Health Insurance Plans glossary
Confused by health insurance terms? Our comprehensive glossary breaks down key terms like premiums, deductibles, copays, and more. Learn how to navigate your coverage, compare plans, and avoid unexpected costs. Perfect for anyone enrolling in or reviewing their health insurance!
ACA (Affordable Care Act)
Also known as Obamacare, this law aims to make health insurance more affordable and accessible.
Allowed Amount
The maximum amount an insurance plan will pay for a covered service.
Annual Limit
The maximum amount an insurance plan will pay for covered services in a year.
Appeal
A request for your health insurance company to review a denied claim.
Authorization
Prior approval required from your insurance company for certain services.
Balance Billing
When a provider bills you for the difference between their charge and what your insurance pays.
Beneficiary
A person eligible to receive benefits under a health insurance plan.
Benefits
The healthcare services or items covered by your insurance plan.
Catastrophic Health Insurance
A plan with low premiums and high deductibles, designed for worst-case scenarios.
Claim
A request for payment submitted to your insurance company for services rendered.
COBRA
A law that allows you to continue employer-sponsored insurance after leaving your job.
Coinsurance
The percentage of costs you pay for a covered service after meeting your deductible.
Copayment (Copay)
A fixed amount you pay for a covered service, like $20 for a doctor’s visit.
Cost-Sharing
The portion of healthcare costs you pay out-of-pocket, including deductibles and copays.
Covered Services
Medical services or items that your insurance plan agrees to pay for.
Deductible
The amount you pay out-of-pocket before your insurance starts to pay.
Dependent
A person, such as a child or spouse, covered under your health insurance plan.
Drug Formulary
A list of prescription drugs covered by your insurance plan.
Embedded Deductible
A deductible structure in family plans where each individual has their own deductible.
EOB (Explanation of Benefits)
A statement from your insurance company explaining what services were covered.
EPO (Exclusive Provider Organization)
A plan that only covers care from in-network providers, except in emergencies.
Essential Health Benefits
A set of 10 categories of services that all ACA-compliant plans must cover.
Flexible Spending Account (FSA)
A pre-tax account for eligible medical expenses, typically used within the plan year.
HMO (Health Maintenance Organization)
A plan that requires a primary care physician and referrals for specialists.
Health Savings Account (HSA)
A tax-advantaged savings account for individuals with high-deductible health plans.
High-Deductible Health Plan (HDHP)
A plan with a higher deductible, often paired with an HSA.
In-Network
Providers or facilities that have contracted with your insurance plan.
Individual Mandate
A requirement under the ACA that most Americans have health insurance.
Out-of-Network
Providers or facilities that do not have a contract with your insurance plan.
Lifetime Limit
The maximum amount an insurance plan will pay over your lifetime.
Medicaid
A joint federal and state program providing health coverage to low-income individuals.
Medicare
A federal health insurance program for people aged 65 and older.
Metal Tiers
Categories of ACA plans (Bronze, Silver, Gold, Platinum) indicating cost-sharing.
Network
The group of providers that have contracted with your insurance plan.
Open Enrollment
The annual period when you can enroll in or change your health insurance plan.
Out-of-Pocket Maximum
The most you’ll pay for covered services in a year, including deductibles and copays.
POS (Point of Service)
A plan combining features of HMO and PPO plans.
PPO (Preferred Provider Organization)
A plan allowing you to see any provider, in-network or out-of-network.
Premium
The amount you pay monthly for your health insurance plan.
Pre-Existing Condition
A health condition you had before enrolling in a health insurance plan.
Preventive Care
Services like vaccinations and screenings covered at no cost under ACA plans.
Referral
A recommendation from your primary care physician to see a specialist.
Reimbursement
Payment from your insurance company for covered services you’ve already paid for.
Special Enrollment Period (SEP)
A time outside of open enrollment to sign up for health insurance due to a qualifying event.
Subsidy
Financial assistance to help lower the cost of health insurance premiums.
Telemedicine
Virtual healthcare services, such as video consultations with doctors.
Tiered Network
A system where providers are grouped into tiers based on cost.
Urgent Care
Medical services for conditions requiring immediate attention but not life-threatening.
Waiting Period
The time you must wait before your health insurance coverage begins.
Understanding Health Insurance: A Comprehensive Glossary of Key Terms
Navigating the world of health insurance can feel overwhelming, especially with the abundance of industry-specific terms and jargon. Whether you’re enrolling in a new plan, reviewing your current coverage, or simply trying to understand your benefits, having a clear understanding of common health insurance terms is essential. To help you make informed decisions, we’ve put together a comprehensive glossary of key health insurance terms. Let’s break it down!
Why Understanding Health Insurance Terms Matters
Health insurance is a critical part of managing your healthcare costs and ensuring access to necessary medical services. However, the terminology can be confusing, and misunderstanding key terms can lead to unexpected expenses or gaps in coverage. By familiarizing yourself with these terms, you can:
- Compare plans more effectively.
- Understand your benefits and costs.
- Avoid surprises when receiving medical care.
- Make the most of your health insurance coverage.
