Glossary
64 terms covering coverage, claims, billing, networks, and the regulatory acronyms you'll meet.
Showing all 101 terms
An accumulator is a running total of money you’ve paid towards your out-of-pocket max for covered health care services.
The Patient Protection and Affordable Care Act (PPACA) is the official name of the Affordable Care Act (ACA), also known as Obamacare.
An allowed amount, sometimes called a negotiated rate, is the amount an insurance company agrees to pay for a medical service or supply from a specific doctor or group.
The period of time during the year when you can sign up for, switch or disenroll from a Medicare Advantage health plan.
If your insurer denies a claim, terminates your plan, or makes a benefits decision you believe is incorrect, you have the right to file a formal appeal.
Balance billing is a term used for the amount a doctor charges after your insurance company pays the negotiated rate for a service, device, or drug.
Medical benefits refer to the perks, protections, and services that are included in your health insurance plan.
Under 30 and in great health? You may want to consider a catastrophic health insurance plan.
A certificate of coverage is a legal contract that explains the health benefits you and your dependents have under your insurance plan.
Need health insurance for your child? Your family may qualify for the Children's Health Insurance Program (CHIP).
CiOX
A health insurance claim is essentially an invoice that your provider sends to your health insurance company for services you received.
COBRA is the name of a federal law that may let you continue your group health insurance coverage if you lose your job.
Coinsurance is how much you owe for a covered health care service or prescription, calculated as a percentage of the allowed service amount.
Colorado's official health insurance Marketplace.
When two insurance companies coordinate with one another to pay benefits for the same person.
Copayments are fixed dollar amounts you’re responsible for paying for covered appointments, services, medical equipment, or prescriptions.
Cost sharing is a catch-all term for any covered medical expenses you pay before your health insurance company picks up the tab.
A coverage area is a specific region where a health insurer’s members can get covered care under their plan.
Covered California is the state marketplace for Californians who need to buy individual health plans.
The health care and prescriptions you get fall into three categories: covered, covered-in-full, and not covered.
A deductible is the dollar amount you pay out-of-pocket for covered services before your health insurance plan begins to pay for your care.
A dependent is anyone you claim on your income tax return during the year – usually, your spouse and your children.
Imaging services provide images of the inside of your body using a variety of different technologies and techniques.
Durable medical equipment (DME) includes any health care equipment or supplies ordered by a doctor or medical facility.
An effective date is the date your health insurance coverage actually starts covering your care.
Eligibility is the set of criteria an insurer uses to decide if a person can legally sign up for one of their plans.
A medical emergency is any situation where you risk losing your life or a limb if you don’t get immediate medical care.
Employee waivers are official forms submitted to an employer to decline group health coverage.
Essential health benefits, sometimes called Obamacare benefits, are mandatory health insurance benefits that all individual insurance plans must offer.
The site you use to purchase a health insurance plan. Also known as the Marketplace.
Excluded services are services that your health insurance plan won’t cover.
Non-exempt employees are paid hourly and entitled to overtime. Exempt employees are salaried and not eligible for overtime.
An explanation of benefits (EOB) is a statement from your insurance company outlining what your doctor billed and what they paid.
A flexible spending account (FSA) is an account set up by an employer for an employee to contribute to pre-tax.
A formulary is a list of prescription drugs covered by an insurance plan’s benefits.
FTE is a combination of full-time employees and part-time employee hours aggregated to account for full-time work.
A grace period is a period of time after you miss a payment when you can catch up on your bills.
Guaranteed renewal is a legal requirement that your health insurer has to offer to renew your plan as long as you continue to pay your premium on time.
A type of insurance coverage that pays for some or all of your medical costs.
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects consumers' personal health information.
A health reimbursement arrangement (HRA) is an account with pre-tax contributions from an employer that employees can use to pay for medical expenses.
A health savings account (HSA) is a long-term savings account you set up to pay for health care expenses throughout the year.
HealthCare.gov is the federal Marketplace where you can buy individual health insurance for yourself and your family.
High deductible health plans (HDHPs) typically have a lower monthly premium and a higher deductible.
HMO, PPO, EPO, POS – these acronyms for health insurance plans get tossed around a lot. Here’s what each plan type means.
Hospice care includes any service that provides medical, emotional, spiritual, and social support for terminally-ill patients and their families.
All ACA-compatible health insurance plans cover a variety of preventive immunizations for babies, children, and adults.
Health insurance plans fall into two primary categories: individual and group.
The seven-month period of time when you can enroll for the first time in a Medicare plan.
Insurance brokers are trained professionals who can guide you through a wide array of health insurance options to find the best option.
In most states, large groups are defined as employers with more than 50 full-time equivalent employees.
Level funding is a group health insurance product that allows some employers to get coverage at more competitive rates than fully-insured plans.
Long-term care is ongoing medical and non-medical care you receive to perform everyday activities.
The health insurance Marketplace, also called the exchange, is where you can buy health insurance under the Affordable Care Act.
Medicaid is a government-administered program that provides free or low-cost health insurance for millions of Americans.
Medically necessary health care services are those required to diagnose or treat a condition and meet accepted medical practices.
Medicare is a government-administered program that provides health insurance benefits for adults age 65 or older.
Medicare Advantage is a type of Medicare health plan offered by a private company.
HealthCare.gov established metal tiers to make it easier for consumers to compare health plans across insurance companies.
Modified adjusted gross income (MAGI) is the pre-tax income for your entire household that you expert to claim on your tax return.
A negotiated rate is the amount an insurance company agrees to pay for a medical service or supply from a specific doctor or group.
A health insurance network includes the medical professionals, facilities, and suppliers your insurer has contracts in place with.
The New York State of Health (NYSoH) is the online health insurance marketplace where residents of New York can sign up for plans.
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA).
Open Enrollment is the period when individuals and families can enroll in health insurance plans in the individual marketplace.
Your out-of-pocket max is the most you could pay for covered health care in a calendar year aside from your monthly premium.
Outpatient care requires an admission. while inpatient care involves an admission to the hospital.
A participation requirement is a minimum percentage of employees who must sign up for a health insurance plan through a specific insurer.
A payroll provider is a third-party company that handles everything related to employee compensation.
A pre-existing condition is a medical condition you have on or before the start date of a new health insurance plan.
Here's how generic and brand-name prescription drugs are classified and covered by insurance companies.
Preventive care includes tests, exams, and services to check your general health. Diagnostic care is given to diagnose a medical condition.
Medical doctors (MDs) fall into two categories: primary care providers (PCPs) and specialists. Here’s the difference.
A Professional Employer Organization (PEO) is a company that provides HR services for small and medium-sized businesses.
Protected Health Information (PHI) is any health information that can be tied to you as an individual.
Providers are individuals, groups, and facilities that we partner with. They provide care to members depending on their geography and plan.
A qualifying life event is an event in your life that qualifies you to sign up for a health insurance plan outside of Open Enrollment.
Reconstructive surgery is performed to improve or restore the function or shape of a body part.
A referral is an official recommendation made by your primary care doctor to see a specialist for additional care.
Rehabilitation services are designed to help you maintain, regain, or improve everyday skills affected by an illness or injury.
Reinstatement is what happens when you make up missed premium payments after your plan has been terminated by your insurance company.
When you enroll in the same health insurance plan for another year.
A Schedule of Benefits (SOB) is a document that outlines the fees associated with each type of health care service covered by your plan.
Skilled nursing is any medical care provided by a licensed medical professional.
SHOP stands for Small Business Health Options Program and it’s a great way to offer quality and affordable health insurance to your employees. SHOP coverage is generally available to small businesses with 1-50 full-time equivalent employees (FTEs)
Small groups are defined as employers with 50 or fewer full-time equivalent employees.
Special Enrollment for health insurance starts after Open Enrollment ends.
Advance Premium Tax Credits are a type of subsidy used to make your individual health insurance plan more affordable.
Telemedicine is a term used to describe health consultations from doctors that are given by phone, secure message, or video chat.
Urgent care clinics provide quick access to care for an illness, injury, or condition that’s serious, but not life-threatening.
Vaccines are medical products that cause immunization, giving you protection against specific diseases.
A waiting period is a duration of time between when an employee is hired and when they're eligible to sign up for health benefits.
Well-baby and well-child visits are regular check-ups with a pediatrician from birth to age 18.
The Affordable Care Act entitles all women to one free well-woman exam every year.
A 1095-B, is a form used to let the IRS know that you had health insurance during a particular tax year.