The Health Insurance industry has become more and more complicated over the years. Our mission is to not only help you connect the dots, but to help you understand what the best option is for you. Explore our glossary below to learn more about some of the health insurance industry jargon and remember, ComPro is health insurance simplified.
Advance Premium Tax Credit (APTC)
A tax credit you can take in advance to lower your monthly health insurance premium. The APTC is reconciled on your federal tax return.
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).
The health care items or services covered under a health insurance plan.
Brand Name (Drugs)
A drug sold by a drug company under a specific name or trademark and that is protected by a patent
Bronze Health Plan
One of 4 plan categories (also known as “metal levels”) offered to individuals and families. Bronze plans are designed to pay 60% of covered medical expenses.
Catastrophic Health Plan
The plan with the lowest benefit levels offered to individuals. To qualify for a Catastrophic plan, you must be under 30 years old OR get a “hardship exemption” because the Marketplace determined that you’re unable to afford health 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.
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.
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.
A federal law that allows you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event.
The percentage of costs of a covered health care service you pay after you’ve paid your deductible. 80% / 20% means the insurance plan pays 80% and you pay 20%.
A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
Convenient Care Clinic
A healthcare clinic offering limited medical services that is located in a retail establishment. Example: a clinic found inside a grocery store.
A fixed amount (such as $20) you pay for a covered health care service. Copays are commonly offered for doctor visits and prescription drugs.
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 Reduction (CSR)
A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. If you qualify, you must enroll in a plan in the Silver category to get the extra savings.
Health insurance coverage that meets the requirements of the Affordable Care Act.
The amount you pay for covered health care services before your insurance plan starts to pay.
Benefits that help pay for the cost of visits to a dentist..
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).
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.
Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working.
Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”) that is determined by the total cost of your prescriptions year-to-date. You pay a higher percentage of the cost of prescriptions while in the “donut hole”.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. It is also referred to as a formulary
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Employer or Union Retiree Plans
Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families. These plans are offered to people through their (or a spouse’s) former employer or employee organization.
Essential Health Benefits
A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. pregnancy and childbirth, mental health services, and more.
Health care services that your health insurance or plan doesn’t pay for or cover.
Most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee.
Family and Medical Leave Act (FMLA)
A federal law that guarantees up to 12 weeks of job protected 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.
Federal Poverty Level (FPL)
A measure of income issued every year by the Department of Health and Human Services (HHS).
Federally Recognized Tribe
Any Indian or Alaska Native tribe, Alaska Native Claims Settlement Act (ANCSA) Corporation (regional or village), band, nation, pueblo, village, rancheria, or community that the Department of the Interior acknowledges to exist as an Indian tribe.
Fee For Service
A method in which doctors and other health care providers are paid for each service performed.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
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.
A prescription drug that has the same active-ingredient formula as a brand-name drug.
Gold Health Plan
One of 4 health plan categories (or “metal levels”) in the Health Insurance Marketplace. Gold plans are designed to pay 80% of covered medical expenses,
A short period — usually 90 days — after your monthly health insurance payment is due. If you haven’t made your payment, you may do so during the grace period and avoid losing your health coverage.
Grandfathered Health Plan
An individual health insurance policy purchased on or before March 23, 2010. They may not include some rights and protections provided under the Affordable Care Act.
Group Health Plan
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
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.
A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums.
Health care services that help you keep, learn, or improve skills and functioning for daily living.
Under the Affordable Care Act, most people must pay a fee if they don’t have health coverage that qualifies as “minimum essential coverage.” One exception is based on showing that a “hardship” prevented them from becoming insured.
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
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.
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.
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. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP).
High Deductible Health Plan (HDHP)
A plan with a higher deductible than a traditional insurance plan that does not provide “first dollar” benefits.
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
The Marketplace generally considers your household to be you, your spouse if you’re married, and your tax dependents.
The percent you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.
A fixed amount you pay for covered health care services to providers who contract with your health insurance or plan.
Individual Health Insurance Policy
Policies for individuals and families that aren’t connected to job-based coverage.
Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
IRMMA is an additional amount that you pay for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums if you are a person who has high annual earnings.
Large Group Health Plan
In general, a group health plan that covers employees of an employer that has 51 or more employees.
A cap on the total lifetime benefits you may get from your insurance company.
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living.
Shorthand for the “Health Insurance Marketplace,” a shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010.
A state based insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities.
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.
A federal health insurance program for people 65 and older and certain younger people with disabilities.
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; and usually includes Part D prescription drug benefits.
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.
Modified Adjusted Gross Income (MAGI)
The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children’s Health Insurance Program (CHIP). MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.
In general, a group health plan that’s sponsored jointly by 2 or more employers.
An individual or organization that’s trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2018 runs from Nov 1, 2017 to Dec 15, 2017.
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.
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.
Patient Protection and Affordable Care Act
The first part of the comprehensive health care reform law enacted on March 23, 2010.
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.
Platinum Health Plan
One of 4 categories (or “metal levels”) of Health Insurance Marketplace plans. Platinum plans are designed to pay 90% of eligible medical expenses.
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.
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts.
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.
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.
The amount you pay for your health insurance every month.
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.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Drugs and medications that, by law, require a prescription.
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
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.
Qualified Health Plan
An insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act.
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 annual open enrollment.
Quality Ratings (or ‘star’ ratings)
Ratings of health plan quality used in the Health Insurance Marketplace, shown as 1 to 5 stars on plan information pages.
A written order from your primary care doctor for you to see a specialist or get certain medical 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.
Rider (exclusionary rider)
A rider is an amendment to an insurance policy.
Second lowest cost Silver plan (SLCSP)
The second-lowest priced Marketplace health insurance plan in the Silver category that is used as the basis for determining the amount of Premium Tax Credit for which each person is eligible.
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.
A geographic area where a health insurance plan accepts members if it limits membership based on where people live
Silver Health Plan
One of 4 categories of Health Insurance Marketplace plans (sometimes called “metal levels”). Silver plans are designed to pay 70% of eligible medical expenses.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home.
Social Security Benefits
The amount you get from Social Security Disability, Retirement (including Railroad retirement), or Survivor’s Benefits each month.
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.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
State Health Insurance Assistance Program (SHIP)
A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare.
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.
Supplemental Security Income (SSI)
A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older.
The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return.
A health care program for active-duty and retired uniformed services members and their families.
UCR (Usual, Customary, and Reasonable)
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 medical service.
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.
A health benefit that at least partially covers vision care.
Waiting Period (Job-based coverage)
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
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.
A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees.
An insurance plan that employers are required to have to cover employees who get sick or injured on the job.
Zero cost sharing plan
A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is between 100% and 300% of the federal poverty level and qualify for premium tax credits.