Health Insurance Marketplace Toolkit


Glossary

Appeal: A request for your health insurer or plan to review a decision or a grievance again.1

Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.1

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.1

Annual Limit: A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.1

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.1

Biologics: Medications genetically engineered from a living organism, such as a virus, gene or protein, to simulate the body’s natural response to infection and disease. The body naturally produces small amounts of these agents, but when produced in large amounts in the laboratory and given by injection or infusion, biologics can interfere with different inflammatory substances, cells or pathways responsible for the symptoms and damage of rheumatoid arthritis and some other inflammatory forms of arthritis.2

Biosimilar Biological Products: The generic version of more complicated medications.1

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.1

Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.1

Copayment (copay): A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.1

Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.1

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.1

Essential Health Benefits: A set of health care service categories that must be covered by certain plans, starting in 2014. The Affordable Care Act ensures 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 2014.1

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.1

Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.1

Health Plan Categories (Metal Levels): 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.1

Health Insurance Marketplace: A resource 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. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state. In others it is run by the federal government.1

Health Insurance: A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.1

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.1

In-Network vs. Out-of-Network: Doctors and other health-care providers, or institutions like hospitals or clinics that are in-network have a special agreement with your insurance company and are on an approved list. By using these services, you will pay less out-of-pocket costs for your care. Health-care providers or institutions that are out-of-network are not on that list, and do not have an agreement with your insurer. Therefore, you may have to pay more or all of the costs of using their services if you choose.2

Medicaid: 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. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.1

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).1

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees.

Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.2

Occupational Therapy: When you have arthritis, even the simplest everyday activities can be difficult and painful. Turning a key or using a kitchen knife can suddenly become a real challenge. Those daily difficulties can be eased by working with an occupational therapist, a particular type of therapist who helps people with arthritis live life to its fullest by maximizing their ability to participate in activities, promoting safety, and enhancing quality of life.2

Out-of-pocket Maximum/Limit: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.1

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.1

Out-of-pocket Estimates: An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.1

Physical Therapy: Taught or administered by a health-care professional called a physical therapist, physical therapy is a rehabilitation program focusing largely on exercise to strengthen the muscles in your back. Your doctor may recommend physical therapy to strengthen a bad back, which can help prevent the recurrences of pain or help you recover from back surgery.2

Pre-existing Condition:  A health problem you had before the date that new health coverage starts.1

Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.1

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.1

Preauthorization: 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.1

Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.1

Prescription Drugs: Drugs and medications that by law require a prescription.1

Primary Care Physician: 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.1

Quantity Limits: Limits on how much medication you can get at a time.3

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.1

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.1

Step Therapy: You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.3

Subsidized Coverage (subsidies): Health coverage that's obtained through financial assistance from programs to help people with low and middle incomes.1

Total-Cost Estimate (for Health Coverage): The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage.1

Vision or 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.1

 

1 Terms and definitions from www.healthcare.gov
2 Terms and definitions from www.arthritis.org
3 Terms and definitions from www.medicare.gov

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