Glossary

a

Affordable Care Act

A new health reform law passed in 2010, aimed at reforming America's health care system to improve access and affordability for more Americans.

b

Benefits

The health care items or services covered by an insurance plan sometimes called a "benefit package."

c

Claim

An itemized bill for services that have been provided to a plan member, spouse or dependent.

Coinsurance

Your share of the costs of a covered health care service - usually a percentage of an eligible expense. You may pay 20% of an allowed service and your plan 80%.

Copayment

A fixed dollar amount you are required to pay for a covered service at the time you receive care.

d

Deductible

A fixed amount of the eligible expenses you are required to pay before you are reimbursed for a covered service. For example, if your deductible is $1,000, your plan won't pay anything until you've met your $1,000 deductible.

e

Emergency Medical Care

Services provided for outpatient treatment of an acute medical condition, usually in a hospital.

Essential Health Benefits

Beginning in 2014, most insurance plans you can choose from - whether you buy on the health insurance exchange or go directly to the insurance company of your choice - will include many essential benefits that are meant to make sure basic health concerns are covered.

Explanation of Benefits (EOB)

The form sent to you after a claim has been processed by your health care provider. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, the amount you may owe the provider and the claims appeal process.

h

Health Insurance Marketplace

The websites where millions of people shop for, compare and buy health insurance, during open enrollment periods. Also called health insurance marketplaces, these sites will be operated by the federal or state government or a combination of the two.

i

In-Network

Covered services provided or ordered by your primary care physician (PCP) or another provider who is in the specific network of providers that your health plan has contracted with.

n

Network

The doctors, hospitals and other health care providers that a plan has contracted with to deliver health care services to its members/subscribers.

o

Open Enrollment Period

The period when you choose from available health insurance plans, usually once a year. The next open enrollment period for purchasing insurance on the health insurance marketplace begins on November 1, 2016, and is extended through January 31, 2017.

Out-of-Pocket

The maximum amount you have to pay for eligible expenses under your health plan during a defined benefit period.

p

Pre-Existing Condition

A condition, disability or illness that you have been treated for before applying for new health coverage.

Premium

The ongoing amount that must be paid for your health insurance or plan. You and/or your employer pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for coverage. Typically, you will also have a copayment or deductible amount too.

Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent or detect illnesses, disease, or other health problems.

Primary Care Physician (PCP)

The physician you choose to be your primary source for medical care who coordinates all your medical care, including hospital admissions and referrals to specialists. Not all plans require a PCP.

t

Tax Credits

To help people better afford health insurance, those eligible will receive premium tax credits to help defray insurance costs. These credits will make it easier for millions of low and middle-class Americans to pay for health insurance.