Health Insurance Glossary
Affordable Care Act (ACA):
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or "Obamacare").
The law has 3 primary goals:
Make affordable health insurance available to more people. The law provides consumers with subsidies ("premium tax credits") that lower costs for households with incomes between 100% and 400% of the federal poverty level.
Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs; Pennsylvania did expand Medicaid.)
Support innovative medical care delivery methods designed to lower the costs of health care generally.
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 care visits per year before the plan's deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a Catastrophic plan, you must be under 30 years old OR get a "hardship exemption" because the Marketplace determined that you're unable to afford health coverage.
Certified Application Counselor:
An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers.
Children's Health Insurance Program (CHIP):
Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.
Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply any time. If you qualify, your coverage can begin immediately, any time of year.
CHIP Managed Care:
Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Children's Health Insurance Program (CHIP) managed care provides for the delivery of CHIP health benefits through contracted arrangements between state CHIP agencies and managed care plans that accept a set per member per month (capitation) payment for these services.
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, or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.
Example of coinsurance with high medical costs
Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.
Out-of-pocket maximum: $6,850
You'd pay all of the first $3,000 (your deductible).
You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).
So, your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.
If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.
Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
If you've paid your deductible: You pay $20, usually at the time of the visit.
If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details.
All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.
Some plans have separate deductibles for certain services, like prescription drugs.
Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
In Pennsylvania, an Exchange Assister is an individual or organization, including a Navigator, Navigator Organization or Certified Application Counselor (CAC) who provides public education or assists consumers for or on behalf of the Affordable Care Act Marketplace. This term does not include a licensed insurance producer. This term also does not include an individual employed to provide insurance enrollment or coverage assistance by a health care facility as defined in section 103 of the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act.
Group Health Plan:
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children's Health Insurance Program (CHIP).
Individual Health Insurance Policy:
Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.
The hospital or provider has a contract with your insurance company. Contact your insurance company or visit its website for a list of in-network hospitals and providers.
Large Group Health Plan:
In general, a group health plan that covers employees of an employer that has 51 or more employees.
Living Independently for the Elderly (Life) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.
Shorthand for the "Health Insurance Marketplace," a shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010.
In most states, the federal government runs the Marketplace (sometimes known as the "exchange") for individuals and families. On the web, it's found at HealthCare.gov.
Fill out a Marketplace application and you'll find out if you qualify for lower monthly premiums or savings on out-of-pocket costs based on your income.
You may find out if you qualify for Medicaid or the Children's Health Insurance Program (CHIP).
You can shop for and enroll in affordable medical insurance online, by phone, or with in-person help from a trained assister or an agent or broker (in Pennsylvania agents and brokers are called producers).
Medical Assistance (MA), also known as Medicaid:
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.
Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states.
You can apply anytime. If you qualify, your coverage can begin immediately, any time of year.
A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare isn't part of the Health Insurance Marketplace
Medicare Advantage (Medicare Part C):
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Part D:
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.
Or Act 2 of 2009, is a Pennsylvania law that gives employees of small businesses (2-19 employees) who receive health insurance from their employers the right to purchase continuation health insurance after they leave.
Minimum Essential Coverage (MEC):
Any insurance plan that meets the Affordable Care Act requirement for having health coverage. Examples of plans that qualify include: Marketplace plans; job-based plans; Medicare; and Medicaid & CHIP.
An individual or organization that's trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Open Enrollment Period:
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2020 is over, but you may still be able to enroll in a Marketplace health insurance plan for 2020 if you qualify for a Special Enrollment Period.
You're eligible for a Special Enrollment Period if you have certain life events, like getting married, having a baby, or losing other health coverage.
Job-based plans may have different Open Enrollment Periods. Check with your employer.
You can apply and enroll in Medicaid or the Children's Health Insurance Program (CHIP) any time of year
The hospital or provider does not have contract with your insurance company. Contact your insurance company or visit its website for a list of in-network hospitals and 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.
Qualified Health Plan (minimum essential coverage):
An insurance plan that's certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as "minimum essential coverage."
Examples of qualifying health coverage:
Any health plan bought through the Marketplace
Individual health plans bought outside the Marketplace, if they meet the standards for qualified health plans
Any "grandfathered" individual insurance plan you've had since March 23, 2010, or earlier
Any job-based plan, including retiree plans and COBRA coverage
Medicare Part A or Part C (but Part B coverage by itself doesn't qualify)
Most Medicaid coverage, except for limited coverage plans
The Children's Health Insurance Program (CHIP)
Coverage under a parent's qualified health plan
Most student health plans (check with your school to see if the plan counts as qualifying health coverage)
Health coverage for Peace Corps volunteers
Certain types of veterans health coverage through the Department of Veterans Affairs
Most TRICARE plans
Department of Defense Nonappropriated Fund Health Benefits Program
Refugee Medical Assistance
See a more detailed list of types of plans that do and don't count as qualifying health coverage from the IRS.
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.
Primary Care Provider:
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
Self-Insured Plan (Self-Funded Plan):
Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees' and dependents' medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.
Special Enrollment Period (SEP)
A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you've had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the event to enroll in a plan. If you miss your Special Enrollment Period window, you may have to wait until the next Open Enrollment Period to apply.
You can enroll in Medicaid or the Children's Health Insurance Program (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.
Job-based plans must provide a Special Enrollment Period of at least 30 days.