GLOSSARY OF INSURANCE TERMS

The average value of the benefits that a certain health plan covers, calculated as a percentage of total costs.

The comprehensive health care reform law enacted in March 2010.

The process of submitting information to justify why health insurance should cover a product or service after coverage has initially been denied.

When a health plan refuses to cover a product or service. Benefits exclusions can typically be appealed through a defined exceptions process.

When a health plan limits either the amount of money that will be paid for benefits or the number of benefits allowed over a set amount of time.

A process, such as prior authorization or step therapy, through which a suggested treatment plan must be reviewed and approved before it is implemented.

A planned approach to manage services or treatment for an individual with a serious medical problem. Its dual goal is to contain costs and promote more effective interventions to meet the patient’s needs.

Coverage provided by the insurance company after the beneficiary has personally paid a certain amount of medical expenses out-of-pocket as predetermined by the payer.

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.

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.

An insurance program jointly funded by a state and the federal government that provides health insurance to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but who cannot afford to purchase private health insurance coverage.

Information submitted to the insurer by the member or health care provider for the payment of services under a policy.

An amount that an individual is required to pay out of pocket when they receive covered medical care that is a percentage of the total cost of that coverage.

A federal law that allows individuals leaving a company to continue the health insurance policy they had when employed.

A method of integrating benefits payable under more than one health insurance plan so that the insured’s benefits from all sources do not exceed allowable medical expenses.

A fixed-dollar amount a person is required to pay out of pocket when they receive covered medical care.

A limit on the amount of money an insurance company will pay for benefits.

The term that insurance plans use to describe costs they “share” with the beneficiary, also often known as out-of-pocket costs.

Drug coverage that pays, on average, as much as or more than the standard Medicare Part D drug coverage.

The amount of money that someone pays before their insurance plan covers any medical care or prescriptions.

A state-level regulatory agency that oversees and enforces state insurance laws.

Medical equipment that can be used repeatedly and is not disposable, examples include wheelchairs, pumps and oxygen equipment.

A federal law that governs pension plans and private health insurance provided by self-funded institutions that requires insurance providers to disclose plan benefits and funding levels, as well as ways to manage and access your benefits.

A set list of benefits that insurance plans must include if they are sold through a state or federal health insurance marketplace created under the Affordable Care Act.

Steps outlined by an insurance company that allow someone to petition for certain health care benefits ordinarily not covered by the insurance plan.

A description, sent to patients and health care providers by health plans, of benefits received and services for which the health care provider has requested payment.

A federal law that guarantees up to 12 weeks of job-protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member.

A measure of income level issued annually by the Department of Health and Human Services that is used to determine eligibility for certain benefits and programs, such as Medicaid.

An arrangement with an employer that allows an employee to pay for many of their out-of-pocket medical expenses with tax-free dollars.

An approved list of prescription drugs covered by a health insurance plan.

A federal law that prohibits insurance providers and employers from discriminating on the basis of genetic information.

As used in connection with the Affordable Care Act, a group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010.

Protection that provides payment of benefits for covered illness or injury.

Online marketplaces where consumers can compare and purchase insurance plans.

A set of laws that provides rights and protections for participants and beneficiaries in group health plans; it protects personal information while also allowing health care administrators to conduct necessary business operations.