health insurance plan showing evidence of participation in the insurance.
47. Certificate of Creditable Coverage A written statement from your prior insurance company or health plan documenting the length of time you were covered.
48. Certified Applicant Counselor An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses, and their employees as they look…
49. Children's Health Insurance Program (CHIP) (CHIP) Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women…
50. Chronic Condition A medical condition or disease that goes on for a long period of time. Examples are diabetes and cystic fibrosis.
51. Chronic Disease Management An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education.
52. Claim Your request for the insurance company to pay you an amount under the terms of your policy.
53. Co-Insurance After you have met the deductible for the covered period of time, your health policy may have a “co-insurance” that provides the patient will be…
54. Co-op A non-profit organization in which the same people who own the company are insured by the company.
55. Co-pay A “co-pay” is a fixed payment amount that is the responsibility of the patient.
56. Co-payment The portion of charges you pay to your provider for covered health care services in addition to any deductible.
57. COBRA A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee…
58. COBRA coverage Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986.
59. Coinsurance When your healthcare insurance has a coinsurance provision, you and your insurer divide the responsibility for paying doctor and hospital bills by…
60. Community Rating A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
61. Competitive Bidding Open bidding for federal contracts between independent groups that compete for the contract by providing the best bid.
62. Complication of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus.
63. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus.
64. Connector Organizations The Connector Organizations will help uninsured individuals and small businesses learn about, apply for and enroll in health plans, including Medicaid…
65. Consumer Assistance Program The consumer assistance program for Maryland Health Connection consists of a consumer support center (call center), the website MarylandHealthConnection.
66. Consumer Assistance Workers This is a broad term that refers to all who assist with education, applications and enrollment, for example, case workers, navigators and assisters.
67. Consumer Operated and Oriented Plans A qualified non-profit health insurance company that must use profit to lower premiums, increase benefits and increase the quality of health care to be…
68. Consumer Support Center The consumer support center (CSC) provides live personal help with finding, applying for and enrolling in health plans.
69. Contestability An individual health insurance policy may have a defined contestability period, so if the insured person becomes seriously ill during that time the health…
70. Conversion The ability, in some states, to switch your job-based coverage to an individual policy when you lose eligibility for job-based coverage.
71. Coordination of Benefits A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
72. Copayment If you have a managed-care health insurance plan, your copayment is the fixed amount you pay - often $10 to $25 - for each in-network doctor's office…
73. Cost Sharing The share of costs covered by your insurance that you pay out of your own pocket.
74. Cost Sharing Reduction A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments.
75. Court Awards Money that's due to you as the result of a lawsuit. This money may be taxable. Examples of lawsuit proceeds that aren't taxable are amounts awarded to you…
76. coverage The scope of protection provided by an insurance contract which includes any of the listed benefits in an insurance policy.
77. Creditable Coverage Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid…
78. Creditable Coverage or Prior Qualifying Coverage The number of months you had health insurance in place before your current or new policy became effective.
79. Deductible The dollar amount you must pay out-of-pocket for each claim before the insurance company begins paying.
80. Denial An insurance company decision to withhold a claim payment or preauthorization. A denial may be made because the medical service is not covered, not…
81. Dental Coverage Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings.
82. Department of Health and Human Services (HHS) (HHS) The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace…
83. Dependent A qualifying child or qualifying relative, other than the taxpayer or spouse, who entitles the taxpayer to claim a dependency exemption.
84. Dependent Coverage Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
85. Disability A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working.
86. disclosure A disclosure document explains how a financial product or offering works. It also details the terms to which you must agree in order to buy it or use it…
87. Discount Health Plan A “discount health plan” refers to a type of “buyers’ club” that specifically markets reduced-rate health care services.
88. Disease managem ent A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and…
89. Dividend See Dividends
90. Doctor Visits For some plans, you can receive benefits like doctor visits before you meet your deductible.
91. Domestic Partnership Two people of the same or opposite sex who live together and share a domestic life, but aren't married or joined by a civil union.
92. Donut Hole, Medicare Prescription Drug Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole").
93. Drug Formulary A list of drugs that an insurer will pay for. Drugs that are not on the formulary ("off-formulary") are sometimes covered but are more expensive (see…
94. Drug List A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
95. Durable Medical Equipment (DME) (DME) Equipment and supplies ordered by a health care provider for everyday or extended use.
96. Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) (EPSDT) A term used to refer to the comprehensive set of benefits covered for children in Medicaid.
97. Eligibility Assessment In certain states, the Marketplace doesn't provide the final decision on Medicaid eligibility.
98. Eligibility determination A notice sent by MNsure to let a MNsure consumer know the decision about whether the consumer qualifies (is eligible) for MNsure programs.
99. Eligible Immigration Status An immigration status that's considered eligible for getting health coverage through the Marketplace.
100. Elimination Period If you have disability insurance or long-term care insurance, there's a waiting period, called the elimination period, from the time you become disabled…