Health Care Glossary

Understand the terms to understand your policy. These definitions are similar to those found on healthcare.gov. Please refer to your policy for definitions specific to your coverage.

A

Accidental Death Benefit
The payment due to the beneficiary, or recipient, of an accidental death insurance policy.
Accountable Care Organization (ACO)
A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings.
Accreditation
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Actuarial Value
If a Marketplace health plan is approved, this is the "seal of approval" given to the plan by an independent organization to show that the plan meets national quality standards.
Admission
Overnight or inpatient admittance to an acute care general hospital, skilled nursing facility, birthing center or mental health facility.
Admitting Privileges
The right or privilege granted to a physician to admit patients to a particular hospital.
Adult Dental Benefits
Preventive, basic and major dental services, such as oral exams, x-rays, fillings and extractions for adults ages 19 and older.
Adult Vision Benefits
May include routine vision services, such as eye examinations, prescription eyeglasses and contact lenses for adults ages 19 and older.
Advanced Premium Tax Credit (APTC)
A tax credit that can reduce what you pay for health insurance. When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If your estimate falls in the range to save, you can use an advance payment of the premium tax credit to lower your monthly insurance bill (known as your “premium”).
  • If at the end of the year you’ve taken more premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return.
  • If you’ve taken less than you qualify for, you’ll get the difference back.
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).
The law has 3 primary goals:
  • Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
  • Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
  • Support innovative medical care delivery methods designed to lower the costs of health care generally.
Affordable Coverage
A job-based health plan covering only the employee that costs 9.66% or less of the employee’s household income. If a job-based plan is “affordable,” and meets the “minimum value” standard, you're not eligible for a premium tax credit if you buy a Marketplace insurance plan instead.
  • The plan used to define affordability is the lowest priced “self-only” plan the employer offers — meaning a plan covering only the employee, not dependents. This is true even if you’re enrolled in a plan that costs more or covers dependents.
  • The cost is the amount the employee would pay for the insurance, not the plan’s total premium.
  • The employee’s total household income is used. Total household income includes income from everybody in the household who’s required to file a tax return.
Agent
An agent or broker is a person or business who can help you apply for help paying for coverage and enroll you in a Qualified Health Plan (QHP) through the Marketplace. They can make specific recommendations about which plan you should enroll in. They're also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an insurer's plans. Some agents and brokers may only be able to sell plans from specific health insurers.
Alimony
Alimony is money you get from a spouse with whom you no longer live, or a former spouse, if paid to you as part of a divorce agreement, separation agreement, or court order. Payments designated in the agreement or order as child support or as non-taxable property settlement aren't alimony.
Allowed Amount
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”

If your provider charges more than the plan’s allowed amount, you may have to pay the difference.
Ambulatory or Outpatient Surgical Center
A licensed facility (pursuant to Chapter 395 of the Florida Statues or a similar applicable law of another state) that primarily provides elective, same-day surgical care.
Annual Deductible Combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
Annual Limit
A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.
Appeal
A request for your health insurance company or the Health Insurance Marketplace to review a decision that denies a benefit or payment.
  • If you don’t agree with a decision made by the Marketplace, you may be able to file an appeal. You can also appeal decisions by the SHOP Marketplace for small businesses.
  • If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
    At-Home Recovery
    Short-term, at-home assistance with daily living activities, such as bathing and dressing, while you are recovering from an illness, injury or surgery.
    Authorized Representative
    Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
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    B

    Balance Billing
    When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
    Basic Dental Care
    Dental services, such as fillings, extractions and anesthesia.
    Benefits
    The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
    Benefit Period
    The timeframe when your health plan benefits begin and end, typically between January 1 and December 31.
    Benefit Year
    A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
    Brand Name Drugs
    A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.
    Broker
    An agent or broker is a person or business who can help you apply for help paying for coverage and enroll in a Qualified Health Plan (QHP) through the marketplace. They can make specific recommendations about which plan you should enroll in.They're also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer's plans. Some brokers may only be able to sell plans from specific health insurers.
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    C

    Care Coordination
    The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.
    Catastrophic Illness
    Serious or life-threatening health problems that can result in financial hardship without the appropriate health care coverage.
    Centers for Medicare & Medicaid Services (CMS)
    The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace. For more information visit cms.gov.
    Certificate of Creditable Coverage
    Documentation of proof of prior insurance coverage.
    Certificate of Coverage
    Documentation outlining your specific policy and benefits and coverage provisions, such as what is and is not covered, and dollar limitations.
    Children's Health Insurance Program (CHIP)
    Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.

    Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply any time. If you qualify, your coverage can begin immediately, any time of year.
    Chronic Disease Management
    An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease.
    Claim
    A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
    COBRA
    A federal law that may allow you to temperarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
    Coinsurance
    The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
    Complication of Pregnancy
    Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or fetus. Morning sickness and a non-emergency caesarean section aren't complications of pregnancy.
    Coordination of Benefits
    A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
    Copayment (copay)
    A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

    Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
    • If you've paid your deductible: You pay $20, usually at the time of the visit.
    • If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
    Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.

    Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
    Cost Sharing
    The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
    Cost Sharing Reduction (CSR)
    A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. In the Health Insurance Marketplace, cost-sharing reductions are often called “extra savings.” If you qualify, you must enroll in a plan in the Silver category to get the extra savings.
    • When you fill out a Marketplace application, you’ll find out if you qualify for premium tax credits and extra savings. You can use a premium tax credit for a plan in any metal category. But if you qualify for extra savings too, you’ll get those savings only if you pick a Silver plan.
    • If you qualify for cost-sharing reductions, you also have a lower out-of-pocket maximum — the total amount you’d have to pay for covered medical services per year. When you reach your out-of-pocket maximum, your insurance plan covers 100% of all covered services.
    • If you're a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
    Coverage
    Services eligible to be paid for by your health plan.
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    D

    Deductible
    The dollar amount you must pay each calendar year before insurance begins to pay for certain health services. You pay the plan deductible first then coinsurance (%) may apply.
    Dental Coverage
    Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a "stand-alone" dental plan.
    Department of Health and Human Services (HHS)
    The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP).
    Dependent
    A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
    Dependent Coverage
    Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
    Disability
    A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working. Because different programs may have different disability standards, please check the program you're interested in for its disability standards.

    The list of activities mentioned above isn't exhaustive. A legal definition of disability can be found here.
    Doctor Office Visit
    Going to a licensed physician’s office.
    Domestic Partnership
    Two people of the same or opposite sex who live together and share a domestic life, but aren't married or joined by a civil union. In some states, domestic partners are guaranteed some legal rights, like hospital visitation.
    Donut Hole, Medicare Prescription Drug
    Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
    Drug List
    A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
    Durable Medical Equipment (DME)
    Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
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    E

    Emergency Medical Condition
    An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
    Emergency Medical Transportation
    Ambulance services for an emergency medical condition.
    Emergency Room
    Hospital department responsible for providing immediate medical or surgical care.
    Emergency Room Care
    Emergency services you get in an emergency room.
    Emergency Services
    Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
    Endorsement
    An amendment to your contract to add or exclude coverage of benefits or modifying administrative processes (e.g., eligibility requirements or claims).
    Essential Health Benefits
    A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services.

    Plans must offer dental coverage for children. Dental benefits for adults are optional.

    Specific services may vary based on your state’s requirements. You’ll see exactly what each plan offers when you compare plans.
    Exchange
    Another term for the Health Insurance Marketplace, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance.
    The Marketplace is accessible through websites, call centers, and in-person assistance.
    When you fill out a Marketplace application, you’ll find out if you qualify to save money when you enroll in a medical insurance plan. You’ll also find out if you qualify for Medicaid and the Children’s Health Insurance Program (CHIP).
    Whether you qualify for these programs depends on your expected income, household members, and other information.
    Excluded Services
    Health care services that your health insurance or plan doesn't pay for or cover.
    Exclusive Provider Organization (EPO) Plan
    A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).
    Explanation of Benefits (EOB)
    A written description of your benefits in regard to a claim stating what the plan pays and your financial responsibility.
    External Review
    A review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn't yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan's decision or overturns all or some of the plan's decision. The plan must accept this decision.
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    F

    Family and Medical Leave Act (FMLA)
    A Federal law that guarantees up to 12 weeks of job projected 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. When on leave under FMLA, you can continue coverage under your job-based plan.
    Federal Poverty Level (FPL)
    A measure of income issued every year by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
    Fee for Service
    A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.
    Flexible Spending Account (FSA)
    An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.

    There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.

    (Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.)
    Formulary
    A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
    Full-Time Employee (FTE)
    Any employee who works an average of at least 30 hours per week for more than 120 days in a year. Part-time employees work an average of less than 30 hours per week.
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    G

    Generic Drug
    A prescription drug that has the same active- ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
    Grievance
    A complaint that you communicate to your health insurer or plan.
    Group Health Plan
    In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
    Guaranteed Issue
    A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn't limit how much you can be charged if you enroll.
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    H

    HIPAA Eligible Individual
    Your status once you have had 18 months of continuous creditable health coverage. To be HIPAA (Health Insurance Portability and Accountability Act) eligible, at least the last day of your creditable coverage must have been under a group health plan; you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare or Medicaid; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. When you're buying individual health insurance, HIPAA eligibility gives you greater protections than you would otherwise have under state law.
    Habilitative/Habilitation Services
    Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
    Health Coverage
    Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children's Health Insurance Program (CHIP).
    Health Insurance
    A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
    Health Insurance Marketplace
    A service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.
    The Health Insurance Marketplace (also known as the “Marketplace” or “exchange”) provides health plan shopping and enrollment services through websites, call centers, and in-person help.
    Small businesses can use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance for their employees.
    When you apply for individual and family coverage through the Marketplace, you’ll provide income and household information. You’ll find out if you qualify for:
    • Premium tax credits and other savings that make insurance more affordable
    • Coverage through the Medicaid and Children’s Health Insurance Program (CHIP) in your state
    On HealthCare.gov, you may be asked to select your state or enter your ZIP code. If you live in a state that runs its own Marketplace, we’ll send you to your state’s Marketplace website.
    Health Maintenance Organization (HMO)
    A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
    Health Options, Inc.
    An HMO affiliate of Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue HMO. Both companies are Independent Licensees of the Blue Cross and Blue Shield Association.
    Health Reimbursement Account (HRA)
    Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.
    Health Savings Account (HSA)
    A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses if you have a “high deductible” health insurance plan.
    Combining a High Deductible Health Plan with a Health Savings Account (HSA) allows you to pay for certain medical expenses, like your deductible and copayments, with untaxed dollars. High-deductible plans usually have lower monthly premiums than plans with lower deductibles.
    Unlike a Flexible Spending Account (FSA), HSA funds roll over year to year if you don't spend them. You can take the funds with you if you change jobs or leave the work force. Your HSA may also earn interest.
    You can start an HSA through your own bank or other financial institution.
    Health Statement
    A summary of claims processed from the prior month and is also known as Explanation of Benefits (EOB).
    Health Status
    Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
    High Deductible Health Plan (HDHP)
    A plan with a higher deductible than a traditional insurance plan. Usually the monthly premium is lower, but you have to pay more health care costs yourself (your deductible) before the insurance company starts to pay its share. A high deductible plan can be combined with a health savings account or a health reimbursement arrangement. This allows you to pay for certain medical expenses with untaxed dollars.
    For 2016, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,300 for an individual or $2,600 for a family.
    Home and Community-Based Services (HCBS)
    Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing. This care is covered when provided by care workers or, if your state permits it, by your family.
    Home Health Care
    Health care services a person receives at home.
    Hospice Services
    Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
    Hospital and ER Physician Services
    Services performed by a licensed physician at a hospital or hospital’s emergency room department.
    Hospital Outpatient Care
    Care in a hospital that usually doesn't require an overnight stay.
    Hospital Readmissions
    A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn't properly organized, or that you weren't fully treated before discharge.
    Hospitalization
    Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
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    I

    In-Network
    A group of physicians, hospitals and other health care providers offering pre-negotiated rates, known as Allowed Amount.
    In-Network Coinsurance
    The percentage (for example, 20%) you pay for the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
    In-Network Copayment
    A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.
    Individual Health Insurance Policies
    Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.
    Inpatient Services
    Services received when admitted to a facility as a patient for medically necessary care or treatment offered by a licensed physician.
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    J

    Job-based Health Plan
    Coverage that is offered to an employee (and often his or her family) by an employer.
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    L

    Large Group Health Plan
    In general, a group health plan that covers employees of an employer that has 101 or more employees. Until 2016, in some states large groups are defined as 51 or more.
    Lifetime Limit
    A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.
    Limitations
    The maximum amount insurance will pay for benefits on specific covered expenses.
    Long-Term Care
    Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don't pay for long-term care.
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    M

    Mail Order Drug
    A program allowing you to purchase prescription drugs, typically for chronic conditions needing extended use, and ship the drugs to your home.
    Major Dental Care
    Includes procedures such as root canals, periodontal services (scaling and root planning), complete and partial dentures, crowns and bridges.
    Marketplace
    See Health Insurance Marketplace.
    Metal Plans
    Four levels of health insurance plans, Bronze, Silver, Gold and Platinum, offered by the Marketplace with similar health benefits, but different out-of-pocket costs and premiums.
    Medically Necessary
    Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
    Medicare
    A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
    Medicare isn’t part of the Health Insurance Marketplace. If you have Medicare coverage you don’t have to make any changes. You’re considered covered under the health care law.
    Medicare Advantage (Medicare Part C)
    A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
    Medicare Disability
    Coverage for 18 to 64 year olds who collect or qualify for Social Security Disability Income and are unable to work for at least a year due to a qualifying physical or mental impairment.
    Medicare Part D
    A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.
    Medicare Prescription Drug Donut Hole
    Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
    Medication Guide
    A list of prescription drugs that may be covered by your health plan.
    Member Survey Results
    A survey conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) which asks health plan members to rate the care, their experiences with their health plan and its services.
    Mental Health Services
    Care or treatment for emotional or behavioral conditions by a licensed physician or mental health professional.
    Metal Plans
    Four levels of health insurance plans, Bronze, Silver, Gold and Platinum, offered by the Marketplace with similar health benefits, but different out-of-pocket costs and premiums.
    Minimum Essential Coverage (MEC)
    Any insurance plan that meets the Affordable Care Act requirement for having health coverage. To avoid the penalty for not having insurance you must be enrolled in a plan that qualifies as minimum essential coverage (sometimes called “qualifying health coverage”).
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    N

    Network
    The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
    Network Plan
    A health plan that contracts with doctors, hospitals, pharmacies, and other health care providers to provide members of the plan with services and supplies at a discounted price.
    Non-Preferred Brand Name Drugs
    Brand name prescription drugs that may have a generic equivalent or similar drug available, but generally cost more to purchase.
    Non-Preferred Provider
    A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
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    O

    Open Enrollment Period
    The yearly period when people can enroll in a health insurance plan.
    Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You qualify if you have certain life events, like getting married, having a baby, or losing other health coverage.
    • Job-based plans may have different Open Enrollment Periods. Check with your employer.
    • You can apply and enroll in Medicaid or the Children's Health Insurance Program (CHIP) any time of year.
    Out-of-Network
    Health care providers that are not contracted or participating providers for your health plan and may charge full price for medical care. You may be responsible for charges over your plan’s Allowed Amount (see balance billing).
    Out-of-Network Coinsurance
    The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
    Out-of-Network Copayment
    A fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
    Out-of-Pocket Costs
    Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
    Out-of-Pocket Estimate
    An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
    Out-of-Pocket Maximum
    The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
    The out-of-pocket limit doesn't include your monthly premiums. It also doesn't include anything you may spend for services your plan doesn't cover.
    Outpatient Services
    Medical care or treatment performed in a doctor’s office, hospital or facility that does not require overnight stay, such as x-rays, ultrasounds and CAT scans.
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    P

    Pediatric Dental
    Routine dental services for children up to age 19, such as oral exams, x-rays, fillings, extractions and more.
    Pediatric Vision
    Routine vision services for children up to age 19, such as eye examinations, prescription eyeglasses and contact lenses.
    Physician
    A licensed doctor, such as Doctor of Medicine (MD), Doctor of Osteopathy (DO), Doctor of Podiatry (DPM), Doctor of Chiropractic (DC), Doctor of Dental Surgery or Dental Medicine (DDS or DMD) or Doctor of Optometry (OD).
    Physician Services
    Health care services a licensed medical physician (M.D.- Medical Doctor or D.O.- Doctor of Osteopathic Medicine) provides or coordinates.
    Plan
    A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
    Plan Type
    A category of health care plans, such as PPO, HMO and EPO.
    Plan Year
    A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).
    Policy Year
    A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer. (Note: In group health plans, this 12-month period is called a “plan year”).
    Pre-Existing Condition
    A health problem you had before the date that new coverage starts.
    Pre-Existing Condition (Job-based Coverage)
    Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.
    Preauthorization
    A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
    Preferred Provider
    A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
    Preferred Provider Organization (PPO)
    A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
    Premium
    The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit.
    Premium Tax Credit
    A tax credit you can use to lower your monthly insurance payment (called your “premium”) when you enroll in a plan through the Health Insurance Marketplace. Your tax credit is based on the income estimate and household information you put on your Marketplace application.
    If your estimated income falls between 100% and 400% of the federal poverty level for your household size, you qualify for a premium tax credit.
    You can use all, some, or none of your premium tax credit in advance to lower your monthly premium.
    • If you use more advance payments of the tax credit than you qualify for based on your final yearly income, you must repay the difference when you file your federal income tax return.
    • If you use less premium tax credit than you qualify for, you’ll get the difference as a refundable credit when you file your taxes.
    You can buy health insurance through other sources, but the only way to get a premium tax credit is through the Health Insurance Marketplace.
    Prescription Drugs
    Drugs and medications that, by law, require a prescription.
    Prescription Drug Coverage
    Health insurance or plan that helps pay for prescription drugs and medications.
    Prevention
    Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.
    Preventive Dental Care
    Refers to oral exams, X-rays, cleanings, and child flouride treatment.
    Preventive Medical Care
    Focuses on preventing health problems from occurring and diagnosing health conditions early for greater chances of recovery and may be included in your plan at no additional cost. Care includes wellness exams, vaccines, routine health screenings and more.
    Preventive Services
    Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
    Primary Care
    Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
    Primary Care Physician
    A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient./dd>
    Prior Authorization
    Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
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    Q

    Qualified Medical Expenses (QMEs)
    Out-of-pocket medical expenses that qualify for tax-free withdraws from a Health Savings Account (HSA), such as doctor visits, hospital care, prescription drugs, and more. See IRS publication 502 for a complete list.
    Qualifying Life Event (QLE)
    A change in your situation – like getting married, having a baby, or losing health coverage – that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.
    There are 4 basic types of qualifying life events. (The following are examples, not a full list.)
    • Loss of health coverage
    • Losing existing health coverage, including job-based, individual, and student plans
    • Losing eligibility for Medicare, Medicaid, or CHIP
    • Turning 26 and losing coverage through a parent’s plan
    Changes in household
    • Getting married or divorced
    • Having a baby or adopting a child
    • Death in the family
    Changes in residence
    • Moving to a different ZIP code or county
    • A student moving to or from the place they attend school
    • A seasonal worker moving to or from the place they both live and work
    • Moving to or from a shelter or other transitional housing
    Other qualifying events
    • Changes in your income that affect the coverage you qualify for
    • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
    • Becoming a U.S. citizen
    • Leaving incarceration (jail or prison)
    • AmeriCorps members starting or ending their service
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    R

    Reconsctructive Surgery
    Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
    Recurrent Benefit
    An additional benefit payout of critical illness products for the recurrence and reoccurrence of an illness.
    Referral
    A written order from your primary care doctor for you to see a specialist or get certain medical services. With some plans you may need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services.
    Rehabilitative/Rehabilitation Services
    Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
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    S

    Same-Sex Marriage
    Lawful marriage between spouses of the same sex. Same-sex marriage is legal and recognized in every U.S. state and the District of Columbia.
    As long as a same-sex couple is married in a jurisdiction with legal authority to authorize the marriage, a health insurance company that offers health coverage to opposite-sex spouses must do the same for same-sex spouses.
    The Health Insurance Marketplace also treats married same-sex couples the same as married opposite-sex couples in every state when they apply for premium tax credits and lower out-of-pocket costs on private insurance plans.
    Self-Insured Plan
    Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees' and dependents' medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.
    Service Area
    A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan's service area.
    Skilled Nursing Care
    Services from a licensed nurse in your home or nursing home; or known as skilled care if from a licensed technician or therapist.
    Skilled Nursing Facility
    Offers 24-hour medical and custodial care for temporary or long-term stays.
    Skilled Nursing Facility Care
    Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
    Social Security
    A system that distributes financial benefits to retired or disabled people, their spouses, and their dependent children based on their reported earnings. While you work, you may pay taxes into the Social Security system. When you retire or become disabled, you, your spouse, and your dependent children may get monthly benefits that are based on your reported earnings. Your survivors may be able to collect Social Security benefits if you die.
    Social Security Benefits
    The amount you get from Social Security Disability, Retirement (including Railroad retirement), or Survivor's Benefits each month.
    Social Security Survivors Benefits
    Social Security benefits based on your record (if you should die) that are paid to your:
    • Widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22
    • Children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22; and
    • Parents if you provided at least one-half of their support.
    An ex-spouse could also be eligible for a widow/widower's benefit on your record. A special one-time lump sum payment of $255 may be made to your spouse or minor children.
    Special Enrollment Period (SEP)
    A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
    If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.
    You can enroll in Medicaid and the Children’s Health Insurance Plan (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.
    Job-based plans must provide a special enrollment period of at least 30 days.
    Special Health Care Need
    The health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.
    Specialist
    A physician specialist focuses on a specific area of medicine or group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
    Speciality Drug
    An FDA-approved prescription drug designated by Florida Blue because it requires special handling, storage, training, distribution requirements and/or management of therapy. They can be provider administered or self administered and are identified in the Medication Guide.
    Subscriber
    A contract holder or member who consistently meets all eligibility requirements and is enrolled under the contract not as a dependent.
    Subsidized Coverage
    Health coverage available at reduced or no cost for people with incomes below certain levels.
    Examples of subsidized coverage include Medicaid and the Children’s Health Insurance Program (CHIP). Marketplace insurance plans with premium tax credits are sometimes known as subsidized coverage too.
    • In states that have expanded Medicaid coverage, your household income must be below 138% of the federal poverty level to qualify.
    • In all states, your household income must be between 100% and 400% of the federal poverty level to qualify for a premium tax credit that can lower your insurance costs.
    Subsidy or Premium Tax Credit
    Assistance from the government to help pay for the monthly insurance bill for those that qualify. The tax credit depends on taxable household income, family size and ages and location of residence. It does not pay for out-of-pocket health care costs, but financial assistance may be available to those who qualify.
    Substance Dependency
    A condition where alcohol or drug use injures one’s health; interferes with social or economic function; or causes loss of self-control.
    Summary of Benefits and Coverage (SBC)
    An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your jobs, renew or change coverage, or request an SBC from the health insurance company.
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    T

    TTY
    A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don't have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.
    Term
    The time period coverage is in effect.
    Transgender People
    A transgender person’s assigned sex at birth doesn’t match their gender identity, expression, or behavior.
    Transgender people have important details to consider in the Health Insurance Marketplace, including the name and sex they put on their Marketplace application, sex-specific recommended preventive services, and health insurance plans that have transgender exclusions.
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    U

    Urgent Care
    Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.
    Urgent Care Centers
    A non-hospital emergency center offering medical services by physicians, nurses and x-ray technicians to treat primarily injuries and illnesses that need immediate care but do not require an emergency room visit.
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    W

    Waiver of Premium
    A provision to continue life insurance coverage without premium payments if the insured becomes totally disabled.
    Well-baby and Well-child Visits
    Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.
    Wellness Programs
    A program intended to improve and promote health and fitness that's usually offered through the workplace, although insurance plans can offer them directly to their enrollees. The progam allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.
    Worker's Compensation
    An insurance plan that employers are required to have to cover employees who get sick or injured on the job.
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