ACA Health Insurance
ACA health insurance refers to private medical plans that comply with the federal regulations set by the Affordable Care Act.
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Resources
Glossary
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A
Affordable Care Act
The Affordable Care Act, often referred to as the ACA or Obamacare, is a comprehensive healthcare reform law enacted in March 2010.
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Allowed Amount
One of the most critical concepts to grasp is the allowed amount, a figure that dictates exactly how much your insurance company will pay for a specific medical service.
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Annual Enrollment Period
The yearly window when people with Medicare can change their Medicare Advantage or drug plans.
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Annual Wellness Visit
An annual wellness visit is a dedicated appointment with your primary care provider specifically designed to create or update a personalized prevention plan.
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Appeal
An appeal is a formal request for your health insurance company to reconsider a decision to deny coverage for a service, supply, or prescription.
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B
Balance billing
When a provider bills you for the difference between their charge and the plan's allowed amount.
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Benefit Period
A benefit period is the specific window of time during which an insurance policy provides active coverage for medical services or financial compensation.
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Brand-name Drug
A brand-name drug is a medication marketed under a specific name by the pharmaceutical company that developed it.
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C
Catastrophic Health Insurance
Catastrophic health insurance is a specific category of health plan designed to provide a safety net for worst-case medical scenarios.
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Catastrophic plan
A low-premium, very high-deductible Marketplace plan available to certain younger people or those with a hardship exemption.
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Claim
A claim is a formal request sent by a healthcare provider or a patient to an insurance company, asking for payment for services rendered.
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COBRA
The Consolidated Omnibus Budget Reconciliation Act, commonly known as COBRA, is a federal law that provides a vital safety net for workers and their families.
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COBRA Continuation Coverage
COBRA continuation coverage is a federal law passed in 1985 that gives workers and their families the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances.
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Coinsurance
Coinsurance is a core component of most health insurance plans, representing the percentage of costs you pay for covered healthcare services after you have met your deductible.
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Coordination of Benefits
Coordination of benefits is a standardized insurance industry process used to determine the payment responsibilities of two or more health insurance carriers covering the same individual.
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Copay
A copay (short for copayment) is a fixed dollar amount you pay for a covered health care service after you have paid your deductible.
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Copay vs Coinsurance
A copay is a fixed dollar amount you pay for a specific medical service, such as a doctor's visit or a prescription.
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Copayment
A copayment is a fixed amount you pay for a covered healthcare service, usually when you receive the service.
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Cost Sharing
At its core, cost sharing is the portion of specialized medical expenses you pay out of your own pocket.
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Cost-Sharing Reduction
Extra savings that lower deductibles, copays and coinsurance for eligible people who choose certain Marketplace plans.
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Coverage Effective Date
Your coverage effective date is the specific day, and often the exact time, when your insurance policy becomes active and the insurer assumes financial responsibility for your risks.
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Creditable Coverage
Creditable coverage is a formal designation given to healthcare or prescription drug plans that meet specific government standards of value.
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D
Deductible
Whether you are selecting a plan through an employer, the federal marketplace, or a private broker, the deductible acts as a primary lever that dictates your monthly costs and your potential financial exposure.
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Deductible vs Coinsurance
A deductible is the fixed amount you pay out of pocket for covered services before your insurance plan begins to pay.
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Deductible vs Copay
A deductible is a fixed dollar amount you must pay for covered services before your insurance company begins to pay, whereas a copay is a fixed fee you pay at the time of a specific service or for a prescription.
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Denied Claim
Understanding the Impact of a Denied Claim Receiving a letter stating your insurance provider has issued a denied claim can be a stressful and confusing experience.
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Drug Tier
A drug tier is a specific category used by insurance providers to determine the cost-sharing amount you are responsible for when picking up a prescription.
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Dual Eligibility Medicare Medicaid
Dual eligibility Medicare Medicaid refers to a specific status where an individual qualifies for both the federal Medicare program and their state’s Medicaid program simultaneously.
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Dual Eligible
A dual eligible individual is someone enrolled in Medicare—the federal program primarily for those 65 and older or with specific disabilities—who also meets the income and asset requirements for Medicaid, the joint federal and state program for low-income…
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E
Employer-sponsored Health Insurance
Employer-sponsored health insurance is a health policy selected and purchased by an employer and offered to eligible employees and their dependents.
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EOB
One of the most important documents you will receive after seeking medical care is the EOB, or Explanation of Benefits.
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EPO
An EPO, or Exclusive Provider Organization, is a unique type of managed care plan that combines elements of more common insurance structures.
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Explanation of Benefits
After you visit a doctor or receive medical treatment, you will likely receive a document in the mail or via email that looks like a bill but explicitly states, "This is not a bill." This document is your explanation of benefits (EOB).
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Extra Help Medicare
Extra Help Medicare is a federal program designed to alleviate this burden by assisting eligible individuals with the costs associated with Medicare Part D.
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F
Flexible Spending Account
A flexible spending account (FSA) is an employer-sponsored benefit that allows you to set aside a portion of your earnings before taxes are deducted to pay for qualified medical or dependent care expenses.
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Formulary
A formulary is a comprehensive list of generic and brand-name drugs covered by a specific health insurance plan.
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FSA
An FSA, or Flexible Spending Account, is a tax-advantaged financial account that allows employees to set aside a portion of their earnings to pay for qualified medical or dependent care expenses.
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G
General Enrollment Period
The general enrollment period is a yearly window from January 1 through March 31.
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Generic Drug
A generic drug is a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use.
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Group Health Plan
A group health plan is an insurance program established by an employer or employee organization to provide medical care for employees and their dependents.
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H
HDHP
A health insurance plan with a high deductible, known as an HDHP, is a specific type of health coverage defined by the Internal Revenue Service (IRS).
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Health Insurance Claim
A health insurance claim is an itemized bill submitted to a medical insurance carrier for payment of services rendered by a healthcare professional.
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Health Insurance Deductible
A health insurance deductible is the specific dollar amount you must pay out-of-pocket for covered medical services before your insurance plan begins to pay its share.
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Health Insurance Marketplace
The health insurance marketplace is a federally mandated service that allows individuals, families, and small businesses to compare and purchase medical coverage.
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Health Insurance Premium
A health insurance premium is the fixed amount of money you pay to an insurance company every month to keep your coverage active.
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Health Savings Account
A health savings account is a personal savings account that you can use to pay for healthcare costs using money that has not been taxed.
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High Deductible Health Plan
A high deductible health plan (HDHP) is a unique category of health insurance characterized by lower monthly premiums and higher initial costs for care.
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HMO
An HMO is a type of health insurance plan that limits coverage to care from doctors who work for or contract with the organization.
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HMO vs PPO
The choice between an HMO vs PPO dictates how you access medical care, which doctors you can see, and how much you will pay out of your own pocket.
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Home Health Care
Home health care is a wide range of health care services that can be given in your home for an illness or injury.
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Hospice Care
Hospice care is a specialized form of medical treatment that prioritizes comfort and quality of life when a cure is no longer the primary goal.
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HSA
A HSA, or Health Savings Account, is a tax-advantaged financial vehicle designed for individuals enrolled in a High Deductible Health Plan (HDHP).
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I
In-network
When a doctor, hospital, or pharmacy is in-network, it means they have a formal contract with your insurance provider to offer services at pre-negotiated, discounted rates.
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Initial Enrollment Period
The initial enrollment period is a specific window of time when you first become eligible for Medicare.
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L
Long-term Care
Long-term care refers to a variety of services designed to meet a person's health or personal care needs during a short or long period of time.
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Long-term Care Insurance
Long-term care insurance is a specialized type of coverage designed to help cover the costs of services that aren't typically covered by standard health insurance or Medicare.
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M
Mail-order Pharmacy
A mail-order pharmacy is a specialized service that delivers prescription medications directly to your home through the mail.
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Marketplace Health Insurance
Marketplace health insurance refers to the health coverage options available through the federal platform (HealthCare.gov) or state-based exchanges.
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Medicaid
A joint federal and state program that provides health coverage to eligible people with limited income.
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Medicare Advantage
Medicare Advantage is a health insurance option offered by private companies that contract with the federal government.
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Medicare Advantage vs Medigap
Choosing the right health coverage is one of the most significant financial decisions you will make during your retirement years.
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Medicare Assignment
One of the most critical terms you will encounter in the federal health program is Medicare assignment.
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Medicare Eligibility
Medicare eligibility refers to the specific set of legal and health-based criteria an individual must meet to enroll in the federal health insurance program.
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Medicare Enrollment Period
The Medicare enrollment period refers to designated timeframes during which individuals can sign up for, change, or drop their Medicare coverage.
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Medicare Excess Charges
One of the most misunderstood aspects of outpatient care is the potential for additional costs known as Medicare excess charges.
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Medicare Late Enrollment Penalty
The Medicare late enrollment penalty is a lifelong surcharge added to Medicare premiums for individuals who fail to sign up for Medicare Part A, Part B, or Part D during their initial enrollment period without having other "creditable" insurance coverage.
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Medicare Part A
Medicare Part A is a cornerstone of the United States federal health insurance program, specifically designed to cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
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Medicare Part B
Medicare Part B is the portion of Original Medicare that covers medically necessary services and preventive care.
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Medicare Part C
By opting for a Medicare Part C plan, you are essentially choosing to receive your Medicare benefits through a private insurance company approved by the federal government.
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Medicare Part D
Medicare Part D is the federal government's program designed to help Medicare beneficiaries pay for self-administered prescription drugs.
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Medicare Savings Program
A Medicare Savings Program (MSP) is a federally funded, state-administered initiative that assists eligible beneficiaries with their out-of-pocket Medicare expenses.
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Medicare Supplement Insurance
Medicare Supplement Insurance, also known as Medigap, is a private insurance policy designed to fill these financial "gaps."
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Medicare vs Medicaid
Among the most common points of confusion is the distinction between Medicare vs Medicaid.
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Medicare-approved Amount
One of the most critical terms you will encounter is the Medicare-approved amount.
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Medigap
Medigap is a specialized type of private insurance designed specifically to fill these financial "gaps."
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Metal tiers (Bronze/Silver/Gold/Platinum)
Marketplace categories that show how a plan splits costs between you and the plan, from Bronze (you pay more when you get care) to Platinum (you pay less).
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Minimum Essential Coverage
Minimum essential coverage refers to the type of health insurance that satisfies the individual responsibility requirement under the Affordable Care Act (ACA).
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Multi-employer Health Plan
A multi-employer health plan is a specific type of benefit arrangement created through a collective bargaining agreement between one or more labor unions and two or more employers.
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N
Network
The doctors, hospitals and pharmacies your plan has contracted with to provide care at agreed rates.
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O
Open Enrollment
Open enrollment is the specific time of year when you can sign up for health insurance, switch your current plan, or make changes to your existing coverage.
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Original Medicare
Original Medicare is the federal health insurance program primarily designed for individuals aged 65 or older, though it also serves younger people with specific disabilities or permanent kidney failure.
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Out-of-network
When a doctor, hospital, or specialist does not have a contract with your health insurance company, they are considered out-of-network.
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Out-of-pocket Costs
In the simplest terms, out-of-pocket costs are the expenses for medical care that aren't reimbursed by insurance.
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Out-of-pocket Maximum
Among the various terms you encounter, the out-of-pocket maximum is perhaps the most significant for your financial security.
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Out-of-pocket Maximum vs Deductible
In contrast, the out-of-pocket maximum is the absolute ceiling on your spending for the year.
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P
POS
A Point of Service plan that blends HMO and PPO features: you usually need a primary doctor and referrals, but some out-of-network care is covered.
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POS Health Plan
A POS health plan, or Point of Service plan, is a hybrid insurance model that combines the cost-saving structure of an HMO with the out-of-network flexibility of a PPO.
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PPO
A PPO, or Preferred Provider Organization, is a type of health plan that offers a significant amount of freedom in how you access medical care.
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PPO vs EPO
In the United States, two of the most common managed care architectures are Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs).
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Pre-existing Condition
A pre-existing condition is generally defined as any health issue, such as asthma, diabetes, or cancer, that you had before your new health coverage started.
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Preferred Provider
One of the most common terms you will encounter while shopping for insurance is preferred provider.
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Premium
In the world of insurance, a premium is the fundamental building block of your coverage plan.
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Premium Tax Credit
The premium tax credit is a refundable federal tax credit designed to help eligible individuals and families afford health insurance coverage purchased through the Health Insurance Marketplace.
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Premium-free Medicare Part A
For many Americans reaching age 65, one of the most significant benefits available is premium-free Medicare Part A.
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Prescription Drug Coverage
Prescription drug coverage is a form of insurance specifically designed to pay for a portion of your outpatient prescription medications.
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Preventive Care
Preventive care refers to healthcare services intended to prevent illnesses, disease, and other health problems, or to detect them at an early stage when treatment is likely to work best.
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Primary Care Physician
Selecting a primary care physician is one of the most significant decisions you will make for your long-term health.
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Primary Insurance
Primary insurance is the healthcare policy that has the initial legal obligation to pay for your medical claims.
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Prior Authorization
Between premiums, deductibles, and network restrictions, you may encounter a process known as prior authorization.
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Provider Network
A provider network is a pre-established group of doctors, specialists, hospitals, and other healthcare facilities that have agreed to provide services to a specific insurance plan’s members at discounted rates.
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Q
Qualifying Life Event
A qualifying life event is a specific change in your circumstances that allows you to enroll in or modify your health insurance plan outside of the standard Open Enrollment Period.
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Quantity Limit
A quantity limit is a health insurance requirement that restricts the number of doses, pills, or units of a specific medication covered within a certain timeframe.
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R
Referral
In the United States healthcare system, a referral is a formal written order from your primary care provider (PCP) that allows you to see a specialist or receive specific medical services.
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Retiree Health Benefits
Retiree health benefits are medical insurance provisions offered to former employees by their previous employers, often alongside or in addition to Medicare.
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Retiree Health Coverage
Retiree health coverage refers to the various insurance strategies and plans that protect your savings from high healthcare costs once you leave the workforce.
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S
SBC
An SBC is a standardized document required by federal law that provides a clear, concise overview of what a health insurance plan covers and what it costs.
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Secondary Insurance
Secondary insurance is a health insurance policy that pays for medical claims only after your primary insurance provider has paid its portion.
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Secondary Payer
When you have multiple layers of coverage, the term secondary payer refers to the insurance plan or program that pays for medical expenses only after the primary insurance has processed the claim.
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Short-term health insurance
Temporary coverage meant to fill gaps, which may not cover all essential benefits or pre-existing conditions.
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Skilled Nursing Facility
A skilled nursing facility is a licensed healthcare institution that provides high-level medical care and rehabilitation services.
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Special Enrollment Period
A special enrollment period is a specific timeframe outside the annual Open Enrollment Period during which you can sign up for health insurance or change your existing plan.
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Specialist
A specialist is a physician who has completed advanced education and clinical training in a specific area of medicine.
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Step Therapy
One of the most common methods insurance companies use to control spending is a process called step therapy.
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Summary of Benefits and Coverage
A summary of benefits and coverage, often called an SBC, is a standardized document designed to help you understand how a specific health plan works.
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Supplemental Health Insurance
Supplemental health insurance is a type of secondary policy purchased to complement a primary health insurance plan.
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