A
Accountable Care Organization (ACO)
A healthcare organization that is responsible for providing coordinated care to a defined patient population while aiming to improve quality and reduce costs.
Advance Directive
Legal documents, such as living wills and durable power of attorney for healthcare, that specify an individual's healthcare preferences and decisions in advance.
Advanced Beneficiary Notice (ABN)
A notice provided to Medicare beneficiaries by healthcare providers, informing them that a specific service may not be covered and that they may be responsible for the cost.
Affordable Care Act (ACA)
A U.S. healthcare reform law aimed at increasing access to healthcare insurance and improving healthcare delivery.
Ambulatory Setting
A type of healthcare environment in which health services are provided on an outpatient basis, meaning patients do not require an overnight stay.
Ancillary Services
Additional healthcare services and procedures, often supportive or complementary to primary medical care, provided to patients to assist in diagnosis, treatment, or recovery. These services can include diagnostic tests, radiology, laboratory services, physical therapy, and other supportive healthcare offerings.
Appeal
In the context of healthcare insurance is a formal request made by a patient or their healthcare provider to review and reconsider a decision made by the insurance company to deny coverage for a specific medical service or treatment. To initiate an appeal or learn more about the process, please contact your health insurer.
B
Beneficiary
A person designated to receive healthcare benefits from an insurance plan or government program.
Benefit Year
Refers to the 12-month period during which certain benefits, such as health insurance coverage or unemployment benefits, are available to an individual. It typically starts on a specific date, often aligned with the enrollment or eligibility date, and lasts for one year.
C
Children's Health Insurance Program (CHIP)
Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.
COBRA
A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Coinsurance
The percentage of healthcare costs you're responsible for after meeting your deductible, with the remaining percentage covered by your insurance.
Coordination of Benefits (COB)
A process used when an individual has multiple health insurance plans to determine which plan is primary and which is secondary in paying claims.
Copayment (Copay)
A fixed amount you pay for specific healthcare services or medications, typically due at the time of service.
D
Deductible
The amount you must pay out of pocket for covered healthcare services before your insurance plan starts to pay.
Denial
In the context of healthcare insurance refers to the rejection or refusal by an insurance company to cover all or part of a claim for medical services or treatment. Denials can occur for various reasons, including lack of medical necessity, policy limitations, or incomplete documentation. To learn more about why a claim was denied, it's best to contact your health insurer.
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.
Durable Medical Equipment (DME)
Medical devices and equipment meant for repeated use by patients, including items like wheelchairs and oxygen tanks.
E
Emergency Care
Immediate medical treatment for severe injuries or life-threatening conditions provided in emergency departments to stabilize and address critical health issues.
Excluded Services
Health care services that your health insurance or plan doesn’t pay for or cover.
Exclusive Provider Organization (EPO)
A health plan that only covers care provided by doctors, specialists, and hospitals within the plan's network.
Explanation of Benefits (EOB)
A statement from your insurance company that explains how a claim was processed, including the amount billed, what was paid, and any patient responsibility
F
Federal Poverty Level (FPL)
A set annual income threshold established by the U.S. government to determine eligibility for various government assistance programs. The FPL is adjusted annually and varies based on household size and location within the United States. It serves as a guideline to assess whether an individual or family's income falls below the poverty line, making them eligible for certain forms of financial assistance and support.
Fee-for-Service (FFS)
A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.
Flexible Spending Account (FSA)
A tax-advantaged savings account that allows you to set aside pre-tax dollars for eligible healthcare expenses, such as copayments, deductibles, and prescription drugs.
Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
G
Gross Income
The complete income earned by an individual or entity before taxes and deductions. It includes all sources of revenue, such as wages, investments, and other forms of income.
H
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 Insurance Portability and Accountability Act (HIPAA)
Federal legislation that protects the privacy and security of personal health information and establishes certain rights related to health insurance coverage.
Health Maintenance Organization (HMO)
A type of managed care plan that requires members to select a primary care physician (PCP) and obtain referrals to see specialists.
Health Savings Account (HSA)
A tax-advantaged savings account paired with a high-deductible health plan (HDHP) that allows you to save money for medical expenses.
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 (also called your deductible). A high deductible plan can be combined with a health savings account (HSA), for you to pay for certain medical expenses with money you set aside in your tax-free HSA. This is why it’s more commonly called an HSA-eligible plan.
Hospitals
These facilities provide a wide range of medical services, including emergency care, surgeries, inpatient care, diagnostic testing, and specialized treatments. Hospitals may be categorized into general hospitals, teaching hospitals, and specialty hospitals.
I
Inpatient
Involves treatment for patients who stay overnight in a healthcare facility, often for more serious medical conditions or surgeries.
M
Medicaid
A state and federally funded program that provides healthcare coverage to eligible low-income individuals and families.
Medical Record
A medical record, also known as a health record or medical chart, is a comprehensive and organized documentation of an individual's healthcare information and history.
Medicare
A federal health insurance program primarily for individuals aged 65 and older, as well as some younger individuals with disabilities.
Medicare Part A
Covers hospital care, skilled nursing facility care, hospice, and some home healthcare services under Medicare.
Medicare Part B
Covers doctor visits, outpatient services, preventive care, and durable medical equipment under Medicare.
Medicare Part C (Medicare Advantage)
An alternative to traditional Medicare that combines Part A and Part B coverage and often includes additional benefits such as prescription drug coverage (Part D).
Medicare Part D
Provides prescription drug coverage for Medicare beneficiaries.
N
Network
The group of doctors, hospitals, and other healthcare providers that are contracted with your insurance plan to provide care at discounted rates.
No Surprises Billing Act
A U.S. federal law designed to protect patients from unexpected and excessive medical bills, especially when they receive out-of-network care during emergencies or non-emergencies.
O
Out-of-Network
Healthcare providers who do not have a contract with your insurance plan, often resulting in higher costs for services.
Out-of-Pocket (OOP) Maximum
The maximum amount you're required to pay for covered healthcare services in a plan year, after which your insurance covers 100% of eligible expenses.
Outpatient
Provides medical services to patients during scheduled appointments without requiring overnight stays.
P
Pharmacy/Pharmacies
Pharmacies dispense medications, offer medication counseling, and provide some healthcare services, such as vaccinations and health screenings.
Point of Service (POS)
A type of health plan that combines features of HMO and PPO plans, often requiring referrals for specialists but allowing some out-of-network coverage.
Pre-Existing Condition
A health condition that existed before obtaining health insurance, which may impact coverage or premiums under certain circumstances.
Preferred Provider Organization (PPO)
A type of health plan that offers more flexibility in choosing healthcare providers, both in-network and out-of-network, without needing referrals.
Preventive Care
Healthcare services, screenings, and vaccinations that aim to prevent illness or detect health conditions early, often covered at no cost to the patient.
Primary Care Clinics
These are typically the first point of contact for patients seeking routine and preventive healthcare services. Primary care clinics are often staffed by family physicians, internists, pediatricians, and nurse practitioners.
Primary Care Physician (PCP)
A healthcare provider who serves as the first point of contact for patients and coordinates their overall care.
Prior Authorization/Preauthorization
A process used by health insurance companies to determine if they will cover certain medications, treatments, or procedures. It requires healthcare providers to obtain approval from the insurance company before performing or prescribing these services.
R
Referral
A recommendation from one healthcare provider (usually a primary care physician or PCP) to another specialist or healthcare professional for consultation or treatment of a specific medical condition. Referrals are often required by health insurance plans to ensure coordinated care and to see specialists within the plan's network.
Rehabilitation Centers
Rehabilitation facilities offer specialized care and therapy for patients recovering from surgery, injuries, or chronic conditions. This includes physical therapy, occupational therapy, and speech therapy.
S
Specialty Clinics
These clinics focus on specific medical specialties, such as cardiology, orthopedics, dermatology, or neurology. Patients are referred to specialty clinics for in-depth evaluation and treatment of specific health conditions.
T
Third-Party Liability (TPL)
A situation where a third party, typically responsible for causing harm or losses, is legally obligated to compensate the injured party for those damages.
U
Urgent Care
Urgent care locations provide immediate medical care for non-life-threatening illnesses and injuries that require prompt attention but are not severe enough to warrant an emergency room visit.
W
Worker's Compensation
An insurance plan that employers are required to have to cover employees who get sick or injured on the job.