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  • a

  • Affordable Care Act
    The health reform law passed in 2010 aimed at changing America’s health care system to improve access and affordability for more Americans.
  • Allowable Charge
    The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
  • Allowed Amount
    The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
  • Annual Deductible
    The amount of eligible expenses you’re required to pay annually before reimbursement by your health plan begins.
  • Annual Dollar Limit
    A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. Limits may be placed on particular services or on the dollar amount of covered services.
  • Annual Out-of-Pocket
    The maximum amount per year you’re required to pay out of your own pocket for covered health care services.
  • b

  • Benefits
    The health care items or services covered by an insurance plan, sometimes called a “benefit package.”
  • c

  • Catastrophic Plan
    A health plan that has a lower premium than other health plans, but that has a high deductible. It usually doesn’t provide coverage for a lot of services that other plans typically cover. It is designed to provide a kind of “safety net” coverage in case you have an accident or serious illness. The Health Insurance Marketplace offers a catastrophic health plan option for people under 30 and to some low-income people.
  • Claim
    An itemized bill for services provided to a plan member, spouse or dependent.
  • Coinsurance
    Your share of the costs of a covered health care service — usually a percentage of an eligible expense. For example, you may pay 20% of an allowed service while your plan pays 80%.
  • Copayment
    A fixed dollar amount you’re required to pay for a covered service at the time you receive care.
  • Cost-sharing Assistance
    Federal funds available for eligible people to help reduce health care coverage out-of-pocket costs such as deductibles, coinsurance or copayments. This does not include the cost of premiums. Also known as "cost-sharing reductions". 
  • Covered Person
    The person in whose name a health care policy is issued (the member) and — under family coverage — the member’s dependents.
  • Covered Service
    A service that's covered according to the terms of your health care policy.
  • d

  • Deductible
    A fixed amount of expenses you’re required to pay before you’re reimbursed for a covered service. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 in expenses for health care.
  • Dependent
    A person (generally a spouse or child) other than the member who receives health care coverage under the member’s policy.
  • Drug Formulary
    A list of prescribed drugs covered by a health plan. Not all drugs are covered under a plan.
  • e

  • Effective Date
    The date your health care coverage begins.
  • Emergency Medical Care
    Services provided for treatment of a sudden onset medical condition, usually in a hospital.
  • EOB
    See Explanation of Benefits
  • Essential Health Benefits
    Most insurance plans you can choose from include coverage for certain benefits considered “essential” for basic good health.
  • Exchange
    See Health Insurance Marketplace.
  • Exclusions
    Specific medical conditions or circumstances that aren’t covered under a health plan. As of 2014, certain exclusions went away for most insurance plans. These include age, gender or pre-existing health problems.
  • Explanation of Benefits (EOB)
    The form sent to you after a claim has been processed by your health care provider. The EOB explains the actions taken on the claim, including the amount paid, the benefit available, the amount you may owe the provider and other information, such as how to appeal a claim decision.
  • f

  • Family Coverage
    Health care coverage for a member and their eligible dependents.
  • Federal Poverty Level (FPL)
    A level of income used by the U.S. Department of Health and Human Services to determine eligibility for certain government programs and benefits. FPL is one factor that’ll be used to determine the amount of tax credits you may qualify for to help with the cost of buying health insurance through the Health Insurance Marketplace.
  • FPL
    See Federal Poverty Level (FPL)
  • g

  • Group Plan
    A group of people covered under the same health care policy through the same employer or association.
  • Guaranteed Coverage
    The Affordable Care Act says that most individuals can enroll in some form of insurance regardless of health status, age, gender or other factors.
  • h

  • Health Insurance Marketplace
    People in most states use the Health Insurance Marketplace at to apply for and enroll in health care coverage. In certain states like New Mexico, people use their state’s website Exchange to enroll in individual/family or small business health coverage, or both. Use the Exchange to find your state's website (or for residents of New Mexico).  
  • Health Maintenance Organization (HMO)
    An organization that provides health care coverage to its members through a network of doctors, hospitals and other health care providers.
  • i

  • In-network
    Covered services provided or ordered by your primary care provider (PCP) or another provider who is in the specific network of providers with which your health plan has contracted. 
  • Individual Health Insurance Plan
    Health care coverage an individual buys, rather than a plan offered through a job or group.
  • Individual Mandate
    Until 2019, the Affordable Care Act required most Americans and legal residents to get and maintain health care coverage. While this is no longer a federal requirement, you may be required to pay a penalty on your state income tax return.
  • Inpatient Services
    Services provided when you’re admitted for an overnight stay into a health care facility, such as a hospital.
  • Insured Person
    The person a contract holder (an employer or insurer) has agreed to provide coverage for, often referred to as a member or subscriber.
  • l

  • Lifetime Limit
    A cap on the total lifetime benefits you may get from your insurance plan, or for certain conditions. There is no lifetime limit on essential health benefits, such as emergency care and hospital stays.
  • m

  • Marketplace
    See Health Insurance Marketplace.
  • Medicaid
    A joint federally and state-funded program that provides health care coverage for low-income children and families, and for certain older or disabled people. A provision of the Affordable Care Act significantly expands the program in the states that agree to the expansion.  
  • Medicare
    A federal program established to provide health care coverage for eligible senior citizens (age 65 and over), certain younger people with disabilities and people of any age with End-Stage Renal Disease.
  • Member
    The person a contract holder (an employer or insurer) has agreed to provide coverage for, sometimes referred to as the insured or insured person/subscriber.
  • n

  • Network
    The doctors, hospitals and other health care providers that are contracted with to deliver health care services to members/subscribers in your health plan.
  • o

  • Open Enrollment Period
    The timeframe when you make changes to your health plan coverage or choose a new health plan. Open Enrollment usually occurs each fall.
  • Out-of-Network
    Services provided by health care professionals or at facilities that aren’t in the network of contracted providers and facilities in your health plan.
  • Out-of-Pocket Maximum
    The maximum amount you have to pay for expenses under your health plan during a certain benefit period. This protects you in case of serious or expensive medical conditions.
  • Outpatient Services
    Treatment provided to you without an overnight stay in a hospital or other inpatient facility.
  • p

  • Participating Provider Option (PPO)
    A health care plan that supplies services at a higher level of benefits when members use contracted health care providers. PPOs also provide coverage for services rendered by health care providers who aren’t part of the PPO network; however, the plan member generally shares a greater portion of the cost for such services.
  • PCP
    See Primary Care Provider
  • PPO
    See Participating Provider Option. 
  • Premium
    The ongoing amount that must be paid to a health insurance company to receive health coverage. You and/or your employer pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for coverage. Typically, you’ll also have a coinsurance, copayment and/or deductible amount.
  • Preventive Services
    Routine health care that includes screenings, check-ups and patient counseling to prevent or detect illnesses, disease or other health problems.
  • Primary Care Provider (PCP)
    The doctor you choose to be your primary source for medical care and who coordinates all your medical care, including hospital admissions and referrals to specialists. HMO Plans require you to select a PCP to direct your care.
  • Provider
    A licensed health care facility, program, agency, doctor or health professional that delivers health care services.
  • q

  • Qualifying Event
    A situation that causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming an over-aged dependent, Medicare eligibility, death or divorce of a covered employee. The federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event.
  • s

  • Special Enrollment Period
    A time outside the yearly Open Enrollment Period when you can sign up for health insurance. Individuals qualify for a Special Enrollment Period if they’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child. The timeframe for special enrollment varies, but it is typically up to 60 days following the event to enroll in a plan.
  • Subsidy
    See Cost-sharing Assistance.
  • t

  • Tax Credits
    To help you afford health insurance, you may qualify for tax credits to help with health care coverage costs (premiums) when you enroll in coverage through the Health Insurance Marketplace or Exchange.