GLOSSARY

 

 

 

Advocate: A professional in the field, who supports, assists, or recommends on behalf of individuals or an organization in a specific area of expertise.

Affordable Care Act (ACA):  The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).

Agent: A trained insurance professional who can help you enroll in a health insurance plan. 

Allowed Amount: The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”

Allowable Charge: This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. (See Usual, Customary and Reasonable Charge)

 

Allowable Costs: Charges for healthcare services and supplies for which benefits are available under your health insurance plan.

Annual Deductible Combined: Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.

Authorized Representative: Someone who you choose to act on your behalf w, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowed amount.

Benefits: The health care items or services covered under a health insurance plan.

Benefit Package: A description of the healthcare services and supplies that a health insurance company covers for members of a specific health insurance plan.

Benefit Year:  A year of benefits coverage under an individual health insurance plan.

Broker: A broker is a person or business that can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer's plans. Some brokers may only be able to sell plans from specific health insurers

 

Claim: A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.

 

COB (Coordination of Benefits): This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy.

Co-payment: A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "co-pay." For example, your health insurance plan may require a $15 co-payment for an office visit.

 

Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible.  For example, 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.

Date of Service: The date on which a healthcare service was provided.

 

Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims.

 

Exchange: Another term for the Health Insurance Marketplace

 

Explanation of Benefits (EOB): A statement sent from the health insurance company listing services that were billed by a healthcare provider, how those charges were processed, and the total amount of patient responsibility for the claim.

 

Flexible Spending Account (FSA): An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices. You decide how much to put in an FSA, up to a limit set by your employer. You aren't taxed on this money.

Fee For Service:  A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.

Group: A number of individuals covered under a single health insurance contract, usually a group of employees.

 

Group Health Plan (Insurance): A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.

Health Insurance: A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

High Deductible Health Plan (HDHP): A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible).

HIPAA (Health Insurance Portability and Accountability Act of 1996): Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline the healthcare and insurance industries and to protect the privacy and identity of healthcare consumers.

 

HRA (Health Reimbursement Account): An employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year.

 

HSA (Health Savings Account): A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made to the account on a tax-free basis.

 

Health Insurance Marketplace: A service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.

 

In-network Coinsurance: The percent you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

 

Inpatient: A term used to describe a person admitted to a hospital for at least 24 hours.

Marketplace: Short for the “Health Insurance Marketplace”

 

Network: 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.

 

Out-of-Pocket Costs: 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.

 

Out-of-pocket maximum/limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

 

Out-of-Network Copayment: A fixed amount you pay for covered health care services from providers who don't contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

 

Outpatient: A term referring to a patient who receives care at a medical facility but who is not admitted to the facility overnight, or for 24 hours or less.

 

Preferred Provider: A provider who has a contract with your health insurer or plan to provide services to you at a discount.

 

Premium: The amount you pay for your health insurance every month

 

Protected Health Information (PHI): Any information about health status, provision of health care, or payment for health care that can be linked to a specific individual.

 

Secondary Coverage: When a person is covered under more than one health insurance plan, this term describes the health insurance plan that provides payment on claims after the primary coverage.

 

Uniform Billing Code of 1992 (UB-92): The Uniform Billing Code of 1992 set industry-wide standards for medical billing practices.

UCR (Usual, Customary, and Reasonable): The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.