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The health insurance terms you need to know

Health insurance is... pretty complicated. And every Open Enrollment Period, you probably come across something you’re not familiar with — whether it’s terms, coverage options, or even the difference between an HSA and FSA.

That’s why we put together this glossary — for all the head-scratching, super-confusing acronyms, health terms, and insurance speak — so you can enroll, switch, or search for healthcare plans confidently.

Class is in session! Keep reading to learn more.

Health insurance term glossary

Bronze health plan: One of four health plan categories which represent how you and your plan split the cost of your healthcare. Bronze plans have the lowest monthly premium and the highest costs when you need care. Bronze plan deductibles can be thousands of dollars. Keep this in mind as you budget!

Benefit year: The benefit year for health plans begins January 1 of each year and ends December 31 of the same year. (Excluding instances of mid-year qualifying life events.)

COBRA: Also known as the Consolidated Omnibus Budget Reconciliation Act, COBRA is a federal law that may allow you to temporarily keep health coverage after your employment ends, if you lose coverage as a dependent, or experience another qualifying event. If you elect COBRA, you pay 100% of the premiums — including the share your employer used to pay.

Claim: A request for payment that you submit to your health insurance plan when you get billed for items or services that you believe should be covered by insurance.

Coinsurance: After meeting your deductible, you still will have to pay a (smaller) portion of your medical bills — usually a percentage. For example, if you meet your deductible in June and your coinsurance is 20%, you only have to pay 20% of each medical bill that comes your way for the remainder of the calendar year, until you hit your MOOP.

Co-pay: This is the amount you owe each time you receive care. This can depend on the kind of care you’re getting, though — for example, a specialist visit might cost $60, while your visit to a general practitioner might only be $30. Typically, co-pays cannot be used to meet your deductible, but this varies. (Be sure to read the fine print on your plan to find out.)

Deductible: What you will pay for your healthcare needs before your health insurance plan begins to pay.

Dependent: A child or other individual for whom a parent, relative, or other person may claim for a tax deduction.

Dental coverage: Benefits that help pay for the cost of visits to a dentist for services like teeth cleaning, X-rays, and fillings. Most dental plans must be purchased in addition to a health insurance plan.

Drug list: A list of prescription drugs covered by an insurance plan offering prescription drug benefits. All Marketplace plans cover prescription drugs at varying levels.

Flexible Spending Account (FSA): A designated account set up through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Click here to learn about some of the most common IRS-qualified expenses. If money is left at the end of the year, your employer can offer one of two options, but not both: you get 2.5 more months to spend the money, or you can carry over up to $500 to spend the next plan year.

Fee for service: A way in which doctors and other healthcare providers are paid for each service (like tests and office visits) performed.

Generic drugs: Prescription drugs that have the same active ingredients as their brand-name counterparts, but for a lower cost.

Gold health plan: One of four health plan categories which represent how you and your plan split the cost of your healthcare. Gold plans have a high monthly premium and low costs when you need care. If you need routine, specialized care and can afford to pay more each month, this plan could be a great value.

Healthcare provider: A person or organization licensed to give care. For example, a doctor, nurse, or hospital.

Health Insurance Marketplace: A service that helps people shop for and enroll in health insurance through websites, call centers, and in-person help.

Hospice care: A special way of caring for people who are terminally ill, addressing the medical, physical, social, emotional, and spiritual needs of the patient. (And the patient’s family or caregiver.)

Hospitalization: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.

Health Maintenance Organization (HMO): With an HMO plan, you’ll typically see lower out-of-pocket expenses (like your monthly premium) but have less flexibility in your choice of doctors or hospitals. If you want coverage with an HMO plan, you must stay in-network, meaning the doctors that accept your HMO. However, an HMO does cover preventive services and some immunizations. If you’re young, healthy, and don’t have much of a provider preference, an HMO plan might be for you.

Health Savings Account (HSA): A designated account that lets you set aside money pre-tax to pay for qualified medical expenses. Click here to learn about some of the most common IRS-qualified expenses. You may only contribute to an HSA if you have a high-deductible health plan. HSA funds may roll over year to year if you don’t spend them, and funds may earn interest or other earnings (which are also not taxable).

High-deductible health plans (HDHPs) with HSA-eligibility: These plans are like a PPO plan, but with higher deductibles (meaning a lower monthly premium). Because you might have a higher deductible, those costs can be paid using a health savings account (HSA), which is a savings account that you can contribute to pre-tax and use on any qualifying medical expense — even prescription eyeglasses! Plus, your account balance rolls over each year, even if you don’t use it. If you prefer greater control over your costs and want to save money for medical expenses now and in the future, an HDHP is worth looking into.

Home health care: Healthcare services and supplies a doctor decides you may get in your home.

Hospital outpatient care: Care in a hospital that doesn’t require an overnight stay.

Household: You, your spouse (if you’re married), and your tax dependents (if applicable).

Inpatient care: Healthcare that you get when you’re admitted to a healthcare facility, like a hospital or skilled nursing facility.

Long-term care: Medical and non-medical care provided to people who are unable to perform daily living activities, like dressing or bathing. Long-term care can be provided at home, in the community, in assisted living, or in nursing homes.

Maximum out-of-pocket (MOOP): The most you’d have to pay each year for your healthcare needs. Once you’ve met your MOOP, your healthcare plan will pay for any covered services for the rest of the year.

Medicaid: A federal and state program that helps with medical costs for people with limited income and resources. Medicaid programs vary by state.

Medically necessary: Healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease, or symptoms.

Network: The facilities, providers, and suppliers your health plan has contracted with to provide healthcare services.

Open Enrollment Period: The annual period of time when people can enroll in or change their health insurance for the next calendar year. Open Enrollment dates vary by state — you can check your deadline here.

Out-of-pocket costs: Health costs that you must pay on your own, like deductibles, coinsurance, and co-pays.

Platinum health plan: One of four health plan categories which represent how you and your plan split the cost of your healthcare. Platinum plans have the highest monthly premium and lowest costs when you need care. Deductibles are very low for platinum plans.

Pre-existing conditions: A health problem (like diabetes, for example) you had before the date your new health coverage begins. Insurance companies cannot refuse to cover treatment for your pre-existing condition.

Preferred Provider Organization (PPO): A PPO plan encourages you to use a designated network of doctors and hospitals that are contracted with the insurance plan to offer negotiated or discounted rates to insurance members. Generally, you have an annual deductible you’ll have to meet before the insurance company begins covering your bills, and you’ll usually have to pay a copay for your services needed. If the flexibility of a large network of doctors is important to you, consider a PPO plan.

Premium: A set amount of money that you pay each month, once a quarter, or once per year to keep your insurance plan active.

Preventive services: Healthcare to prevent or detect illness at an early stage. For example, flu shots and mammograms.

Primary care provider: The doctor you see first for most health problems and who can refer you to specialists. For HMO plans, you must see your primary care provider before you see any other healthcare provider.

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 60-day Special Enrollment Period outside the annual Open Enrollment Period.

Referral: A written order from your primary care provider for you to see a specialist or receive certain medical services.

Rehabilitation services: Healthcare services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services.

Service area: A geographic area where your plan accepts members and (generally) where you can get routine services.

Silver health plan: One of four health plan categories which represent how you and your plan split the cost of your healthcare. Silver plans have a moderate monthly premium and moderate costs when you need care. You’ll pay slightly less than you would with a bronze plan, but care costs can still remain high (if you have a lot of health needs).

Special Enrollment Period: A 60-day enrollment period for when certain qualifying life events occur, like losing employer-covered insurance, or if you move out of your plan’s service area.

Specialist: A physician focused on a specific area of medicine to diagnose, manage, prevent, or treat certain symptoms or conditions.

Telemedicine: Medical or other healthcare services given to a patient through a computer, phone, or television by a practitioner in a location different than the patient’s.

Usual, customary, and reasonable (UCR): The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar service.

Vision coverage: Benefits that help pay for the cost of services like eye exams and eyeglasses. Most vision plans must be purchased in addition to a health insurance plan.


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Tags: Health, Health Insurance, Care

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