{"active_group":"All","term_list":[{"term":"Actuarial value","groups":["All","A"],"definition":"<p>The average value of the benefits that a certain health plan covers, calculated as a percentage of total costs.<\/p>\n"},{"term":"Affordable Care Act","groups":["All","A"],"definition":"<p>The comprehensive health care reform law enacted in March 2010. This federal law, also known as “Obamacare” or the “ACA,” prohibits discrimination in health insurance coverage based on preexisting health conditions. It also allows young people to stay on a parent’s or guardian’s health insurance until age 26. The law established the health insurance marketplace to buy of individual health insurance coverage that meets minimum coverage requirements and doesn’t have annual or lifetime benefit caps.<\/p>\n"},{"term":"Americans With Disabilities Act","groups":["All","A"],"definition":"<p>The Americans With Disabilities Act, or ADA, is a federal law that prohibits discrimination based on disabilty, in employment, state and local government, public accommodations, commercial facilities, transportation and telecommunications.<\/p>\n"},{"term":"Appeal","groups":["All","A"],"definition":"<p>The process of justifying why a health insurance company should cover a beneficiary’s product or service after initially denying coverage.<\/p>\n"},{"term":"Benefit exclusion","groups":["All","B"],"definition":"<p>When a health plan refuses to cover a product or service. Benefit exclusions can typically be appealed through a defined exceptions process.<\/p>\n"},{"term":"Benefit limitation","groups":["All","B"],"definition":"<p>When a health plan limits the amount of money it will pay for benefits or the number of benefits it will allow over a set period of time.<\/p>\n"},{"term":"Benefit management","groups":["All","B"],"definition":"<p>A process, such as prior authorization or step therapy, that requires suggested treatments to be reviewed and approved before a patient can receive the prescribed service.<\/p>\n"},{"term":"Case management","groups":["All","C"],"definition":"<p>A planned approach to manage services or treatment for a person with a serious medical problem. Its goal is to contain costs and promote more effective interventions to meet the patient’s needs.<\/p>\n"},{"term":"Catastrophic coverage","groups":["All","C"],"definition":"<p>Catastrophic health insurance offers coverage for emergencies and some preventive care. Catastrophic health plans typically have low monthly premiums but high deductibles. Beneficiaries must meet the deductible before the plan will pay for emergency care. The plans are available to people under 30 and anyone facing financial hardship.<\/p>\n"},{"term":"Certificate of coverage","groups":["All","C"],"definition":"<p>A document that specifies the benefits issued to a member of group health insurance. This can change yearly depending on what an employer group elects to purchase.<\/p>\n"},{"term":"CHAMPVA","groups":["All","C"],"definition":"<p>A a health benefit program for the families of veterans with 100% service–connected disability and a surviving spouse or children of a veteran who dies from a service-connected disability.<\/p>\n"},{"term":"Children\u2019s Health Insurance Program","groups":["All","C"],"definition":"<p>CHIP is an insurance program funded by a state and the federal government. It provides health insurance to low-income children and, in some states, pregnant women in families who earn too much to qualify for Medicaid but can’t afford private health insurance. Learn more about <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/basics\/">insurance options<\/a>.<\/p>\n"},{"term":"Claim","groups":["All","C"],"definition":"<p>Information submitted to the insurer by the member or healthcare provider for the payment of services under a policy.<\/p>\n"},{"term":"COBRA","groups":["All","C"],"definition":"<p>The Consolidated Omnibus Budget Reconciliation Act is a federal law that allows people to continue their health insurance policies when they leave their employer.<\/p>\n"},{"term":"Coinsurance","groups":["All","C"],"definition":"<p>An amount a person must pay out of pocket when they receive covered medical care, often a percentage of the total cost of that coverage.<\/p>\n"},{"term":"Coordination of benefits","groups":["All","C"],"definition":"<p>A method of integrating benefits payable under more than one health insurance plan so the insured’s benefits from all sources don’tt exceed allowable medical expenses.<\/p>\n"},{"term":"Copay","groups":["All","C"],"definition":"<p>A fixed amount a person must pay out of pocket for covered medical care.<\/p>\n"},{"term":"Cost limit","groups":["All","C"],"definition":"<p>A limit on the amount of money an insurance company will pay for benefits.<\/p>\n"},{"term":"Cost sharing","groups":["All","C"],"definition":"<p>The term that insurance plans use to describe costs they “share” with the beneficiary, also often known as out-of-pocket costs.<\/p>\n"},{"term":"Creditable coverage","groups":["All","C"],"definition":"<p>Drug coverage that pays, on average, as much as or more than the standard <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/medicare-basics\/">Medicare<\/a> Part D drug coverage.<\/p>\n"},{"term":"Deductible","groups":["All","D"],"definition":"<p>The amount of money that someone pays before their insurance plan covers any medical care or prescriptions.<\/p>\n"},{"term":"Department of insurance","groups":["All","D"],"definition":"<p>A state-level regulatory agency that oversees and enforces state insurance laws.<\/p>\n"},{"term":"Department of Veterans Affairs","groups":["All","D"],"definition":"<p>The VA is an independent agency of the federal government created in 1930 to provide federal benefits to veterans and their dependents.<\/p>\n"},{"term":"Durable medical equipment","groups":["All","D"],"definition":"<p>Medical equipment that can be used repeatedly and isn’t disposable, including wheelchairs, pumps and oxygen equipment.<\/p>\n"},{"term":"Employee Retirement Income Security Act","groups":["All","E"],"definition":"<p>ERISA is a federal law that governs pension plans and private health insurance provided by self-funded institutions. It requires insurance providers to disclose plan benefits and funding levels, as well as ways to manage and access your benefits.<\/p>\n"},{"term":"Essential health benefits","groups":["All","E"],"definition":"<p>A set list of benefits insurance plans must include if the plans are sold through a state or federal health insurance marketplace created under the Affordable Care Act.<\/p>\n"},{"term":"Exception process","groups":["All","E"],"definition":"<p>Steps outlined by an insurance company that allow someone to petition for certain health care benefits ordinarily not covered by the insurance plan.<\/p>\n"},{"term":"Explanation of benefits","groups":["All","E"],"definition":"<p>An EOB is a statement that describes benefits received and services for which the healthcare provider has requested payment. Insurers send EOBs to patients and healthcare providers.<\/p>\n"},{"term":"Family and Medical Leave Act","groups":["All","F"],"definition":"<p>FMLA is a federal law that guarantees up to 12 weeks of job-protected leave when eligible employees need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member.<\/p>\n"},{"term":"Federal poverty level","groups":["All","F"],"definition":"<p>A measure of income level issued annually by the Department of Health and Human Services to determine eligibility for some benefits and programs, such as Medicaid.<\/p>\n"},{"term":"Flexible spending account","groups":["All","F"],"definition":"<p>An FSA is an arrangement with an employer that allows an employee to pay for many out-of-pocket medical expenses with pre-tax dollars.<\/p>\n"},{"term":"Formulary","groups":["All","F"],"definition":"<p>An approved list of prescription drugs covered by a health insurance plan.<\/p>\n"},{"term":"Genetic Information Nondiscrimination Act","groups":["All","G"],"definition":"<p>A federal law that prohibits insurance providers and employers from discriminating on the basis of genetic information.<\/p>\n"},{"term":"Grandfathered health plan","groups":["All","G"],"definition":"<p>As used in connection with the Affordable Care Act, a group health plan that was created — or an individual health insurance policy purchased — on or before March 23, 2010.<\/p>\n"},{"term":"Health insurance","groups":["All","H"],"definition":"<p>Protection that provides payment of benefits for covered illness or injury.<\/p>\n"},{"term":"Health insurance exchange or marketplace","groups":["All","H"],"definition":"<p>Online marketplaces where consumers can compare and purchase insurance plans.<\/p>\n"},{"term":"Health Insurance Portability and Accountability Act","groups":["All","H"],"definition":"<p>HIPAA is a federal law that prohibits the release of medical records. It provides protections for beneficiaries in group health plans. It protects personal information while allowing healthcare administrators to conduct necessary business operations.<\/p>\n"},{"term":"Health maintenance organization","groups":["All","H"],"definition":"<p>A payer that provides services for members in a particular geographic area.<\/p>\n"},{"term":"Health savings account","groups":["All","H"],"definition":"<p>A health savings account, or HSA, is tax-free medical savings account available to taxpayers enrolled in a high deductible health plans.<\/p>\n"},{"term":"High-risk insurance pools","groups":["All","H"],"definition":"<p>State programs that enable people with health problems to join together to purchase health insurance. Even with subsidies, premium rates are high because pool members are high risk.<\/p>\n"},{"term":"In network","groups":["All","I"],"definition":"<p>A list of providers who participate in a health plan’s provider network<\/p>\n"},{"term":"Indemnity plans","groups":["All","I"],"definition":"<p>Also known as traditional health insurance, indemnity plans pay a certain percentage of charges billed by a provider. The patient is responsible for the balance.<\/p>\n"},{"term":"Itemized bill","groups":["All","I"],"definition":"<p>A type of bill for inpatient hospital services that lists every charge, grouped into specific categories.<\/p>\n"},{"term":"Lifetime maximum benefit","groups":["All","L"],"definition":"<p>A lifetime maximum benefit, also known as a lifetime cap, is the total amount of money an insurance company will pay for an enrollee’s healthcare expenses.<\/p>\n"},{"term":"Managed care plans","groups":["All","M"],"definition":"<p>An insurance plan that implements specific measures to control costs associated with healthcare services.<\/p>\n"},{"term":"Medicaid","groups":["All","M"],"definition":"<p>A government health insurance program for eligible, low-income individuals. Eligibility varies by state. <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/basics\/">Learn more about Medicaid<\/a>.<\/p>\n"},{"term":"Medical benefits exclusion","groups":["All","M"],"definition":"<p>Specific healthcare products, services and circumstances not covered in a health insurance plan. Excluded benefits vary by plan and commonly include injuries sustained in the act of committing a felony or misdemeanor, workers compensation, self-inflicted injuries or suicide attempt and cosmetic surgery.<\/p>\n"},{"term":"Medical loss ratio","groups":["All","M"],"definition":"<p>The percentage of the premium that an insurance company spends on medical care, as opposed to administrative or overhead costs.<\/p>\n"},{"term":"Medically necessary","groups":["All","M"],"definition":"<p>Term used when the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.<\/p>\n"},{"term":"Medicare","groups":["All","M"],"definition":"<p>A federal health insurance program primarily for those 65 and older and people who have received Social Security disability benefits for at least 12 months. Medicare has several types of coverage, typically referred to by parts A, B, C and D. <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/medicare-basics\/">Learn more about Medicare<\/a>.<\/p>\n"},{"term":"Medigap","groups":["All","M"],"definition":"<p>Also known as Medicare Supplement, Medigap is a policy sold by private insurance companies to cover products and services not covered, or are covered in lower amounts, by Original Medicare (Medicare A and B).<\/p>\n"},{"term":"National Drug Code","groups":["All","N"],"definition":"<p>A numeric code assigned to a prescription drug by the FDA.<\/p>\n"},{"term":"Navigators","groups":["All","N"],"definition":"<p>People employed by their state insurance marketplace to help consumers through the process of choosing an insurance plan.<\/p>\n"},{"term":"Open enrollment","groups":["All","O"],"definition":"<p>The period of time set up to allow individuals to review and change their health insurance coverage without a penalty, usually once a year.<\/p>\n"},{"term":"Original Medicare","groups":["All","O"],"definition":"<p>Refers to coverage provided by Medicare parts A and B.<\/p>\n"},{"term":"Out of network","groups":["All","O"],"definition":"<p>Providers who do not participate in the network of a managed care plan.<\/p>\n"},{"term":"Out-of-pocket costs","groups":["All","O"],"definition":"<p>Costs that beneficiaries “share” with their insurance company and pay for themselves. The most common out-of-pocket costs are deductibles, copays and coinsurance.<\/p>\n"},{"term":"Out-of-pocket maximum","groups":["All","O"],"definition":"<p>The total dollar amount of the expenses a member would have to pay for covered medical charges during a specified period of time.<\/p>\n"},{"term":"Payer","groups":["All","P"],"definition":"<p>A public or private organization that pays or underwrites coverage for healthcare expenses.<\/p>\n"},{"term":"Per diem","groups":["All","P"],"definition":"<p>Term that is applied to the cost of care for a day and is an average that does not reflect the true cost for each patient.<\/p>\n"},{"term":"Pharmacy benefit manager","groups":["All","P"],"definition":"<p>A company specializing in the administration of commercial pharmacy benefits.<\/p>\n"},{"term":"Point of service plan","groups":["All","P"],"definition":"<p>A type of plan in which a person pays less if they use doctors, hospitals and other healthcare providers that belong to the plan’s network.<\/p>\n"},{"term":"Preferred provider organization","groups":["All","P"],"definition":"<p>Groups of health care providers that contract with employers, insurance companies or other third-party payers to provide medical care services at a reduced fee. Also known as a PPO.<\/p>\n"},{"term":"Premium","groups":["All","P"],"definition":"<p>The monthly payment made by an employer or individual to purchase insurance.<\/p>\n"},{"term":"Primary care","groups":["All","P"],"definition":"<p>Health services that cover a range of prevention, wellness and treatment for common illnesses.<\/p>\n"},{"term":"Primary care physician","groups":["All","P"],"definition":"<p>A physician who oversees a patient’s general health needs and usually is the first contact in a managed care system.<\/p>\n"},{"term":"Prior authorization","groups":["All","P"],"definition":"<p>Review of services to determine medical appropriateness before services are rendered. Also known as pre-certification, pre-determination or pre-authorization. Learn more about <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/basics\/prior-authorization\/">prior authorization<\/a>.<\/p>\n"},{"term":"Provider","groups":["All","P"],"definition":"<p>Institutions and individuals licensed to provide healthcare services, such as hospitals, physicians and pharmacists.<\/p>\n"},{"term":"Qualifying event","groups":["All","Q"],"definition":"<p>An event that would cause someone to lose health coverage under COBRA and\/or become eligible to buy or change health insurance without penalty, for example marriage, divorce, adoption, job loss, etc.<\/p>\n"},{"term":"Quantity limit","groups":["All","Q"],"definition":"<p>A limit on the number of services, prescriptions or products allowed over the course of a particular benefit period.<\/p>\n"},{"term":"Reimbursement","groups":["All","R"],"definition":"<p>Payment made by a payer to a provider for approved medical services.<\/p>\n"},{"term":"Rescission","groups":["All","R"],"definition":"<p>The retroactive cancellation of a health insurance policy.<\/p>\n"},{"term":"Rider (exclusionary rider)","groups":["All","R"],"definition":"<p>An amendment to an insurance policy existing policy that alters, expands or restricts coverage<\/p>\n"},{"term":"Self-funded (self-insured) plan","groups":["All","S"],"definition":"<p>A type of job-based health insurance coverage where the employer pays the claims with its own funds.<\/p>\n"},{"term":"Social Security Disability Insurance","groups":["All","S"],"definition":"<p>Cash benefits paid to people the Social Security Administration determines are disabled and have worked and paid social security taxes for a required amount of time. Learn more about <a href="https:\/\/phassociation.org\/living-with-ph\/insurance-financial-assistance\/social-security-disability\/">SSDI<\/a>.<\/p>\n"},{"term":"State and community health plans","groups":["All","S"],"definition":"<p>Programs that provide coverage and services with minimal private commercial and federal involvement.<\/p>\n"},{"term":"Statement of medical necessity","groups":["All","S"],"definition":"<p>Official documentation from a medical provider to a payer that contains medical information to justify that the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.<\/p>\n"},{"term":"Step therapy","groups":["All","S"],"definition":"<p>A health insurance plan that requires enrollees to “try and fail” a specific medication before it will approve the originally prescribed medication.<\/p>\n"},{"term":"Supplemental Security Income","groups":["All","S"],"definition":"<p>Cash benefits paid to people the Social Security Administration determines are disabled and have limited income.<\/p>\n"},{"term":"Tricare","groups":["All","T"],"definition":"<p>The Department of Defense’s managed health care program for active duty military, active duty service families, retirees and their families, and other beneficiaries.<\/p>\n"}],"group_list":[{"key":"All","active":true},{"key":"A","active":false},{"key":"B","active":false},{"key":"C","active":false},{"key":"D","active":false},{"key":"E","active":false},{"key":"F","active":false},{"key":"G","active":false},{"key":"H","active":false},{"key":"I","active":false},{"key":"J","active":false},{"key":"K","active":false},{"key":"L","active":false},{"key":"M","active":false},{"key":"N","active":false},{"key":"O","active":false},{"key":"P","active":false},{"key":"Q","active":false},{"key":"R","active":false},{"key":"S","active":false},{"key":"T","active":false},{"key":"U","active":false},{"key":"V","active":false},{"key":"W","active":false},{"key":"X","active":false},{"key":"Y","active":false},{"key":"Z","active":false}],"keyword":"","heading":"Explore our insurance term glossary from A to Z","intro_text":"<p>Choose a letter from the A-Z menu and browse insurance terms by their starting letter. Or, you can use the search bar to quickly find specific terms.<\/p>\n","resource_strings":{"results":{"plural":"Showing %n results","singular":"Showing %n result"},"search":{"placeholder":"Enter a search term","submit":"Search","clear":"Clear"}}}