We get it. Sometimes reading insurance terms can be like trying to learn a new language. This glossary and the examples in it help break down those terms into everyday words. When looking up a particular word, click the first letter below to jump to that section. You also may want to check out the Uniform Glossary of Coverage and Medical Terms at HealthCare.gov.
Affordable Care Act
This is the name of the healthcare reform bill signed into law by President Obama on March 23, 2010. You might hear it called “ACA” or even “Obamacare.” Much of the law is about access to healthcare, like making sure you can’t be denied a health plan because of a health issue. It also expands Medicaid, helps some people pay for their health plans, and requires almost everyone to have a health plan.
This is the amount of reimbursement that doctors, hospitals or other healthcare providers who are in your network have agreed to accept for a covered service. Example: A doctor may normally charge $100 for a particular service. But he has an agreement with your plan to accept only $80 as reimbursement for that service. $80 is the “allowed amount.” This is sometimes called a “negotiated rate.” The allowed amount includes any amount paid by your plan, plus any amount you pay as a cost-share. So, if the allowed amount is $80 and you have 20% coinsurance, you will pay $16 and your plan will pay $64. Or, if you have a copay of $25, you will pay $25 and your insurer will pay $55.
This is the difference between the amount a doctor in your network charges for covered healthcare and the allowed amount.
A broker can be a person or a business. Brokers can recommend health plans, help you apply for financial help from the government, and help you enroll in a Qualified Health Plan. They’re licensed and regulated by states. They also receive payments (commissions) from health insurers when they enroll customers in the insurer’s plan. Some brokers may sell plans only for specific health insurers.
This is a request that your doctor or other healthcare provider sends to your health insurer, or plan, asking to be paid for care provided to you. A claim will include the date of service, the name of the provider, the service performed, the diagnosis and the total billed charge.
An acronym for Consolidated Omnibus Budget Reconciliation Act (COBRA). If you work for a company with 20 or more covered employees, COBRA lets you keep buying the same group health coverage for up to 18 months in many situations where you lose your job or change employers. You have to pay 100% of the premiums, including any amount that was paid by your employer, plus a small administrative fee.
The percent of the allowed amount for covered healthcare that you have to pay after meeting any deductible. Example: If your network doctor charges $100 (in this case, the allowed amount) for an office visit and your coinsurance is 20%, your cost would be $20. Your plan would pay the remaining 80%, or $80. You also must pay your deductible, if it has not been paid in full for the benefit year.
Contract or policy holder
The contract holder is the primary person insured under an insurance policy.
Copay (or copayment)
A copay is the fixed or set dollar amount you pay for certain covered healthcare. This payment is due at the time you receive care. Prescriptions and visits to a doctor in your network are examples of covered services that often have copays.
These are the healthcare services or items that are partially or fully paid for by your insurance company under your plan. You can find out which benefits are covered and which services are excluded in the plan’s coverage documents.
A deductible is the amount you owe for covered healthcare before your insurance benefits kick in. Example: You choose a plan with a $1,000 deductible. When you need covered services that require a deductible, such as a hospital stay, your plan won’t begin to pay until you’ve met that $1,000 deductible. Not all services apply to your deductible.
A dependent is a person (example: a spouse or child) who qualifies for coverage under a policy because of his or her relationship to the contract holder.
See contract holder.
Emergency medical transportation
Ambulance services, including transportation and care provided during transport, for an emergency medical condition.
Emergency room services
Healthcare services provided in a hospital emergency room or services performed during an emergency room visit.
Essential health benefits
As of 2014, new individual and small group health plans must include coverage for healthcare services called "essential health benefits" or "EHBs." These fit into 10 categories:
1. Outpatient care
2. Emergency care (ER)
3. Hospital stays
4. Lab tests and exams
5. Pregnancy and newborn care
6. Mental health and substance abuse care
7. Prescription drugs
8. Preventive and wellness care
9. Child healthcare that includes dental and vision
10. Rehabilitative and habilitative care and devices
The Exchange, or Health Insurance Marketplace, is a federally operated website where you can compare and buy qualified health plans (QHPs). To get financial help for your monthly health plan bill or other healthcare costs, you have to buy your plan on the Exchange, which is called the Federally Facilitated Marketplace, or “FFM.”
Healthcare services that your health plan doesn’t pay for or cover.
Grandfathering or Grandfathered
If you’re covered under a group or individual health plan that went into effect on or before March 23, 2010, you may have a grandfathered plan. The Affordable Care Act (ACA) excuses grandfathered plans from following certain parts of the law. See Affordable Care Act. See Affordable Care Act.
As of 2014, you can’t be turned down for a new health plan because of a health issue, age, gender or other factors that might predict the use of health services. This is called “guaranteed issue.” Also, you can’t be charged more because of a health condition.
Health Savings Account (HSA)
HSAs are savings accounts that have tax advantages. The money you put in your HSA can be used to cover the cost of many healthcare services that aren’t paid for by your health plan, such as your member cost share. You can’t use an HSA to pay your premium. You have to enroll in a qualified high-deductible health plan before you can set up an HSA.
Healthcare Reform (HCR)
You might see this abbreviation tossed around from time to time. Healthcare reform, or HCR, is just another term some people use to describe the Affordable Care Act healthcare law.
HMO or Health Maintenance Organization
This is a type of health plan that offers a wide range of healthcare through a contracted network of doctors and hospitals. Healthcare services from doctors outside of the HMO network are usually excluded, except in an emergency or in special circumstances when use is preauthorized.
Care in a hospital that required you be admitted on an inpatient basis. It typically requires at least one overnight stay.
Under the Affordable Care Act (ACA), almost all Americans are required to have a health plan. If you are not exempt and are not enrolled in a plan, you will have to pay a tax penalty. The penalty doesn’t apply until after you have gone without coverage for certain period of time governed by federal law. Visit HealthCare.gov for more information.
Metal Gap coverage
Metal Gap coverage may be used to supplement medical coverage, such as coverage through the Affordable Care Act (ACA) or short-term medical. Benefits may be used to help cover certain gaps in coverage, such as deductibles and coinsurance, or to help with additional personal expenses, such as mortgage or car payments. Benefits include reimbursements for accident-related medical expenses and critical illnesses, among others.
Under the Affordable Care Act (ACA), most health plans offer one of four basic plans or levels of coverage: bronze, silver, gold and platinum. These are often called "metal" plans. The different levels are determined by the amount health plans pay toward medical costs, on average.
Monthly rate (premium)
This amount is the estimated monthly premium you should expect to pay for your plan. Your final premium amount will be determined during the application process.
These are the doctors, hospitals, pharmacies, labs and other professionals or places that provide healthcare services that have a contract with your health insurer. Your out-of-pocket costs are lower when you receive covered services from network providers. For some plans, services may not be covered at all if you don’t use network providers.
See Out-of-network providers.
When a patient meets with a doctor or healthcare provider to get health advice or care for a symptom or condition.
Open enrollment period (OEP)
This is the period of time each year when individuals can enroll in a health plan or change to a different plan. Under healthcare reform, you must enroll before the end of the open enrollment period. If you try to enroll after that date, you won’t be able to do so until the next open enrollment period, unless you qualify for a special enrollment exemption, or have a qualifying life event.
These are healthcare providers—doctors, hospitals, pharmacies, labs and other professionals and places that provide healthcare services but do not have a contract with your health insurance company. You will pay more for services if you see providers outside your network. In some cases, their services may not be covered at all.
Check your policy. Sometimes providers may contract with an insurer for all networks, and other times only for certain networks. If providers are contracted with your insurer, but not your specific network, those providers are still considered non-contracted, or outside the network. They may also be known as non-network or non-contracted providers.
Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services, plus all costs for services that aren't covered. These are also referred to as out-of-pocket expenses.
Out-of-pocket maximum or limit
The most you pay in a year before your health insurance pays 100% of the cost of covered network services. These limits put a cap on healthcare costs if you ever have a major illness or injury. This limit never includes items such as your premium or non-covered services. Costs for services from providers outside your network do not apply to this limit.
Surgery that does not require an overnight stay in a hospital.
Patient Protection and Affordable Care Act
See Affordable Care Act (ACA).
In some cases, you will need an approval—or precertification—in order for certain services or prescriptions to be covered by your plan. This is also known as preauthorization or prior-approval.
A pre-existing condition is a health problem that existed before the date your insurance becomes effective. Under the Affordable Care Act (see guaranteed issue), you cannot be turned down for health insurance based on a pre-existing condition.
Preferred Provider Organization (PPO)
A PPO is a type of health insurance plan that lets members get covered services from any eligible provider, but offers higher levels of coverage for services from network healthcare providers. Members enrolled in a PPO plan can also receive coverage for services outside their network, usually at higher cost share and subject to balance bills.
A premium is the cost you pay each month to keep your health insurance plan active. (see monthly rate)
These are medications or drugs that require a prescription.
Prescription drug levels/tiers
A way to classify prescription drugs for cost-share purposes.
Tier 1: In general, drugs on this tier are commonly prescribed generic drugs , which often, provide better value compared to brand drugs that treat the same conditions.
Tier 2: These drugs cost more than drugs in Tier 1. Drugs may also be on this tier because they are "preferred" among other drugs that treat the same conditions. This may be based on how well they work, if they have fewer side effects, if they’re more affordable, etc.
Tier 3: These drugs are higher cost brand-name drugs. They often cost more because they don’t have a generic equivalent.
These include certain screening services, immunizations, routine physicals, well-baby care, diagnostic lab and x-ray tests, pap smears and mammograms. Under the Affordable Care Act, most preventive services are 100% covered by your plan with doctors in your network. Some services can be classified as preventive or medical, depending on the reason for the service. The claim submitted by the doctor will have a diagnosis that says if the service is preventive. Watch this short video to learn more.
Primary Care Provider (PCP)
A primary care provider (PCP) is a medical professional who provides primary care to you and other members on your health plan. This person is most often a doctor, but a PCP can also be a physician assistant, nurse practitioner or other care provider. For Affordable Care Act plans, BCBSAZ will select a PCP for you, but if you would like to change your PCP, you can do so up to six times a year.
Your provider is the person or business that supplies healthcare services. Providers include both individual professionals, such as doctors and specialists, as well as facility providers and suppliers like hospitals, outpatient surgery centers, labs and pharmacies.
Qualified Health Plan (QHP)
This is a health plan that’s been certified by the government as meeting certain standards. QHPs can be sold through the Exchange. All QHPs need to include coverage for a set of 10 essential health benefits. See essential health benefits and The Exchange.
A written order from your primary care provider (PCP) for you to see a specialist or to get certain medical services. With BCBSAZ HMO plans, you need a referral before you can get care from most specialists. Some exceptions may apply. Without a referral, your plan will not pay for those services.
RX Pay Card
RX Pay Card is a prescription drug card program most often purchased along with a short-term medical plan. RX Pay Card is a discount program and should not be considered insurance.
Short-term medical insurance policies are designed to provide coverage for individuals and families who need temporary health insurance coverage. This may be due to the loss of a job, a waiting period for other benefits to kick in, or not being able to afford alternate options.
Special enrollment period
A time outside of the standard open enrollment period when you can sign up for health coverage. In most cases, your special enrollment period will be the 60 days following certain life events that involve a change in family status or loss of other health coverage.
Watch this short video to learn more.
A specialist is a doctor or other healthcare professional that focuses on a specific area of medicine other than those provided by your primary care provider (PCP).
If you earn less than a set amount of money per year, you may be able to get help from the government to pay your monthly health plan bill (premium). This help is called a subsidy and depends on family size, and household income. Subsidies are available to people with household incomes of up to 400% of the federal poverty level.
Telemedicine is a type of benefit that includes access to a network of board-certified doctors 24 hours a day, seven days a week. The doctors can provide a medical consultation by phone or web video and can send a prescription to your pharmacy, if needed.
Care for an illness, injury or condition that is serious enough to be seen by a medical professional right away, but not serious enough to require emergency room care.