Simplifying health plan terms
Get clear answers so it’s easier to make decisions.
Working with health insurance can be confusing. At times, you might feel like there’s a whole new language to learn. To make it easier, here’s a list of common terms and what they mean.
Affordable Care Act (ACA):
A health insurance reform law aimed at expanding health insurance coverage for people living in the U.S.
Benefit:
A service, drug or item that your health insurance plan covers. Benefits may include office visits, lab tests and procedures.
Claim:
A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.
COBRA:
A federal law that requires group health plans to give continued health insurance coverage to certain employees and their dependents whose group coverage has ended.
Coinsurance:
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
Coordination of Benefits (COB):
A process of figuring out which of two or more insurance policies has the main responsibility of processing or paying a claim and how much the other policies will contribute.
Copayment/Copay:
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Cost Sharing:
The general term that refers to the share of costs for services covered by a plan or health insurance that you must pay out of your own pocket (sometimes called out-of-pocket costs).
Deductible:
The amount you could owe during a coverage period (usually one year) for health care services your health insurance or plan covers before your health insurance or plan begins to pay.
Effective Date:
The date your insurance plan starts covering you.
Essential Health Benefits (EHB):
A set of 10 categories of services that most health insurance plans must cover under the ACA.
These include:
- Ambulatory (outpatient) care
- Emergency services (including emergency room care)
- Hospitalization
- Maternity and newborn care
- Mental health services and addiction treatment
- Prescription drugs
- Rehabilitation services
- Laboratory services
- Preventive care, wellness services, and chronic disease treatment
- Pediatric services (care for infants and children)
Evidence of Coverage (EOC):
A document from your insurance company that describes what your health plan covers. It also may give information about your deductibles, copayments, and the kinds of services or products your plan does not cover.
Explanation of Benefits (EOB):
A list that you get after you've received a medical service, drug or item. This list tells you the full price of the service, drug or item that you received. It also tells you how much you may need to pay for it.
Formulary also known as a Prescription Drug List:
A list of drugs your health insurance or plan covers. A formulary may include how much you pay for each drug.
Health Insurance Marketplace (Exchange):
A resource where individuals, families, and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage.
Network:
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Open Enrollment Period:
The time when you can choose to enroll in a health plan or re-enroll in a health plan you are already in.
Out-of-pocket Maximum:
The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover.
Pre-existing Condition:
A health condition that exists before the date that new health coverage starts.
Premium:
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Premium Tax Credits:
Financial help that lowers your taxes to help you and your family pay for private health insurance.
Preventive Care:
Routine health care, including screenings, check-ups, and patient counseling to prevent or discover illness, disease, or other health problems.
Primary Care Provider (PCP):
A physician, including an M.D. (medical doctor) or D.O. (doctor of osteopathic medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law and the terms of the plan who provides, coordinates or helps you access a range of health care services.
Qualifying Life Event:
A major life change that allows you to make changes to your health plan. Some major changes include marriage, turning 26, divorce, the birth of a child or the loss of a job.
Referral:
A written order from your primary care provider for you to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you may need to get a referral before you can get health care services from anyone except your primary care provider. If you don't get a referral first, the plan or health insurance may not pay for the services.
Renewal:
When a covered person chooses to continue coverage under his or her current health insurance plan. Renewal usually occurs once a year.
Special Election Period:
A period of time where you can sign up for a health insurance plan outside of the normal time frame.
Specialist:
A physician specialist focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
Summary of Benefits and Coverage (SBC):
A document that lists the plan's benefits.
Urgent Care:
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.