Health Insurance Glossary

A:

ACA (Affordable Care Act), sometime interchangeable with Obama Care

Agent (Health insurance agent) Sometimes referred to as producers or representatives, health insurance agents are licensed and regulated at the state level and help individuals and families find plans that fit their needs.  Typically, health insurance agents work with a single health insurance company and represent the company rather than the applicant.

Purchasing a health care plan is just the start of a relationship between you and your agent. Your needs will change as your family grows and ages, and having a reliable advocate in your corner can make a tremendous difference in navigating the complex world of health insurance coverage.

Allowable Charge An allowable charge is an approved dollar amount that a health insurance company will reimburse a provider for a certain medical expense. It is often referred to as an approved charge or an allowed amount.

Actual charges are a bit different, and refer to the amount billed by the provider for the specific service. The allowed amount is the amount your insurance carrier is willing to pay for the rendered service. The difference between these amounts is called a contractual write-off.

APCD All Payer Claims Database

B:

Benefits (Medical service or supply) In the world of health insurance, benefits refer to any medical service or supply covered by your health insurance plan. These include doctor visits, hospitalizations, and medications.  An outline of what your benefits will and won’t cover can be found in you health insurance plan’s coverage documents.  Coverage documents outline and explain your benefits, accessing health care, and much more.

There are so many providers out there, and each provider offers different plans at different levels and costs. Before you make any final decisions, make sure that you understand these basic facts about health insurance plans.

Broker (Health insurance broker) Health insurance brokers are agents who are licensed and regulated at the state level.  Brokers can help you navigate and enroll in plans through the Health Insurance Marketplace, or sell you policies from specific health insurance companies with their extensive knowledge and experience.

C:

Catastrophic Health plans according to the ACA are for people under 30 with fewer benefits.

Catastrophic Insurance Catastrophic health insurance is a specialized insurance plan under the Affordable Care Act.  These plans are designed to be more affordable than other available Qualified Health Plans, which are plans that meet the Health Insurance Marketplace requirements.

Catastrophic health insurance plans allow you to pay a lower monthly premium by increasing your out-of-pocket costs such as deductibles, copayments, and coinsurance.  While these plans may seem appealing to those who consider themselves healthy, they are not available to everyone.  Mostly those under 30 years old.

CDR Condition Deductible Rider

Claim (Health insurance claim) A health insurance claim refers to a request made by either you, or your health provider to cover medical services you received.  These requests come in the form of a detailed invoice, outlining exactly what services were administered.

How A Health Claim Works

• The patient is treated by a healthcare professional.

• The healthcare professional then sends an insurance claim via form or request to a payee. The payee is usually the health insurance company, or the individual who received the services if they do not have insurance.

• The insurance company codes according to the diagnosis and treatment. The codes must follow HIPPA regulation.

• Once the invoice is coded, it is sent to a Universal Clearing House, an establishment for regulated financial exchange, for evaluation.

• After the claim is evaluated, it is forwarded to the patient with an explanation of benefits. Most often, this statement will remind the patient, “This is not a bill.”

COBRA (Consolidated Omnibus Budget Reconciliation Act) COBRA, short for Consolidated Omnibus Budget Reconciliation Act, provides the opportunity for employees and their dependents to stay on their employer group insurance coverage after the loss of employment.

Being let go from your job can be overwhelming and unnerving. Not only do you now have a loss of income, but you also have a loss of health insurance or need to find health insurance elsewhere.

Congress understood this dilemma in 1986 and set forth the COBRA provisions. This new act amended the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act in order to expand benefits for those who had lost insurance coverage through their employer. Employers with 20 or more employees are generally mandated to provide COBRA benefits and need to notify their employees of its availability. Qualifying events for employees for COBRA coverage include:

• Voluntary or involuntary loss of a job as long as it was not for gross misconduct

• Reduced hours on the job

Spouses are also covered in the event that they divorce or legally separate from the covered employee, the covered employee becomes eligible for Medicare, or the covered employee dies. If a dependent child loses their dependent status under the plan rules, they are also eligible for COBRA coverage.

COBRA Basics, Under COBRA, you pay the one hundred percent of the premiums, or monthly cost for your health insurance. This includes your normal premium payment plus the portion that your own employer used to pay as well as a small administration fee. For some people, the total COBRA payments can be two to three times that of the monthly premiums they were paying during their employment.  Find out if it is more cost effective to switch plans by entering info here, or give one of our agents a call 404-825-6971

However, you and your dependents get to keep the same insurance you had during the period of employment. All of your health insurance benefits will remain the same and be through the same health insurance company during the time that you are on COBRA.

Pros And Cons Of COBRA, As with all types of health insurance, there are pros and cons to electing COBRA coverage. It is important to examine them in light of your current situation before deciding whether or not you will elect COBRA.

Pros

• You do not have to worry about finding other health insurance coverage after the loss of a job.

• You have the convenience of keeping the coverage and health care providers that you are already familiar with.

• COBRA provides continuity and stability as you transition from one job to the next.

Cons

• It must be elected; if you do not tell your former employer you want it, you will lose it.

• Premiums can be very expensive.

• In most cases, COBRA only covers you for 18 months.

Coinsurance is the portion of a medical or health care bill that you are responsible for paying on a claim. This is owed in addition to your regular premium amounts. If you have gone to an in-network provider, the bill may be reduced by a contractual write-off between the in-network provider and the health insurance company.  Then, your insurance company will pay their portion, and you will be responsible for the remaining balance.

Copay (Medical or health-related expense) A copay is the fixed portion of a medical or health-related expense that you are required to pay as outlined in your health insurance terms.

D:

Deductible A deductible is the amount of money that you pay to a health insurance provider before your insurance coverage kicks in, and your provider begins to pay for your health care. Since many insurance plans require that you cover co-pays as well as deductibles, you may be wondering what out-of-pocket costs go toward your deductible. Generally speaking, most payments made for medical attention, tests or services go toward your deductible. However, co-pays and insurance premiums do not.

Dependent (Spouses or children) When talking about health insurance, a dependent is a person who relies upon another individual for care and financial support. To qualify as a dependent…In the majority of cases, dependents are spouses, children or children up to the age of 26 years old. However, it may vary plan by plan and state by state,  Here are some circumstances where an older adult child or a person who is not the policy holder's child, may be considered a dependent, and a child or relative may qualify.

To be a qualifying relative, a person must meet a number of criteria:

The qualifying dependent in question must have a specific relationship with the policy holder.

The qualifying dependent may not make more than the exemption amount. The exemption amount as of 2016 was $4,050.

The qualifying dependent must not provide more than half of their own support for the taxable year.

The qualifying dependent must not be listed as a qualifying dependent for anyone else.

DOV (Doctors Office Visit)

E:

Effective Date The effective date is the date at which your insurance policy begins, or becomes effective. Prior to this date, even if your application has been approved, you do not have access to your new health insurance coverage.  This means your health care policy will not begin covering any portion of your medical expenses.

EHB (Essential Health Benefits) Benefits that are included in ACA plans without annual or lifetime limits.  Deductibles may still have to be met before services are covered.  Those benefit include but are not limited to Ambulatory patient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health & behavioral health treatment (substance use disorder), Prescription drugs, Laboratory services, Rehabilitative and habilitative services and devices, Preventive and wellness services and chronic disease management, Pediatric services, including oral and vision care.

Eligible Needs is a Health Share program term that means, costs incurred under provided services after effective date

Employee Contribution If you have a health insurance plan through your employer, it's likely that you have to pay for at least a portion of your premiums. Your employee contribution is the portion of the premium that you have to pay to a health insurance provider for your coverage, but contributions are normally taken out automatically by your employer.

If you're making a contribution as an employee to a healthcare plan, it usually means that you're getting a discount on a plan. However, if your contribution is a large percentage of your premiums, you may be better off finding a plan that's not offered by your employer. Many organizations have healthcare plans that are offered by only one provider. Unless the plan offered is stellar or the employer is making a significant contribution, you may be able to find a cheaper health insurance plan or one that better suits you and your family's needs.

Employer Contribution Employer contribution refers to the dollar amount your employer will pays towards your health insurance coverage.  The employer contribution is paid only if your employer offers health coverage through your work, and you opt in to the employer subsidized health insurance plan. Without a substantial employer contribution, you may find that it's cheaper to obtain your own insurance policy outside of what is offered by your employer. There are a number of insurance providers that offer affordable plans, and many may be cheaper or a better fit than one that is offered through an employer without a discounted premium.

Employer Excise Tax Is a tax that an employer may have to pay if they offer a plan to their employees that is not an ACA/Obama Care/Minimal Essential Coverage plan.  (Click here to read more)

EOB (Explanation of Benefits).  The breakdown of the bill, provided by the Insurance Network.

EPO (Exclusive Provider Organization) An Exclusive Provider Organization, or EPO, is a hybrid health insurance plan, very.  In most conventional health insurance plans, the involvement of a primary care provider is necessary; however, that is not the case when it comes to an EPO. While an EPO can be an accommodating arrangement for those looking to see specialists without a referral, it may not be the best choice for everyone because it limits your choices when it comes to health providers. What an EPO covers is not extended to any out-of-network services, with the exception of a medical emergency.

F:

First Dollar Coverage Plan  means coverage that provides for the payment of  losses up to the specified limit without any use of deductibles.   So, you don't have to satisfy a calendar year deductible before applicable medical expenses are eligible for payment.  Applicable medical expenses are defined in the policy and usually limited to a maximum amount and/or occurrences the underwriter/administrator is willing to pay.

Flexible Spending Account (FSA) Flexible spending accounts are often referred to as FSAs, and they are accounts that you or an employer can put money into and then use the funds to pay for medical expenses. These accounts can allow you to earmark funds that are used exclusively to pay for costs related to healthcare.  The purpose of a flexible spending account is to make it easier to pay for routine and unexpected medical expenses.  There are different types of FSA’s and many rules of use.

Formulary (Drug Formulary) A formulary, or drug formulary, is a list of prescription medications approved for coverage under a health insurance policy or other means of coverage.  A formulary is used by practitioners to identify drugs that offer the greatest overall value. Most drug formularies have at least three or four tiers of drugs. The tier determines what portion of the cost must be covered by the consumer.  Typical tiers include:

• Generic

• Preferred brand name drugs

• Non-preferred brand name drugs

• Specialty drugs

G:

Guaranteed Issue A guaranteed issue, in the health insurance industry, refers to a scenario where an insurance policy is offered to any eligible applicant regardless of health status or pre-existing conditions. Affordable Care Act plans, also known as Obamacare, covers anyone with pre-existing conditions and is considered an Guaranteed Issue health insurance plan.

GIR (Guaranteed Insurability Rider)

GIST (Guaranteed Insurability Short Term)

H:

Health Insurance Marketplace (Exchange) The Health Insurance Marketplace is a service that people can use to buy commercial, or individual and family health insurance policies. Most states use healthcare.gov, which is owned and operated by the federal government, as their marketplace, while other states have their own online marketplaces.

Healthcare Provider In the U.S., a healthcare provider is defined as "a doctor of medicine or osteopathy who is authorized to practice medicine or surgery (as appropriate) by the State in which the doctor practices; or any other person determined by the Secretary to be capable of providing healthcare services."

HSA (Health Savings Account) A health savings account, or HSA, is a type of savings account designed specifically for medical expenses. You can put money aside each month to pay for routine and emergency medical services as needed. Since these accounts aren't taxed, they make it possible to reduce your healthcare costs.  Only certain designated high-deductible plans are eligible to have HSA accounts

Health Share programs, aka Health Care Sharing Ministries or Medical Cost Sharing Ministries are an alternative to insurance that works in much the same way and are more affordable.  Because of lower administration expenses and because some medical procedures are not eligible for sharing (usually those that may be morally offensive like smoking, or certain pre-existing health or lifestyle-related conditions), membership contributions can be less expensive for participants. Since it is not health insurance, they don't have to play by the same rules. They are not limited to the rules of Open Enrollment and are ACA Exempt and in the ACA, they are referred to as “excepted benefit” plans.

HIPAA (Health Insurance Portability and Accountability Act) HIPAA stands for Health Insurance Portability and Accountability Act.  Signed into law by President Bill Clinton in 1996, HIPAA is designed to ensure greater privacy and accountability for sensitive health information.

HMO (Health Maintenance Organization) HMO stands for Health Maintenance Organization, and the way these plans work is that you choose a primary care provider, or PCP, and they manage all of your healthcare needs. Your PCP is normally an in-network general practitioner or a healthcare professional at a similar level, such as a nurse practitioner.  Your PCP is responsible for handling basic healthcare for you. If your PCP is unable to provide a treatment or diagnosis, they will then refer you to an in-network specialist. Until a referral is provided by a patient's PCP, a visit to a specialist will not be covered by the insurance provider. HMO Plans also require a referral from your primary care physician who will refer you to an in-network specialist. HMO plans force you to choose from a list of pre-approved health providers.  This can be particularly frustrating if you have a current doctor who is not part of your HMO plan.

Household Income Your household income is the combined total income of everyone in your household who is required to file federal tax returns. This figure is often used to determine marketplace savings on health insurance plans, and to see eligibility for government sponsored programs such as Medicaid. When calculating your household income for the year, there are many sources you will want to include in your estimate. A few examples of the income you should count are wages, tips, pensions, interest, 401(k) plans, alimony and stocks. You will also want to include rental income and royalties, unemployment benefits and Social Security Disability Income (SSDI). If you have children with jobs, such as summer jobs or work-study programs, you should include their income in your estimate as well if your child would be required to file a federal tax return. Income That Does Not Need To Be Counted is child support payments, gifts, inheritances, workers' compensation benefits and Supplemental Security Income (SSI).

I:

Individual Mandate, In health insurance, the individual mandate, or Individual Shared Responsibility Payment refers to the penalty or fee charged to people who can afford to buy health insurance but choose not to buy it.

J:

K:

L:

Long Term Care, Long care is designed to provide assistance for the elderly, or someone who has a chronic medical condition that requires special and ongoing services to ensure that their needs are met.

M:

Major Medical (Minimum Essential Coverage) There are two different types of major medical insurance offering specific coverage plans to those who have major medical insurance: Comprehensive -This is the more common form of major medical insurance, and it's designed to cover all medical costs after the deductible is satisfied. The other kind of major medical insurance, Supplemental, acts as a boost for your existing health insurance plan. It serves to cover expenses that your employer-provided insurance does not.

Minimum Essential Coverage (MEC), which means they must: Have an “Actuarial Value” of 60% or more and Cover 10 Essential Health Benefits (EHB) to a certain level that “Qualified health plans” (QHPs) must cover or be subject to the individual mandate tax.  They are: Lab Services, Emergency Services, Prescription Drugs, Mental Health, Substance Use Disorder, Maternity and Newborn Care, Pediatric Services (including Oral & Vison Care), Rehabilitative & Habilitative Services & Devices, Ambulatory Patient Services, Preventive & Wellness Services & Chronic Disease Management, & Hospitalization.  Minimum Essential Coverage (MEC) is the coverage an individual must have to comply with the individual mandate and avoid the individual mandate penalty tax.

Medicaid (federally subsidized health coverage) Medicaid is health coverage provided by the federal government for those who are eligible.  Although it is funded by both states and the federal government, the states are responsible for administering and maintaining the program and must follow federal requirements.  Who and how is determined by the individual states.

Medicare (federally funded health insurance program) Medicare is a federally funded health insurance program designed for those who are 65 years old or older.  While you automatically become eligible for Medicare once you turn 65 years old, there are exceptions for people younger than 65, which include those with certain disabilities and those with End Stage Renal Disease.

MIB (Medical Information Bureau) How insurers keep tabs of your medical data. You can request yours for free once a year. 866-692-6901

Monthly Contribution is a Health Share program term that means, Monthly Premium

MSRA (Member Share Responsibility Amount) is a Health Share program term that means, Deductible.

N:

Need is a Health Share program term that means Medical expenses for medical services by a licensed medical practitioner

O:

Obamacare (Affordable Care Act) Obamacare is the unofficial name used to reference the Affordable Care Act, which is a law passed by the federal government with the intent of creating affordable health insurance options for all Americans. The Affordable Care Act was voted into law under the Obama administration, which is why it is often referred to as Obamacare.

Open Enrollment Period (OEP) The Open Enrollment Period, or OEP, refers to the yearly period when people can enroll in a health insurance plan for the following year without restrictions. In 2017 it is from November 1st to December 15th.  Unless you have a qualifying life event, the Open Enrollment Period is the only time you have each year to change or add health insurance coverage, unless you choose to enroll in a private health insurance plan.

Out-of-Pocket, Out-of-pocket costs are any amounts that you have to pay yourself when you go to the doctor, pick up prescription medication, or spend time in the hospital. In most cases, your insurance company will require you to pay a certain amount for your medical care before your policy kicks in, which is known as your deductible. It is possible that your policy will put a cap on how much you pay out of your own pocket per year.

Out-Of-Network Vs. In-Network And Allowable Charges

If you choose to go to a provider that is within your network, your coinsurance will be based on the allowable charges, not the billed amount.  However, if you go to an out-of-network provider, you will need to pay the amount that would have been the contractual write-off in addition to any copayments or coinsurance you may owe the provider.  The extra expenses are why it is a good idea to stay in network when you have the option.

P:

PCP (Primary Care Physician)

POS (Point of Service), or POS, is a managed healthcare plan. It combines elements of Health Maintenance Organization and Preferred Provider Organization plans. With a point-of-service healthcare insurance plan, you typically pay less if you use providers who are in the service plan network.  The networks are typically small.

PPO (Preferred Provider Organization) A PPO, short for Preferred Provider Organization, is a type of health insurance plan.  PPO plans give you flexibility when finding healthcare providers by giving you an approved network of preferred doctors, specialists, and hospitals.  These health care providers have all agreed to charge a negotiated rate for covered medical services, which can in turn pass the savings onto you. Your PPO plan does not require you to choose a primary care physician.  This means you don’t have to go through a referral process to see a specialist.

Pre-Existing Condition In the healthcare industry, a pre-existing condition refers to any medical condition you have that started before your health insurance benefits go into effect.  The definition varies between companies.  Examples being if treated for in the last 12 months or treated for in the last 24 months etc.

Premium (Health insurance premiums) Health insurance premiums are the amounts paid to an insurance company in exchange for monetary coverage of future medical expenses as stipulated in the insurance policy. Your premium is usually paid to the health insurance company on a monthly, bimonthly, or weekly schedule for specific coverage. These payments represent a contractual agreement that the insurer will provide for and pay for the stated policy coverage.

Premium Tax Credit (Government Tax Subsidy) A premium tax credit is designed to help individuals afford health insurance plans that are available through the government's Health Insurance Marketplace.  Premium tax credits allow people who have lower incomes to afford health insurance plans as part of the Affordable Care Act. It's important to note that you must file a tax return to be able to take advantage of a premium tax credit.

Preventive Services, Preventive services refer to the proactive measures taken to prevent disease from occurring rather than reactively treating a disease. For example, medical tests that screen patients for a particular disease are not being used to treat any disease or illness. They are being used in an effort to help prevent the disease or disorder.

Primary Care Physician (PCP), A primary care physician is a doctor who provides the first line of contact and treatment for a health concern. They also provide continuing care and treatment of medical conditions that are already verified. Developing and maintaining a trusted, long-term relationship with your primary care physician is key to a healthy life.

Provider Network, A provider network is a group of individual healthcare providers that combine their services in order to help lower costs for patients. This usually occurs through an HMO or a PPO. Each provider network covers different medical procedures, and they usually offer more coverage than typical health insurance providers because of the variety of doctors who are working under the umbrella of that network. In-Network, If a health provider is in-network, the medical services you receive will either be covered by your health insurance provider, or total cost will be reduced. Out-of-Network, If your health provider is out-of-network, the medical services your receive will often not be covered by your health insurance provider, or more expensive than if you were to stay in-network.

Q:

Qualifying Life Event (QLE), A qualifying life event, or QLE, refers to a change in situation that makes you eligible for a Special Enrollment Period for Obama Care.  Without a qualifying life event, you may only make changes to your health insurance coverage during the Open Enrollment Period each year.  Your qualifying life event will usually give you a 60 day window outside of the Open Enrollment Period to add, drop, or change your health insurance plan.  This does not pertain to Short Term plans or Private Health Insurance.

R:

Rider (Amendments, or changes, to your health insurance policy), Riders are amendments, or changes, to your health insurance policy.  Historically, health insurance companies had the ability to add riders to your health insurance policy which added or excluded certain coverage permanently or for a specific duration, known as your exclusionary period.  A common example of a rider is when someone decides to purchase a rider that adds maternity or pregnancy coverage to their health insurance plan.  On the flipside, health insurance companies may add riders to your plan that would exclude coverage for a medical condition such as a recurring back problem that you have been seeking medical attention for before you enrolled in your health insurance policy.  Sometimes called Exclusionary Policies.

S:

Shared Responsibility Payment.  In health insurance, the Shared Responsibility Payment, aka, Individual Shared Responsibility Payment also known as the Individual Mandate, refers to the penalty or fee charged to people who can afford to buy health insurance but choose not to buy it. Click here for more information and exemptions to the Individual Mandate.

Sharing/Shared Amount is a Health Share program term that means, Coverage

Short Term, Short term insurance is a type of health insurance plan designed to keep someone protected from the potential costs associated with unplanned medical expenses during periods that they may not have healthcare coverage.  These plans vary greatly in actual coverage so care should be taken when considering and fully read the policy.

Special Enrollment Period (SEP), Special Enrollment Periods allow you to add, drop, or enroll in health insurance plans outside of the annual Open Enrollment Period when you’ve had a qualifying life event.  Your Special Enrollment Period typically lasts up to 60 days, and if you don’t enroll in a plan within your 60 day Special Enrollment Period, you will have to wait until the next Open Enrollment Period. There are a number of reasons that someone may be eligible for a Special Enrollment Period, and they are considered to be significant life changes known as qualifying life events.

T:

Tax Penalty, Shared Responsibility Payment.  When the Affordable Care Act became law, it brought with it the Individual Mandate that requires U.S. citizens to purchase health insurance.  If they do not qualify for an exemption, and still choose to forgo purchasing health insurance, they will be responsible for paying a tax penalty, also known as the shared responsibility payment.  This penalty, along with any exemptions that you are claiming, will be filed with your taxes each year.  There are many exemptions for avoiding the tax penalty. And finally, there are no liens, levies, or criminal penalties for failing to pay the fee.

U:

UCR (Usual, Customary, And Reasonable) The Usual, Customary, and Reasonable amount, or UCR, is what is paid by your health insurance company based on what other providers in the same area are charging for the same or similar medical service. The UCR is sometimes used to determine the allowable charges.

Underwriting, Underwriting is a term used in the health insurance industry to describe the process of risk assessment, which ensures that the cost to cover a patient is proportionate to the risks faced by the individual.  Risk can be looked at in many different ways from health history, current health, dangerous occupation or lifestyle.

V:

W:

Waiting Period, A waiting period in the realm of health insurance simply refers to the amount of time you have to wait between enrolling in your health insurance policy, and your benefits to kick in.

Well-Care, a visit for preventive care. Sometime called a physical and may be defined as you are not sick or injured (there is nothing concerning you, and no specific health reason for the doctor visit).  These recommendations apply to healthy people without disease or physical symptoms. If tests or services beyond the scope of a well-care visit are provided, then additional charges will be incurred for those services.

X:

Y:

Z: