A lot of the time, the words used in healthcare can feel like a totally different language—especially when it comes to understanding health insurance coverage. What is a premium and deductible? What do you actually need to understand your plan? For one thing, having a handy resource full of definitions will make sure you’re getting the care you need!
Look no further, because here’s your comprehensive glossary guide to help you navigate your health plan. Utilize this along with our open enrollment FAQ and scroll through to find the definitions of every term that could potentially throw you off, from appeal to superbill.
Affordable Care Act Marketplace (also called the “Exchange”)
The Affordable Care Act Marketplace is a website that allows you to purchase health insurance for yourself or your family. If you meet certain income requirements and are not eligible for health insurance through an employer, you may qualify for a discount on the monthly premium that you pay for your Affordable Care Act Marketplace health insurance plan. You can find out more about the Affordable Care Act Marketplace options that are available to you by visiting www.healthcare.gov.
This is a request for your insurance plan to reconsider a claim that has been denied. You can also appeal a prior authorization denial.
(Also: Pre-Authorization or Prior-Authorization)
These are an agreement in advance from your insurance plan to pay for a service or medication. Usually a prior authorization requires your doctor to submit paperwork to your insurance plan explaining why you need a service or medication. If the prior authorization is granted, that means your insurance plan has agreed to pay for the service or medication. (You may still owe a copay or other cost out of pocket.) If the prior authorization is denied, that means your insurance does not agree to pay for the service or medication. You can submit an appeal if your prior authorization is denied.
An advocate, sometimes a nurse, medical assistant or social worker, whose purpose is to facilitate recommended treatment plans to assure the appropriate medical care is provided to disabled, chronically ill, behavioral health or injured patients. Their goal is to help reduce emergency room visits, medication errors, infections and provide resources so patients have a high quality experience with good outcomes.
A carrier is another name for an insurance company.
Certificate of coverage (also called a “booklet”)
A very long document listing the terms of your health insurance plan in detail, including a list of covered services and a list of excluded services.
Claim (also called “insurance claim”)
A request for your insurance plan to pay for a health service that you have received. If a claim is approved, your insurance plan will pay for the health service. You may still owe a copay, coinsurance or other cost out of pocket even if a claim is approved. If a claim is denied, your health insurance plan will not pay for the health service and you must pay the full cost to the provider yourself.
Stands for ‘Consolidated Omnibus Budget Reconciliation Act.’ In essence, COBRA serves as an extension of the medical, dental, vision, and in some cases life insurances that you had from an employer or under a group health plan that you then lost access to. For example, you had health insurance through your employer but you were let go, COBRA is then extended to you so that you don’t have a gap in coverage while you seek new employment. The typical length of time you have access to COBRA is 18 months but certain situations (like disability status) offer extensions beyond those 18 months.
The amount that you must pay up-front to receive a health care service or medication. A copay is usually a set amount of money—for example, your copay to see your primary care doctor might be $20. The copay amount is determined by your insurance plan. The copayment is usually different depending on the type of service or medication you receive. For example, the copay to see your primary care doctor is usually lower than the copay to visit an urgent care center, and the copay for a generic medication is usually lower than the copay for a name-brand medication.
The amount that you must pay to receive a health care service or medication. A co-insurance amount is usually a percentage of the total cost of the service or medication–for example, your coinsurance for a surgery might be 20% of the total surgery cost. The co-insurance amount is determined by your insurance plan.
Coordination of Benefits
If you have more than one insurance plan, your insurance plans must decide which plan pays first for services and medications. This is called “coordination of benefits.” This can be affected by state rules and regulations. It’s important to tell your doctors and pharmacies about all of the health insurance plans that you have, so that your plans can coordinate benefits correctly.
DCFSA (Dependent Care Flexible Spending Account)
A special account that is offered by your employer to allow you to set aside money for work-related dependent care expenses without paying taxes on that money. Eligible dependent care expenses may include costs like fees for after-school programs, sick child care, adult day care, or elder care for qualifying dependents. FSA money is usually “use it or lose it,” meaning that you must spend the money you have saved before the end of your health insurance plan year.
The amount that you must pay out of pocket before your health insurance plan begins paying for certain services. If you have paid the full deductible amount out of pocket, you have “met your deductible.” Some services are “subject to deductible,” meaning that you must meet your deductible before a plan will begin to pay for those services. Some services are “not subject to deductible,” meaning that your plan will begin to pay for those services even if you have not met your deductible. If you have a maximum out of pocket amount that is higher than your deductible, you may still pay some costs until you meet your maximum out of pocket amount.
A list of medications that your insurance plan will pay for. Even if the medication is covered, you may still owe a copayment or other out of pocket cost to get your medication at the pharmacy. Drug formularies are often divided into “tiers,” with “lower tier” medications having a less expensive copay and “higher tier” medications having a more expensive copay.
Expert Medical Opinion is a virtual second opinion given by an expert in the field. A member will request an EMO for a specific condition, a clinician will ask questions regarding past treatment, concerns, questions, expectations, etc. and then a full collection of pertinent medical records will be done by the Records Specialists. Once record collection is complete they will be sent to the expert who treats the condition, the expert will review the records and the member’s questions and deliver a written second opinion to the member.
Exclusive Provider Organization (EPO) plan is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Services or medications that are excluded from coverage are services or medications that your health insurance plan will not pay for. Services that are considered experimental, cosmetic, or not medically necessary are often excluded from coverage.
Formulary (see Drug Formulary)
A list of drugs covered by the health plan. These drugs can be both generic and brand-name prescription drugs.
FSA (Flexible Savings Account or Flexible Spending Account)
A special account that is offered by your employer to allow you to set aside money for medical expenses without paying taxes on that money. FSA money is usually “use it or lose it,” meaning that you must spend the money you have saved before the end of your health insurance plan year.
A medication that can be manufactured by many companies. These medications tend to be less expensive than name brand medications. Generic medications are just as effective as name brand medications and are legally required to have the same active ingredients as the name brand versions.
HDHP (High Deductible Health Plan)
HDHP’s have higher deductibles than most health plans.
Health Benefit (Vendor)
Specialized healthcare related services offered by the employer that are not connected to the medical insurance (e.g. Included Health because we specialize in LGBTQ+ care or WinFertility which specializes in care surrounding family planning.)
In a nutshell, insurance is a contract that requires the company that insures you to pay some or all of your health care costs in exchange for your monthly payments.
Your health plan is the specific insurance plan you choose, and will have specific doctors and providers in the network who can take your insurance.
Health Maintenance Organization, a type of health insurance plan with limited coverage. An HMO may require you to live or work in its service area to be eligible for coverage and it generally won’t cover out-of-network care except in an emergency. (www.healthcare.gov)
HSA (Health Savings Account)
A Health Savings Account is a tax free bank account connected to a High Deductible Health Plan to help offset the cost of that higher deductible. You can use the account like you would a personal checking or savings account, to pay for eligible medical, dental and vision expenses throughout the year. In some instances, your employer will contribute funds to this account as well but you’re also able to set aside funds into the account each pay period up to the maximum amount allowed by the IRS.
Providers who are “in-network” for your plan have entered into an agreement with your health insurance plan. The health insurance plan promises to pay a certain amount to the provider for services that are provided to patients. The provider promises to accept the amount that the health insurance plan pays and not charge the patient additional fees. Seeing an in-network provider usually means that you will pay the lowest cost for services. Some health insurance plans will not pay anything for services that are provided by “out-of-network” providers.
LOA (leave of absence)
An LOA can fall under the FMLA (Federal Medical Leave Act) which entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. There are time limits and restrictions regarding pay. See dol.gov for more.
LPFSA (Limited Purpose Flexible Spending Account)
An LPFSA is a pre-tax benefit used to pay for eligible dental, vision care and post-deductible medical expenses for participants enrolled in a High Deductible Health Plan (HDHP) only.
Name brand medication
A medication that is only manufactured by one company. These medications tend to be more expensive than generic medications. After a certain period of time, the company that makes a name brand medication no longer has the exclusive right to make that medication, and other companies can make generic versions of the medication.
Providers who are “out-of-network” for your plan have not entered into an agreement with your health insurance plan. Seeing an out-of-network provider usually means that you will pay the highest cost for services. Some health insurance plans will not pay anything for services that are provided by “out-of-network” providers, meaning that you will pay the full cost of services out of pocket.
Out-of-pocket maximum (also called “maximum out-of-pocket amount”)
Your out-of-pocket maximum is the most you will spend in a calendar year for your and your dependents medical care. This is above and beyond your deductible for the year. Once you hit your out of pocket maximum, insurance covers all of your medical care costs for the remainder of that plan year.
Health insurance plans usually offer coverage for one year. At the end of the year, you must choose whether you will continue to be enrolled in your health insurance plan.
Your deductible and maximum out of pocket amount “reset” at the end of the plan year, meaning that the amount you have paid towards your deductible and maximum out of pocket amount goes back to $0 and you must “meet your deductible” again in the new plan year.
Sometimes the plan year is the same as the calendar year (January 1 through December 31). Sometimes the plan year is different from the calendar year (July 1 through June 30).
PPO (Preferred Provider Organization)
A type of health plan where you pay less for going to providers in the plan’s network. In this situation, you can still go to doctors, hospitals, and providers outside of the network without a referral but there will be an additional cost.
The amount that you pay every month to continue to have coverage through your health insurance plan. If you receive your health insurance through an employer, this amount is usually taken directly out of your paycheck. If you stop paying your premium, your health insurance plan will drop your coverage, and you will be uninsured.
A doctor, nurse practitioner, pharmacist, therapist, or other type of health care worker who provides health care services to you.
Single Case Agreement
A single case agreement is an agreement in which a medical service provider, such as a health system, psychiatrist, psychologist or a therapist enters into an agreement with an insurance company they are not contracted with so the patient can see the provider and it will be as if they are using their in-network benefits.
An easy-to-read summary that lets a person make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you.
Summary Plan Description (SPD)
The SBC is a detailed guide to the benefits the program provides and how the plan works. It should be written in such a way that employees of the benefits plan can easily understand. The SBC must be provided to participants and beneficiaries free of charge at times of renewal, upon special enrollment and upon request.
A Superbill is an itemized list in the form of a receipt that is provided to the client for reimbursement purposes when working with out of network providers. It is also referred to as an invoice, a claim form, a receipt of services, a statement of services, or an encounter ticket. The bill usually contains:
- Provider’s first and last name
- Provider’s NPI number and/ or tax identification number (the unique identification number for covered health care providers)
- Office location where services took place
- Provider’s phone number
- Provider’s email address
- The first and last name of the provider who referred you (if applicable)
- Referring provider’s NPI number (if applicable)
- Client’s first and last name
- Client’s address
- Client’s phone number
- Client’s date of birth
- Diagnosis or procedure codes
- Fees charged
- Date of service
The client would pay the out of pocket costs at the time of service, and then submit the “superbill” through their insurance for reimbursement. This is not available for all out of network providers, it must be applicable to your plan and your provider must be willing to provide the information for the claim.
Find even more terms at the resources below:
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About the author
Our Editorial Team is composed of our leaders, clinicians, and care coordinators, as well as other Included Health employees, all who are working to raise the standard of healthcare for everyone. Together, they combine decades of subject matter experience across all fields of healthcare.