Glossary

The percent of total costs a particular health care plan will cover for benefits.

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

The health insurance exchanges established by the new health care law will include a catastrophic plan option. Catastrophic plans have lower premiums, but begin to pay only after you’ve first paid a certain amount for covered services, or just cover more expensive levels of care, like hospitalizations. Catastrophic plans are an option to consider for young, healthy adults and people for whom coverage would otherwise be unaffordable.

After a person meets a deductible, what they will have to pay for health care. Co-insurance is your share of the costs of a covered health care service. This is a percent of the allowed amount for the service – plus any deductible you may owe. Example: Your health insurance plan states that your co-insurance is 20% and your plan allows $100 for an office visit. If you’ve met your deductible, your co-insurance payment of 20% would be $20. The plan pays the rest of the allowed amount.

A fixed dollar amount you are required to pay for covered services at the time you receive care.

The amount you pay out-of-pocket for health care services before your health insurance plan begins to pay.
Example: Your deductible is $1,000. Your plan won’t pay anything until you’ve paid the first $1,000 deductible for covered health care services. The deductible may not apply to all services.

Medicare D – Prescription Drugs
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (often called the "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Starting in 2014, if an employer with at least 50 full-time equivalent employees doesn't provide affordable health insurance and an employee uses a tax credit to help pay for insurance through a health insurance exchange, the employer must pay a fee to help cover the cost of tax credits.

A set of health care services that must be covered by new qualified health plans, starting in 2014. These benefits will be in the individual and small group markets, both inside and outside of the health insurance exchange websites.

An Exchange is an online marketplace where individuals and small businesses may compare and buy affordable and qualified health insurance plans beginning in October 2013 for insurance plans that become effective on January 1, 2014.

A level of income issued annually by the Department of Health and Human Services -- used to determine eligibility for certain programs and benefits. FPL will be used to determine the amount of tax credit you may qualify for to offset the cost of purchasing health insurance on a health insurance exchange.

A list of drugs your insurance plan covers. A formulary may include how much you pay for each drug. (If the plan uses “tiers,” the formulary may list which drugs are in which tiers.) Formularies may include both generic drugs and brand-name drugs.

A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010, is exempt from some ACA reform provisions. The new “grandfather” rule is designed to allow strong health plans to continue to grow and remain vibrant. The grandfather rule enables businesses and families to keep their plan while adding important new benefits for those with private insurance.

A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn't limit how much you can be charged if you enroll.

A contract that requires your health insurer to pay some or all of your health care costs in return for you payment of an insurance premium.

These plans are offered by state governments and provide coverage if you have been locked out of the individual insurance market because of a pre-existing condition. High-risk pool plans may also offer coverage if you're HIPAA eligible or meet other requirements.

A contract that requires your health insurer to pay some or all of your health care costs in return for you payment of an insurance premium.

Services a person receives at home.

Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing.

Services to provide comfort and support to families and a family member who is in the last stages of a terminal illness.

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.

There are some exceptions, but most of us will be required to have health insurance coverage beginning in 2014. This means that if you don't have insurance through an employer, you will need to purchase your own insurance.

A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Medicare and most health insurance plans don’t pay for long-term care.

A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults (varies state-to-state). The federal government provides a portion of the funding and sets guidelines.

A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities.

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs; you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage.

The period of time set up to allow you to choose from available health insurance plans, usually once a year.

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.

A condition, disability or illness (either physical or mental) that you have before you're enrolled in a health plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. This term is defined under state law and varies significantly by state.

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Health insurance or plan that helps pay for prescription drugs and medications.

Drugs and medications that by law require a prescription. A patient obtains from a physician a written script with instructions for a specific medication and its use.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

A public exchange (either state or federal) is a marketplace for consumers to compare, purchase and enroll for health care coverage. These online marketplaces offer consumers and small employers a wide choice of affordable health plans.

These private businesses are typically operated by brokers or insurers that sell insurance products to health care consumers online. They are designed to help consumers find plans for specific health conditions. They may help you find preferred doctors/hospitals and budget levels. Employers may purchase health care insurance plans through a private exchange. Their employees can then choose a health plan from those supplied by participating payers.

Government tax credits that are a primary way the Affordable Care Act makes buying health care insurance more affordable. Premium and cost-sharing credits are available to individuals/families with income ranges between 133-400% of the federal poverty level. To see if you are eligible for any type of subsidy, you may answer a few questions on an exchange website. Based on your family size, income and situation, you'll learn the amount of any subsidy for which you are eligible.

A program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them directly to their enrollees. The programs may include help to stop smoking, manage diabetes or weight loss and provide preventative health screenings.