Actuarial Value (AV)
The average value of the benefits that a certain health plan covers, calculated as a percentage of total costs.
Affordable Care Act (ACA)
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.
Certificate of Coverage
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.
Children’s Health Insurance Program (CHIP)
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.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that allows individuals leaving a company to continue the health insurance policy they had when employed.
Coordination of Benefits (COB)
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.
Department of Insurance
A state-level regulatory agency that oversees and enforces state insurance laws.
Durable Medical Equipment
Medical equipment that can be used repeatedly and is not disposable, examples include wheelchairs, pumps and oxygen equipment.
Employee Retirement Income Security Act (ERISA)
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.
Essential Health Benefits (EHBs)
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.
Explanation of Benefits (EOB)
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.
Family and Medical Leave Act (FMLA)
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.
Federal Poverty Level (FPL)
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.
Flexible Spending Account/Arrangement (FSA)
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.
Genetic Information Nondiscrimination Act (GINA)
A federal law that prohibits insurance providers and employers from discriminating on the basis of genetic information.
Grandfathered Health Plan
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.
Health Insurance Exchange or Marketplace
Online marketplaces where consumers can compare and purchase insurance plans.
Health Insurance Portability and Accountability Act (HIPAA)
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.
Health Maintenance Organization (HMO)
A payer that provides services for members in a particular geographic area.
Health Savings Account (HSA)
A tax-free medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan.
High Risk Insurance Pools
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.
A list of providers who participate in a health plan’s provider network
Also known as traditional health insurance, indemnity plans pay a certain percentage of the charges billed by the provider, and the patient is responsible for the balance.
A type of bill for inpatient hospital services that lists every charge, grouped into specific categories.
Lifetime Maximum Benefit (Lifetime Cap)
A lifetime maximum benefit is the total amount of money that an insurance company will pay for an individual’s health care expenses.
Managed Care Plans
A plan which implements certain health care measures to control costs associated with heath care services.
A government health insurance program for eligible, low-income individuals; eligibility varies by state.
Medical Benefits Exclusion
Health care products, services and circumstances that are specifically not covered in a health insurance plan. Excluded benefits vary by plan but commonly include injuries sustained in the act of committing a felony or misdemeanor, workers comp, self-inflicted injuries or suicide attempt, cosmetic surgery and other areas.
Medical Loss Ratio
The percentage of the premium that an insurance company spends on medical care, as opposed to administrative or overhead costs.
Term used when the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness
A federal health insurance program primarily for those ages 65 and older and individuals who have been receiving Social Security disability benefits for at least 12 months. Medicare coverage can be broken down into several parts, typically referred to by the letters A, B, C and D.
Medicare Part D Coverage Gap (Donut Hole)
Most plans with Medicare Part D have a coverage gap (called a “donut hole”) that requires a certain amount be paid out-of-pocket for covered prescription drugs before coverage resumes.
Medigap (Medicare Supplement)
A policy sold by private insurance companies to cover products and services that are not covered, or are covered in lower amounts, by Original Medicare (Medicare A and B).
National Drug Code (NDC)
A numeric code assigned to a prescription drug by the FDA.
People employed by their state insurance marketplace to help consumers through the process of choosing an insurance plan.
The period of time set up to allow individuals to review and change their health insurance coverage without a penalty, usually once a year.
Refers to coverage provided by Medicare parts A and B.
Providers who do not participate in the network of a managed care plan.
Out-of-Pocket (OOP) Costs
Costs that beneficiaries “share” with their insurance company and thus pay for out of their own “pocket,” the most common forms of OOP costs are deductibles, copayments and coinsurance.
Out-of-Pocket (OOP) Maximum
The total dollar amount of the expenses a member would have to pay for covered medical charges during a specified period of time.
A public or private organization that pays or underwrites coverage for health care expenses.
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.
Pharmacy Benefit Manager (PBM)
A company specializing in the administration of commercial pharmacy benefits.
Point of Service (POS) Plan
A type of plan in which an individual pays less if they use doctors, hospitals and other health care providers that belong to the plan’s network.
Preferred Provider Organization (PPO)
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.
The monthly payment made by an employer or individual to purchase insurance.
Health services that cover a range of prevention, wellness and treatment for common illnesses.
Primary Care Physician (PCP)
A physician who oversees the general health care needs of a patient and may serve as the first contact in a managed care system.
Prior Authorization (also, Pre-Certification Pre-Determination or Pre-Authorization)
Review of services to determine medical appropriateness before services are rendered.
Institutions and individuals that are licensed to provide health care services; for example, hospitals, physicians, pharmacists, etc.
An event that would cause an individual to lose health coverage under COBRA and/or become eligible to purchase or change health insurance coverage without penalty, for example marriage, divorce, adoption, job loss, etc.
A limit on the number of services, prescriptions or products allowed over the course of a particular benefit period.
Payment made by a payer to a provider for approved medical services.
The retroactive cancellation of a health insurance policy.
Rider (Exclusionary Rider)
An amendment to an insurance policy.
Self-Funded (Self-Insured) Plan
A type of job-based health insurance coverage where the employer pays the claims with its own funds.
Social Security Disability Insurance
Cash benefits paid to individuals who the Social Security Administration determines are disabled and who have worked and paid social security taxes for a required amount of time.
State and Community Health Plans
Programs that provide coverage and services with minimal private commercial and federal involvement.
Statement of Medical Necessity
Official documentation from the medical provider to the 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.
A health insurance plan requirement to “try and fail” a specific medication before the originally prescribed medication will be approved.
Supplemental Security Income
Cash benefits paid to individuals who the Social Security Administration determines are disabled and who have limited income.
The Department of Defense’s managed health care program for active duty military, active duty service families, retirees and their families, and other beneficiaries.
VA - Department of Veterans Affairs
An independent agency of the federal government created in 1930 responsible for providing federal benefits to veterans and their dependents.