Rating FactorsHealth insurance premiums are calculated using many rating factors. Rating factors have much more influence on individual policy premiums than on group…
Reconciliation ActLegislation (Public Law 111-152) signed by President Obama on March 30, 2010. One of two laws collectively referred to as the Affordable Care Act (ACA).
Reconstructive SurgerySurgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
ReferralA written order from your primary care doctor for you to see a specialist or get certain medical services.
Rehabilitation ServicesHealth care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person…
Rehabilitative/Rehabilitation ServicesHealth care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were…
ReinsuranceA reimbursement system that protects insurers from very high claims. It usually involves a third party paying part of an insurance company’s claims once…
Rental or Royalty IncomeThe amount someone pays you to use your property, after you subtract the expenses you have for the property.
RescissionThe cancellation, or “tearing-up,” of a contract. Some consumer loans (home mortgages) feature a 3-day right of rescission during which the borrower…
Retirement Benefit (Pension)A payment or series of payments made to you after you retire from work. Generally, the amount of your income from a pension or retirement account…
Rider (exclusionary rider)A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to…
Risk AdjustmentA statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their…
Risk corridorA temporary provision in the ACA that requires plans whose costs are lower than anticipated to make payments into a fund that reimburses plans whose costs…
Self-Employment IncomeThe net income you earn from your own trade or business. For example, any net income (profit) you earn from goods you sell or services you provide to…
Self-insuredGroup health plans may be self-insured or fully insured. A plan is self-insured (or self-funded), when the employer assumes the financial risk for…
Self-Insured PlanType of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying…
Service AreaA geographic area where a health insurance plan accepts members if it limits membership based on where people live.
Skilled Nursing CareServices from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a…
Skilled Nursing Facility (SNF)(SNF)Often called a "SNF." A SNF provides medical care under the supervision of a medical professional or technician, and dispenses medications, performs…
Skilled Nursing Facility CareSkilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility.
Small EmployerIn California's insurance code, a small employer is anyone who employs from 2-50 people. The employer(s) can be included in this number.
Small group marketThe market for health insurance coverage offered to small businesses - those with between 2 and 50 employees in most states, including Minnesota.
Social SecuritySocial Security is a federal government program designed to provide income for qualifying retired people, their dependents, and disabled people who meet…
Social Security BenefitsThe amount you get from Social Security Disability, Retirement (including Railroad retirement), or Survivor's Benefits each month.
SolvencyThe ability of a health insurance plan to meet all of its financial obligations.
Special Enrollment PeriodA time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage.
Special Health Care NeedThe health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions.
SpecialistA specialist or specialist unit is a member of a securities exchange responsible for maintaining a fair and orderly market in a specific security or…
Stand-Alone CoverageSome plans already include dental as part of their basic plans. If the plan you select does not include this, you have the option of buying dental…
State Continuation CoverageA state-based requirement similar to COBRA that applies to group health insurance policies of employers with fewer than 20 employees.
State Insurance DepartmentA state agency that regulates insurance and can provide information about health coverage in its state.
State Medical Assistance OfficeA state agency in charge of the state's Medicaid program and can give information about programs in its state that help pay medical bills for people with…
Stop-LossAn insurer may pay 100% of covered benefit charges after you have met your deductible and coinsurance requirements, and your out-of-pocket maximum.
Subsidized CoverageHealth coverage that's obtained through financial assistance from programs to help people with low and middle incomes.
Summary of Benefits and CoverageYou will receive a Summary of Benefits and Coverage when you enroll in your health plan. It describes the benefits and costs associated with your plan.
Summary of Benefits and Coverage (SBC)(SBC)An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.
Supplemental Security Income (SSI)(SSI)A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older.
Tax CreditA tax credit is an amount you can subtract from the tax you would otherwise owe.
Tax HouseholdThe taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents.
Third Party Administrator (TPA)(TPA)An organization that performs managerial and clerical functions related to an employee benefit insurance plan by an individual or committee that is not an…
Third-Party PayerAnyone who pays for health care other than you. Usually your insurance company. When an insurer contracts with an entity to pay on their behalf.
Total Cost Estimate (for health coverage)The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the…
TRICAREA health care program for active-duty and retired uniformed services members and their families.
TTYA TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment.
UCR (Usual, Customary, and Reasonable)The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.
Uncompensated CareHealth care or services provided by hospitals or health care providers that don't get reimbursed.
UninsuredIf you do not currently have health insurance, you are uninsured.
Urgent CareCare for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency…
Usual and Customary Charges (UCC)(UCC)The amount that your insurance company determines is the normal payment range for a specific medical procedure performed within a given geographic area.
Usual, Customary and Reasonable (UCR)(UCR)The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.
Usual, Customary and Reasonable (UCR) Charges(UCR)The cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic…
Usual, Customary and Reasonable charge (UCR)(UCR)The cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic…
Usual, Customary, Reasonable (UCR)The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.
Utilization ReviewInsurance companies and hospitals watch their costs and quality by having medical personnel review selected medical cases.
Value-Based Purchasing (VBP)(VBP)Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost…
Vision or Vision CoverageA type of health benefit that at least partially covers vision care, like eye exams and glasses.
Waiting PeriodThe time between the date of application and the policy effective date.
Waiting Period (Job-based coverage)The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health…
Well-baby and Well-child VisitsRoutine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21.
Wellness ProgramsA program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them…
Worker's CompensationAn insurance plan that employers are required to have to cover employees who get sick or injured on the job.