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Insurance Glossary

Don’t speak insurance? We’ve got you covered.

This is a general glossary that is provided for informational purposes only. To view additional terms, visit Please note that some of the definitions may vary from those used in your plan depending on the provisions of your specific plan. For definitions that are applicable to your plan, please refer to the applicable, official Plan Documents. If there are any differences between the information provided on this website and your Plan Documents, the information in the Plan Documents will prevail.


start, start date, (i.e., Your health coverage will start on January 1, 2016.)

activation date
start, start date, (i.e., Your health coverage will start on January 1, 2016.)

To process your claim for payment.

Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 that requires the majority of U.S. individuals to have health insurance coverage.

annual out-of-pocket maximum
The maximum amount you pay for covered expenses, which may include deductible, copayments, coinsurance and fees, in a year. Once the annual out-of-pocket maximum has been reached, the plan pays 100 percent of covered health expenses for the rest of that plan year. If your plan includes out-of-network benefits, the annual out-of-pocket maximum will be different for participating and non-participating providers.

approve, approval, (i.e., Your health plan will need to approve the treatment before it begins.)

approve, approval, (i.e., Your health plan will need to approve the treatment before it begins.)

carry over
Last year's unused funds, money left in your health savings account from last year, (i.e. Unused funds in your Health Savings Account at the end of the year will rollover to the next calendar year.)


co-pay, copayment
A fixed dollar amount you pay toward a covered health expense, usually at the time of service. (i.e., You pay $30 toward a doctor's visit and your health plan pays the rest.)

The percentage of covered expenses that you are responsible for paying after the applicable deductible is satisfied; your share of the cost. Coinsurance does not include copayments.

cost-share reductions
A discount available to qualified individuals that lowers the amount that you pay out-of-pocket for deductibles, coinsurance, and co-pays for specific medical expenses like prescriptions and doctor's visits. Financial assistance is determined by your annual household income and family size and requires purchase of a marketplace silver metal level plan.

covered services
The medical or dental services that are eligible for payment under your health plan. Covered expenses are subject to applicable deductibles and other benefit limits.

What you pay before your plan begins to pay. Most health plans have an annual deductible.

A spouse, partner, child or children, who's eligible for coverage under a health plan because of their relationship to the insured adult in the family.

effective date
The date on which coverage begins under your plan. This is commonly referred to as your start date.

emergency care
Emergency medical attention given to an individual who needs it. It includes those medical services required for the immediate diagnosis and treatment of a serious medical condition. Emergency care, as defined in the health plan, must be covered at the in-network level, even if care is received out-of-network.

Enhanced Direct Enrollment (EDE)
Allows you to shop and enroll in a health plan and also apply for federal financial assistance directly from your insurance carrier. They can process your eligibility and any changes to your plan, with no need to go through for any part of the application process.

exchange (federal)
An online resource where the federal government provides individuals and families and small employers an opportunity to shop and buy health insurance. It is commonly referred to as the "Marketplace."

exchange (state)
An online resource where states provide individuals and families and small employers an opportunity to shop and buy health insurance. It is commonly referred to as the "Marketplace."

Exclusive Provider Organization (EPO) Plan
A managed care plan where services are covered only if you visit doctors, specialists, or hospitals in the plan's network (except in an emergency).

explanation of benefits (EOB)
After you visit your doctor, you'll get an explanation of benefits outlining the services you received, how much they cost, and how much your plan paid.

federal financial assistance
Eligibility for federal financial assistance is based on certain household size and income requirements. Subsidies are available from the federal government to help with health care costs for those who qualify. There are two forms of federal financial assistance available: tax credit subsidies, which reduce the monthly premium, and cost-sharing reductions, which reduce out-of-pocket costs.

generic drug
A prescription drug that has the same active-ingredient formula as a brand-name drug but usually costs less.

Health Maintenance Organization (HMO)
A type of medical plan that limits eligible coverage to a local service area and may not provide out-of-network coverage except for emergencies as defined by the plan. Most HMO plans require primary care physician (PCP) selection and referrals to specialists. HMOs often provide integrated care and focus on prevention and wellness.

Health Savings Account (HSA)
A tax-advantaged savings account used to pay for qualified health care costs. The account may be funded by an individual, an employer or both. A person must be covered by a qualified High Deductible Health Plan (HDHP) to contribute to an HSA. Unused funds in the account at the end of the year roll over to the next year.

healthcare provider
A doctor hospital or other health care practitioner that provides health care services within the scope of their license.

High Deductible Health Plan (HDHP)
A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

Outpatient care professionals and hospitals contracted with your health plan to deliver services at a negotiated rate (discount).

individual plan
A health insurance policy you buy directly from a health insurance company or broker rather than through an employer. An individual plan can cover you and/or any of your eligible family members.

inpatient care
Care given to a patient admitted for an overnight stay at a hospital, extended care facility, nursing home or other similar health care institution.

managed care
A way of controlling the cost of health care and access to health care professionals.

An online resource where individuals, families and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits and other important features; and, choose a plan and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate incomes and resources pay for coverage.

medical management
The people and services that help you manage your health, coordinate care and navigate the health care system when you are sick or injured.

You or a family member covered by your health plan.

minimum essential coverage
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. As of January 2014, people that do not have this minimum coverage may have to pay a tax penalty.

Hospitals, health care professionals and labs that have contracted with your health plan to deliver services at a negotiated rate (discount).

Open Enrollment
The time period when you can enroll in a health plan or make changes to your existing one. Most health insurance companies offer open enrollment during a set time each year. An individual may qualify for a Special Enrollment Period allowing them to enroll outside of Open Enrollment if they have a qualifying life event.

Hospitals, health care professionals, and labs that are not contracted with your health plan to deliver services at a negotiated rate (discount). Depending on your plan, you may have to pay a higher percentage of the claim, even up to 100%, for services received from out-of-network providers.

out-of-pocket (OOP)
The total of your payments for covered expenses, which may include deductible, copayments, coinsurance and fees.

out-of-pocket maximum
The most a customer will pay for covered services during a plan year before the health plan begins to pay at 100 percent of covered charges. This limit does not include premiums, balance-billed charges or health care services not covered under the health plan. Some health plans don't include all copays, deductibles, co-insurance payments, out-of-network payments or other expenses towards this limit.

A patient who receives treatment at a hospital, clinic or one's home but does not require an overnight hospital stay.

patient liability
Your financial responsibility.

plan features
An overview of what a particular health plan includes, such as deductibles, monthly premiums, co-pays, services, etc.

Preferred Provider Organization (PPO)
A health plan made up of health care professionals and hospitals contracted to deliver services at a negotiated rate (discount). You pay less if you visit providers that belong to the plan's network. You can visit providers that are out-of-network, but you may pay more for services.

The periodic amount that must be paid for your health insurance or plan to stay active.

preventive care
A routine visit to your doctor or dentist as opposed to seeking treatment for an ailment, commonly referred to as a check-up. The aim is to keep you healthy by detecting and treating any health problems early. Examples include immunizations, screenings, and routine physical exams.

primary care physician (PCP)
Your primary doctor.

provider directory
A comprehensive list of health care professionals who have contracted with your health insurance company to provide care.

provider network
A group of health care professionals who have contracted with your health insurance company to provide health care services.

Qualified Health Plan
A health plan that is certified by the Federal or state exchanges. To be certified, a plan must provide essential health benefits and meet other health care reform rules.

qualifying life event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage.

A written order from your primary care physician for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services.

roll over
Last year's unused health spending account funds, money left in your health savings account from last year EG: Your Health Savings Account pays claims using the money left over from last year, before using this year's funds.

service area
The geographical area where a patient can receive health care from their network of providers.

Special Enrollment Period
A time outside of the Open Enrollment Period during which you and your family may sign up for health coverage if you have a Qualifying Life Event. In the Marketplace, you qualify for a Special Enrollment Period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage.

Health care professionals, whose practices focus on a single disease, part of the body, age group or procedure. For example, oncologists treat cancer patients. Otolaryngologists or ENTs specialize in ear, nose and throat problems. Pediatricians are doctors who serve children. And a cardiac surgeon performs surgeries involving the heart and great blood vessels.

status change
A life-changing event such as marriage, divorce or the birth of a child that allows you to modify your health coverage.

tax credit subsidies
Subsidies available to those who qualify for federal financial assistance based on certain household size and income requirements. They can reduce your monthly premium payments when you enroll in a Marketplace Qualified Health Plan (QHP). You can apply all, or a portion of your Advanced Premium Tax Credit (APTC) to the premium, reducing the monthly bill.

urgent care
Care for an illness, injury or condition that requires prompt care, but not serious enough to require emergency care.