Health Insurance — page 2 of 4

Health Insurance terms

101. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
102. Emergency Medical Transportation Ambulance services for an emergency medical condition.
103. Emergency Room Care Emergency services you get in an emergency room.
104. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
105. Employee Retirement Income Security Act of 1974 (ERISA) (ERISA) is a comprehensive and complex statute that federalizes the law of employee benefits.
106. Employer Choice, Employee Choice Employer choice allows small employers to select one insurance company and allow employees to choose from any plans offered by that company across all…
107. Employer Contribution Employer contribution is the amount or percentage of health care premiums contributed by employers for employees’ health insurance.
108. Employer or Union Retiree Plans Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families.
109. Employer Shared Responsibility Payment (ESRP) (ESRP) The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its…
110. Essential Benefits The ACA requires all health insurance plans sold after 2014 to include a basic package of benefits including hospitalization, outpatient services…
111. Essential Health Benefits A set of health care service categories that must be covered by certain plans, starting in 2014.
112. Evidence-Based Medicine In evidence-based medicine, treatment success is measured by a careful study of the outcome, using both the clinical expertise of the provider, as well as…
113. Exchange An exchange generally occurs when one company acquires another. The shareholders of the acquired company are often given the option to sell their shares…
114. Excluded Drugs Drugs not covered by the insurance policy.
115. Excluded Services Health care services that your health insurance or plan doesn’t pay for or cover.
116. Exclusion A contractual provision in an insurance policy that denies or restricts coverage for certain perils, persons, property or locations.
117. Exclusions and/or Limitations Conditions or circumstances spelled out in an insurance policy which limit or exclude coverage benefits.
118. Exclusive Provider Organization (EPO) Plan (EPO) A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
119. Experimental and/or Investigational Medical Services A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care.
120. External Review A review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan.
121. Family and Medical Leave Act (FMLA) (FMLA) Family and Medical Leave Act (29 U.S.C. 2601 et seq.) is a federal law that ensures that eligible workers are able to take unpaid extended leaves of…
122. Federal Poverty Level (FPL) (FPL) A measure of income level issued annually by the Department of Health and Human Services.
123. Federally Qualified Health Center (FQHC) (FQHC) Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations.
124. Federally Recognized Tribe Any Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe.
125. Fee A charge or payment for products and services, a sum paid or charged for a privilege, for example, some financial institutions charge a monthly fee to…
126. Fee For Service When you're covered by fee-for-service health insurance, you pay your medical bills and file a claim for reimbursement from your insurance company.
127. Flexible Benefits Plan A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans…
128. Flexible Spending Account (FSA) (FSA) An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars.
129. Formulary See "drug formulary."
130. Full-Time Employee An employee who works an average of at least 30 hours per week (so part-time would be less than 30 hours per week).
131. Full-Time Equivalent The number of working hours that represents one full-time employee during a fixed time period, such as one month or one year.
132. Fully Insured Job-based Plan A health plan purchased by an employer from an insurance company.
133. Generic Drug A drug that is similar to a name-brand drug but not covered by original patents and therefore cheaper.
134. Generic Drugs Generic drugs are safe, effective, and approved by the U.S. Food and Drug Administration (FDA).
135. Gold Health Plan See Health Plan Categories
136. Grace Period A time period after the due date that you may pay a premium without penalty. The policy remains in force during this time.
137. Grandfathered As used in connection with the Affordable Care Act: Exempt from certain provisions of this law.
138. Grandfathered Health Plan As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was…
139. Grandfathered plan A health plan that an individual was enrolled in prior to March 23, 2010 is considered a grandfathered plan under the ACA.
140. Grievance A complaint that you communicate to your health insurer or plan.
141. Group Health Plan When groups of individuals are covered under one insurance contract. Usually people are offered group health plans by their employers (see "individual…
142. Guaranteed Issue A health insurance policy that must be issued regardless of any pre-existing medical condition.
143. Guaranteed renewability A requirement that health insurers renew coverage under a health plan except for failure to pay premium, fraud or misrepresentation.
144. Guaranteed Renewal A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums.
145. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living.
146. Habilitative Services Health care services that help a person keep, learn or improve skills and functioning for daily living.
147. Habilitative/Habilitation Services Health care services that help you keep, learn, or improve skills and functioning for daily living.
148. Hardship Exemption Under the Affordable Care Act, most people must pay a fee if they don't have health coverage that qualifies as "minimum essential coverage.
149. Health Care Workforce Incentive The use of incentives and recruiting to encourage people to enter into health care professions like primary care and to encourage providers to practice in…
150. Health Coverage Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan…
151. Health Insurance Health insurance covers some or all of the cost of treating an insured person's illnesses or injuries.
152. Health Insurance Marketplace A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on…
153. Health Maintenance Organization If you select a Health Maintenance Organization (HMO), you will need to choose a primary care doctor or one will be appointed to you.
154. Health Maintenance Organization (HMO) (HMO) A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.
155. Health Plan Categories Plans in the Marketplace are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan…
156. Health Reimbursement Account (HRA) (HRA) Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up…
157. Health Savings Account (HSA) (HSA) A health savings account is designed to accumulate tax-free assets to pay current and future healthcare expenses.
158. Health Status Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information…
159. Health Status Rating Varying premiums based on health status. Though Minnesota statutes do not currently require health plans to issue coverage in the individual market on a…
160. High Deductible Health Plan (HDHP) (HDHP) A high deductible health plan (HDHP) requires substantially higher than average out-of-pocket expenses before the insurance company will start paying for…
161. High Risk Pool Plan (State) Similar to the Pre-Existing Condition Insurance Plan under the Affordable Care Act, for years many states have offered plans that provide coverage if you…
162. High-Cost Excise Tax Under the Affordable Care Act starting in 2018, a tax on insurance companies that provide high-cost plans.
163. High-risk pool A health plan that provides coverage for individuals with pre-existing health care conditions who cannot purchase it in the private market.
164. HIPAA Eligible Individual Your status once you have had 18 months of continuous creditable health coverage.
165. Home and Community-Based Services (HCBS) (HCBS) Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing.
166. Home Health Care Health care provided in your home.
167. Hospice Care Care given to someone expected to live less than six months due to a terminal disease or condition.
168. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
169. Hospital Outpatient Care Care in a hospital that usually doesn’t require an overnight stay.
170. Hospital Readmissions A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days.
171. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
172. In Person Assistance Personnel Program Individual or organizations that are trained and able to provide help to consumers, small businesses, and their employees as they look for health coverage…
173. In-Network Co-Insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.
174. In-Network Co-Payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan.
175. In-network Coinsurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.
176. In-network Copayment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan.
177. In-Network provider A health care provider (such as a hospital or doctor) that is contracted to be part of the network for a managed care organization (such as an HMO or PPO).
178. Income Level If your 2013 income is below $45,950 for an individual or $94,200 for a family of four, your out-of-pocket payment for health services may be lower.
179. Independent Medical Review (IMR) (IMR) A process where expert medical professionals, who have no relationship to your health insurance company or health plan, review specific medical decisions…
180. Individual Health Insurance Policy Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.
181. Individual Health Plan A form of health insurance designed to cover just one person (and often immediate family members), as opposed to someone covered by a group plan (see…
182. Individual mandate A requirement that everyone maintain health insurance coverage. The ACA requires that everyone who can purchase health insurance for less than 8 percent…
183. Inpatient Care Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
184. Insurance Co-Op A non-profit entity in which the same people who own the company are insured by the company.
185. Insurance Company An insurance company must be licensed by the Department of Insurance to sell health insurance. The insurer issues policies which outline coverage.
186. Interest The term interest is used to describe the cost of using money, a right, share, or title in property.
187. Internal review The review of the health plan's determination that a requested or provided health care service or treatment health care service is not or was not…
188. Interstate compact An agreement between two or more states. The ACA requires the NAIC to develop standards for voluntary interstate compacts that will permit sales of health…
189. Investment Income The equity dividends, bond interest, and/or cash interest paid on an investment.
190. Job-based Health Plan Coverage that is offered to an employee (and often his or her family) by an employer.
191. Large Group Health Plan In general, a group health plan that covers employees of an employer that has 101 or more employees.
192. Lifetime Limit A dollar limit on how much the insurance company will pay in your lifetime. An insurer may, for example, cover up to $1 million over your lifetime.
193. Limited Benefit Health Insurance Policies “Limited benefit health insurance policies” can cost far less than traditional insurance, but cap what health insurance carriers will pay toward…
194. Limited Benefits Plan A type of health plan that provides coverage for only certain specified health care services or treatments or provides coverage for health care services…
195. Long-Term Care Services that help meet the medical and nonmedical needs of people with a chronic illness or disability.
196. Major Medical Health Insurance Major Medical health insurance policies typically provide comprehensive coverage for hospital, doctor, x-ray and laboratory expenses.
197. Major Medical Plan A high-limit, high deductible plan to cover catastrophic illness or injury. Major medical used to be called "catastrophic insurance."
198. Managed Care Managed care generally emphasizes cost control and may provide coverage for preventive medicine.
199. Mandated benefit A requirement in state or federal law that all health insurance policies provide coverage for a specific health care service.
200. Mandated Health Benefit Mandated health benefits are benefits that are required to be covered by law. There are both federal and state mandated benefits.