Health Insurance Terms

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Actuarial Value: The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits.

Advanced Premium Tax Credit (APTC): This is a tax credit to help lower your monthly premium payments on health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return. Also called premium tax credit.

Agent: An agent or broker is a person or business who can help you apply for help paying for coverage and enroll you in a Qualified Health Plan (QHP) through the Marketplace. They 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 agents and brokers may only be able to sell plans from specific health insurers.

Allowed Amount: Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Appeal: A request for your health insurer or plan to review a decision or a grievance again.

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Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.

Brand Name (Drugs): A drug sold by a drug company under a specific name or trademark and is protected by a patent. Brand name drugs may be available by prescription or over the counter.

Broker: An agent or broker is a person or business who can help you apply for help paying for coverage and enroll in a Qualified Health Plan (QHP) through the Marketplace. They 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.

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Care Management: Services offered by Ambetter to help its members who have complex medical or behavioral health needs.

Care Manager: Individuals that work under Ambetter's Care Management program to help serve those members with complex medical or behavioral health needs. Each Case Manager helps members better understand their health condition, coordinate services and locate community resources.

Certified Application Counselor (CAC): Individuals affiliated with a designated organization who are trained to help consumers seeking health insurance coverage on the Health Insurance Marketplace. Un-biased guidance is provided to consumers free of charge.

Claim: A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Coinsurance: The portion of your medical bill you pay, for certain services, after you meet your deductible. Think of coinsurance as splitting your healthcare costs with your insurance company. Example: You meet your deductible. You have 20% coinsurance, and your insurance company pays 80% for a $100 service. You will pay $20 and the insurance company will pay $80. The percent you pay remains the same until you reach your maximum out-of-pocket limit. Your plan will then pay 100% of the cost.

Copay: The set amount of money you pay at the time of certain medical services, such as doctor visits or picking up prescriptions. The copay amount may vary depending on the type of healthcare service.

Cost Sharing: The sharing of costs under your insurance plan that you pay out of your pocket. This includes items such as copays, deductibles and coinsurance. Cost sharing does not include premiums, balance billing amounts to non-network providers or the cost for non-covered services.

Cost Sharing Reduction: A type of subsidy that lowers your out-of-pocket costs (copays, deductible, coinsurance). Cost sharing reductions are only available on Silver Plans purchased on the Health Insurance Marketplace. These reductions apply to those who are at or below a certain income level.

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Deductible: The fixed amount of money that you are responsible for paying before your insurance starts to pay. Whether or not you meet your deductible depends on how much healthcare you need throughout the year. After you meet you deductible, your health insurance will begin to pay for these services. Plans with high deductibles usually have lower monthly premiums, and vice versa.

Dependent: A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.

Dependent Coverage: Insurance coverage for family members of the policyholder, such as spouses, children, or partners.

Dental Coverage: Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a "stand-alone" dental plan.

Durable Medical Equipment: Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

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Effective Date: The date that your insurance coverage begins.

Essential Health Benefits (EHBs): Health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace, and all Medicaid state plans must cover these services by 2014.

External Review: A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn’t yet completed.

External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The plan must accept this decision.

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Federal Poverty Level: This is the measure of income level issued annually by the Department of Health and Human Services. These levels are used to determine eligibility for certain programs and benefits. For more information on the Federal Poverty Level, visit the Department of Health & Human Services website.

Formulary: The list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also known as a preferred drug list or PDL.

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Grievance: A complaint that you submit to your health insurance plan.

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Health Insurance Marketplace: An online health insurance market where individuals, families, and small businesses can learn about their health coverage options, compare health insurance plans based on costs, benefits, and other important features, choose a plan, and enroll in coverage. Individuals and families can apply for coverage online, by phone, or with a paper application.

Habilitative/Habilitation Services: Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

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

Health Plan Categories: Plans in the Marketplace are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you'll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn't the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.

Hospitalization: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

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In Person Assistance Personnel Program: Individual or organizations that are trained and able to provide help to consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.

Inpatient Care: Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

In-Network: An in-network provider is a provider that is contracted with a particular health insurance plan. Typically, if you visit an in-network provider, the cost is less than visiting an out-of-network provider.

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Lifetime Limit: A cap on the total lifetime benefits you may get from your insurance company. Lifetime limits no longer exist. 

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Medicaid: The healthcare program that provides medical coverage for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. This program is managed by states, in partnership with the federal government.

Medically Necessary: Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medicare: A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Modified Adjusted Gross Income: The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.

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Navigator: An individual or organization that's trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.

Non-discrimination: A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can't be charged more because of your health status. Job-based plans can restrict coverage based on other factors such as part-time employment that aren't related to health status.

Non-Preferred Brand Name Drug: A drug that is not part of your health plans' formulary or Preferred Drug list. These drugs have a higher coinsurance than preferred brand name drugs.

Notice: An official form of communication that informs individuals about the status of their applications, their eligibility for programs, or other important information. Notices may be sent by the Marketplace or by health insurers.

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Open Enrollment: A period of time during the year when people can buy or make changes to a health insurance plan. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. (See Special Enrollment Period or Life Qualifying Event).

Out-of-Network Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You may pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-Pocket Costs: Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copays for covered services plus all costs for services that aren’t covered.

Out-of-Pocket Maximum: The total amount you’ll spend for healthcare, after which the insurance company pays for all your medical care until the year ends. This does not include your monthly premiums. It includes co-pays, deductibles and coinsurance that you pay.

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Penalty Fee: If someone doesn’t have a health plan that qualifies as minimum essential coverage, he or she may have to pay a fee that increases every year.

Pre-authorization: A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Pre-Existing Condition: A health problem you had before the date that new health coverage starts. Under the ACA, you will be able to obtain health insurance if you have a pre-existing condition.

Preferred Brand Name Drug: A drug that is part of your health plans' formulary or Preferred Drug list. These drugs are safe alternatives to other more expensive drugs.

Premium: The amount of money you pay each month in order to have health insurance. You'll pay your premium once a month, all year long. Premiums depend on:

  • Your age
  • Whether or not you smoke
  • Where you live

If you are on Medicaid, you do not have to pay a monthly premium.

Prescription Drugs: Drugs and medications that by law require a prescription.

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

Primary Care Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Prior Authorization: Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Provider Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

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Qualified Health Plan (QHP): Under the Affordable Care Act, starting in 2014, these are insurance plans that:

  • Are certified by the Health Insurance Marketplace
  • Provide essential health benefits
  • Follow established limits on cost-sharing (like deductibles, copays, and out-of-pocket maximum amounts)
  • And meet other requirements.

A qualified health plan will have a certification by each Marketplace in which it is sold.

Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, changes in your income, and changes in your family size (for example, if you marry, divorce, have a baby, or become pregnant).

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Rehabilitative/Rehabilitation Services: Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

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Special Enrollment Period: A time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other job-based health coverage.

Specialist: A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Specialty Drugs: Drugs that are used to treat serious or chronic medical conditions. They are mostly injectable medications and can be self-administered by the patient.

Subsidy: The amount of money the government pays to your insurer to help pay your premium. This is also known as a Premium Tax Credit.

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Tax Household: The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents.

TTY: A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don't have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.

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Urgent Care: Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

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Vision Coverage: A type of health benefit that at least partially covers vision care, like eye exams and glasses. This coverage can be offered either as part of a comprehensive medical plan, or by itself through a “stand-alone” vision plan. However, stand-alone vision plans may not be offered through the Marketplaces.

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Well-Baby and Well-Child Visits: Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

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