Glossary
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Adjusted Gross Income (AGI)
Adjusted Gross Income (AGI) is your total income from all sources minus certain deductions, as calculated on your federal tax return. AGI is the foundation for determining eligibility for subsidies like the Advance Premium Tax Credit (APTC) in the Health Insurance Marketplace. AGI is calculated by totaling wages, salaries, tips, rental and other incomes and deducting student loan interest, contributions to IRAs and HSAs and other expenses.
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Advance Premium Tax Credit (APTC)
The Advance Premium Tax Credit (APTC) is a subsidy that helps lower the cost of monthly health insurance premiums for people who purchase coverage through the Health Insurance Marketplace. It is designed to make insurance more affordable for individuals and families with low to moderate incomes. Only those not eligible for affordable employer-sponsored insurance, Medicaid, or another qualifying coverage can benefit. There are also income requirements. You can choose to apply the credit in advance, reducing your monthly premiums or claim it as a lump sum when you file your tax return.
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Affordable Care Act (ACA)
The Affordable Care Act (ACA), also known as Obamacare, is a U.S. law enacted in 2010 to make health insurance more accessible and affordable. It introduced key protections for consumers, expanded Medicaid in some states, and created an online Marketplace where individuals and families can compare and purchase health insurance plans. Coverage under the ACA can't be denied based on pre-existing conditions and all essential health benefits must be included in any plans.
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Allowed Amount
The allowed amount in health insurance refers to the maximum amount an insurance company will pay for a covered healthcare service. This is also known as the negotiated rate, eligible expenses, or payment allowance. These amounts may be different if the provider is in-network or out-of-network.
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Annual Enrollment Period
The Annual Enrollment Period (AEP) is the time period each year when people can sign up for, change, or renew their health insurance plans. These time periods vary depending on the type of insurance. Medicare currently runs from October 15 to December 7. For ACA plans, the open enrollment period usually runs from November 1 to January 15, but these dates may vary by state. Enrollment periods for employee plans are typically set by the employer.
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Annual Limit
An annual limit in health insurance refers to the maximum amount a health plan will pay for certain covered services within a single year. When the insured person reaches this limit, they may have to pay the remaining costs out of pocket. These limits may apply to specific benefits or to total spending. Most plans under the Affordable Care Act no longer have an annual limit on essential health benefits. Other types of plans may impose these limits.
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Appeal
An appeal in health insurance is a formal request you can make to your insurance company if they deny coverage for a medical service, treatment, or prescription drug that you believe should be covered. Appeals may be made directly to the insurance company or to a third party who is qualified to review the case.
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Auto Pay/ACH
Auto Pay (ACH) in health insurance refers to a payment method where your monthly insurance premiums are automatically deducted from your bank account. ACH stands for Automated Clearing House, which is an electronic funds transfer system used for automatic payments.
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Benefit Year
A benefit year in health insurance is the 12-month period during which your health plan’s coverage, costs, and benefits apply. For most plans, the benefit year is from January 1 to December 31. Medicare and some employer plans have have different benefit year dates. Your deductible, copayments, and out-of-pocket maximum reset at the start of each new benefit year.
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Billing Delinquency
Billing delinquency in health insurance refers to a situation where a policyholder has missed one or more premium payments, putting their coverage at risk of cancellation. There is usually a grace period (often 30 to 90 days) during which missed payments may be caught up, before the policy is terminated. Reinstatement may be allowed but this may require payment of all overdue premiums or applying newly for coverage.
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Catastrophic Health Plan
A Catastrophic Health Plan is a type of health insurance designed for healthy individuals or those who want to pay lower monthly premiums while having coverage for major medical emergencies. Deductibles are higher and some preventative services are fully covered.
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Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) is the U.S. government agency that manages major healthcare programs, including Medicare, Medicaid, and the Health Insurance Marketplace under the Affordable Care Act (ACA). This service helps low-income individuals and family acquire health insurance coverage and sets standards for healthcare quality in hospitals, nursing homes and other medical facilities.
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Children's Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP) is a government program that provides low-cost health insurance for children in families that earn too much money to qualify for Medicaid but cannot afford private health insurance. In some states, CHIP also covers pregnant women. Coverage normally includes doctor visits, vaccinations, prescriptions, dental and vision care, hospitalization and emergencies.
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Claim Hold
A claim held in health insurance happens when an insurance company temporarily delays processing a request for payment from your doctor or healthcare provider. This can occur due to missing information, billing errors, a missing pre-authorization or other problem.
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COBRA
COBRA is short for Consolidated Omnibus Budget Reconciliation Act, a law that allows employees and their families to keep their health insurance for a limited time after losing their job or experiencing a divorce or other cause for losing health insurance. The insured person must cover the full cost of the insurance. Coverage typically lasts 18 months but, in some cases, can be extended to 36 months.
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Coinsurance
Coinsurance is the percentage of a medical bill that you must pay after you’ve met your deductible (the amount you pay out of pocket before insurance starts covering costs). For example, if your health plan has 80/20 coinsurance, the insurance company pays 80%, and you pay 20% of the covered medical costs. Coinsurance is different from a copay.
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Copayment
A copayment (copay) is a fixed amount you pay for certain medical services or prescriptions when you have health insurance. For a regular doctor's visit, you might pay $30 or $50 for a specialist visit.
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Cost Sharing
Cost sharing refers to the portion of healthcare expenses that are not covered by your insurance, that you pay out of pocket. This portion includes deductibles, copays and coinsurance. Cost sharing helps keep insurance premiums lower. Many plans have an out-of-pocket maximum which limits how much you have to pay in a year.
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Cost Sharing Reduction (CSR)
A Cost-Sharing Reduction (CSR) is financial help that lowers out-of-pocket costs for health insurance, such as deductibles, copayments, and coinsurance. This help is available only to people who enroll in a Silver plan through the Health Insurance Marketplace and have a household income between 100% and 250% of the Federal Poverty Level (FPL).
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Deductible
A deductible is the amount of money you must pay out of pocket for medical expenses before your health insurance starts sharing the costs. If your plan has a $1,500 deductible, you must pay $1,500 for covered medical services before your insurance starts paying. After meeting your deductible, you may still have copayments and coinsurance costs. Some services such as annual checkups, screenings and vaccines may be covered before you meet your deductible.
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Eligibility Requirements
Eligibility requirements refer to the rules that determine who can enroll in a specific health plan. The requirements vary based on the type of insurance, for example, employer-provided health insurance, coverage through the Affordable Care Act, Medicaid or Medicare or the Children’s Health Insurance Program (CHIP).
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Eligible Immigration Status
Eligible Immigration Status refers to the types of immigration statuses that allow non-U.S. citizens to qualify for government-sponsored health insurance programs, such as Medicare, Medicaid, and ACA Marketplace plans. Those who may be eligible include lawful permanent residents, refugees granted protection in the U.S., and holders of work visas, among others.
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Emergency Services
Emergency services refer to urgent medical care that is needed right away to prevent serious harm or death. These services are covered by most health insurance plans, even if you go to an out-of-network hospital. This would include severe injuries, heart attacks, breathing problems, loss of consciousness, drug overdoses and more. No pre-approval is required.
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Essential Health Benefits
Essential Health Benefits (EHBs) are the types of medical services that all health insurance plans sold through the Health Insurance Marketplace (Obamacare) and many other plans must cover. These include outpatient care, emergency services, hospitalization, maternity care, mental health and substance use disorder care, lab tests, wellness care and more.
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Generic Drugs
Generic drugs are lower-cost versions of brand-name medications that have the same active ingredients, dosage, safety, and effectiveness as the original drug. The U.S. Food and Drug Administration ensures that generic drugs are just as effective as brand-name medications.
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Grace Period
A grace period is the extra time you have to pay your premium after the due date without losing your coverage. This extension prevents your insurance from being canceled immediately if you miss a payment. Most plans have a 30-day grace period but subsidized Affordable Care Act plans may provide a 90-day grace period in some situations.
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Guaranteed Issue
Guaranteed issue means that a health insurance company must offer you a policy regardless of your health condition, age, gender, or other factors that might have been used in the past to deny coverage. Before the Affordable Care Act, insurance companies could refuse to cover people with pre-existing conditions or charge them much higher prices. Under the ACA, all major medical insurance plans for individuals and small businesses must be “guaranteed issue.”
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Health Coverage
Health coverage is a contract between you and a health insurance company that helps pay for medical expenses. With health coverage, your insurance company agrees to pay part of the cost for doctor visits, hospital stays, prescription drugs, and other health services. Coverage can come from an employer, an individual plan or a government program like Medicare or Medicaid.
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Health Insurance
Health insurance is a type of insurance that helps pay for medical expenses. Typically, you pay a premium to keep your coverage active and pay part of the costs when you receive care, such as a deductible or copays. Depending on your plan, your insurance may cover surgeries, medications and hospital stays. It can come from your employer, the government or private insurance companies.
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Health Insurance Marketplace
The Health Insurance Marketplace is a government-run website where people can shop for, compare and buy health insurance plans. It was created under the Affordable Care Act to help people obtain coverage, especially if they don’t get insurance through a job. Through the Marketplace, you may qualify for subsidies called premium tax credits to lower your cost.
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Health Maintenance Organization (HMO)
A Health Maintenance Organization or HMO is a type of health insurance plan that lowers costs but requires you to receive care from a specific set of providers in the HMO’s network, except in emergencies and requires referrals to see specialists. There is no coverage for out-of-network care.
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Health Reimbursement Arrangement (HRA)
A Health Reimbursement Arrangement (HRA) is a type of employer-funded account that helps employees pay for medical expenses. The employer puts money into the HRA, and employees use it to cover eligible healthcare costs like doctor visits, prescriptions, and sometimes health insurance premiums. In some cases, individuals can use these funds to purchase health insurance ideally suited to them.
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Health Savings Account (HSA)
A Health Savings Account (HSA) lets you set aside money tax-free to pay for medical expenses. It’s available only to those with high-deductible health plans. Both the funds you put in and the withdrawals are tax free but must be used for approved healthcare costs.
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High Deductible Health Plan (HDHP)
A High Deductible Health Plan (HDHP) has a higher deductible than traditional plans, but lower monthly premiums. Most HDHPs cover certain preventative services before the deductible is met. It’s suitable for people who want lower premiums, who rarely visit the doctor or who want to use Health Savings Accounts to pay for medical expenses.
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Household
Household refers to the group of people who are counted together when applying for health insurance coverage and determining eligibility for financial assistance, like premium tax credits or Medicaid. The household would include the individual applying for insurance, their spouse and dependents (children or others claimed on a tax return).
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In-Network Coinsurance
In-Network Coinsurance is the percentage of medical costs you are responsible for paying when you receive care from doctors, hospitals, or other providers that are part of your insurance plan's network. When you visit an in-network provider, your insurance company covers most of the cost, but you still have to pay the remainder. That remainder is your coinsurance.
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In-Network Copayment
An In-Network Copayment (copay) is a fixed amount you pay for a specific healthcare service when you visit a provider that is in your insurance plan’s network. When you visit an in-network provider (a doctor, clinic, hospital, etc.), you pay a set fee for certain services, like a doctor’s visit, prescription medications, or emergency care. While the amount varies, for a typical visit to your primary care doctor, you might pay $20 or $30.
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Marketplace
The Marketplace (also called the Health Insurance Marketplace) is a government-run website created by the Affordable Care Act where individuals, families, and small businesses can shop for, compare and buy health insurance. Individuals not eligible for employer-provided insurance or a government program like Medicaid or Medicare can find coverage here, even if they have pre-existing conditions. Financial help may be available to some people, depending on their income.
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Medicaid
Medicaid is a government program that provides health insurance to people with low income and limited resources. Individuals who are pregnant, elderly or disabled may also qualify. It is jointly funded by the federal government and state governments, so the specific rules and eligibility requirements can vary from state to state. For those who qualify, it helps cover the cost of doctor visits, hospital stays, prescriptions and some other services.
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Medical Underwriting
Medical underwriting is the process used by insurance companies to evaluate a person's health when they apply for a health insurance plan and calculate the risk of insuring that person. The insurer looks at your medical history, current health status, and any pre-existing conditions to determine whether they will provide coverage and how much it will cost.
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Medically Necessary
Medically necessary refers to treatments, services, or supplies required to diagnose, treat, or prevent a medical condition, and which are considered essential for your health and well-being. Treatments or services are typically only covered by health insurance if they are deemed medically necessary by the insurer. Some treatments or services may require prior authorization from the insurer before they are covered.
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Medicare
Medicare is a federal health insurance program primarily for people who are 65 or older, but which also covers some younger people with disabilities or certain medical conditions like end-stage renal disease or Lou Gehrig’s disease (ALS). Available under Medicare are hospital insurance, general medical insurance, prescription drug coverage and an alternative version of Medicare offered by private insurance companies.
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Medicare Annual Enrollment Period
The Medicare Annual Enrollment Period (AEP) is a period during which you can make changes to your Medicare coverage. You can switch from original Medicare to a Medicare Advantage Plan or vice versa, medical underwriting may apply for Medicare Supplements. This period runs from October 15 to December 7 each year.
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Medicare Part B Premium
The Medicare Part B Premium is the monthly fee that you must pay to have Medicare Part B coverage, which helps pay for outpatient services like doctor visits, lab tests, and preventive care. Those with higher incomes in prior years may have to pay a higher amount. Most people have this premium deducted from their Social Security benefits.
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Medicare Part C (Medicare Advantage Plan)
Medicare Part C, also known as a Medicare Advantage Plan, is an alternative to Original Medicare (Parts A and B). It’s offered by private insurance companies approved by Medicare and provides all the benefits of Part A (hospital insurance) and Part B (medical insurance). Some plans also include additional benefits that Original Medicare doesn’t cover, like vision, dental, and hearing services.
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Medicare Part D (Drug Plan)
Medicare Part D is a prescription drug plan that helps cover the cost of prescription medications. It is offered by private insurance companies approved by Medicare, and it works alongside Medicare Parts A and B or certain Medicare Advantage Plan that does not already include drug coverage. You must pay a monthly premium for Part D and if you don’t have coverage that is as good as Medicare’s, you may face a late enrollment penalty if you decide to join later.
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Minimum Essential Coverage (MEC)
Minimum Essential Coverage (MEC) is health insurance that meets the requirements set by the Affordable Care Act (ACA). This type of plan covers a basic set of health services and benefits including preventative care, hospital stays, emergency services, maternity, prescriptions, lab tests and more. MEC can be provided by employers, Medicare, Medicaid, ACA plans or other government programs.
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Modified Adjusted Gross Income (MAGI)
Modified Adjusted Gross Income (MAGI) is a measure of your income used to determine eligibility for certain government benefits, including healthcare programs like Medicaid and subsidies for health insurance through the Health Insurance Marketplace. It is a modified version of your Adjusted Gross Income (AGI), which is your income after deductions like retirement plan contributions, student loan interest, etc. Certain types of income may be added back into your AGI, like tax-exempt interest, to come up with your MAGI.
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Network
A network refers to the group of doctors, hospitals, and other healthcare providers that have agreed to provide services to people covered by a specific health insurance plan at negotiated rates. A higher portion of the cost of these services will usually be covered compared to services by out-of-network providers. Types of networks include Health Maintenance Organizations, Preferred Provider Organizations and Exclusive Provider Organizations.
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Network Plan
A network plan is a type of health insurance plan that uses a specific group of healthcare providers that have agreements with the insurance company to provide services at reduced rates. The network defines the providers you can visit for your care and can include doctors, hospitals and other medical facilities. Within this network, you generally pay less for your care. With some plans, you will need a referral from a primary care doctor to see a specialist.
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Open Enrollment Period
The Open Enrollment Period (OEP) is a specific time during the year when individuals can sign up for, change, or update their health insurance plans without needing a special reason or event (like a job change or marriage). It’s an important window for both private health insurance plans (through the Health Insurance Marketplace) and Medicare. Missing this period may mean that a person must wait until the next OEP to make a change.
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Original Medicare
Original Medicare is a federal health insurance program for people age 65 and older as well as certain younger individuals with disabilities or specific health conditions. It is the traditional Medicare coverage offered directly by the U.S. government and consists of hospital insurance (Part A) and medical insurance (Part B). When covered by Medicare, certain costs such as deductibles, copayments, and coinsurance must still be paid by the insured person.
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Out-Of-Network Coinsurance
Out-of-Network Coinsurance refers to the percentage of costs you pay for healthcare services when you receive care from a provider who is not on your health insurance plan's network. That means that the provider has not entered into an agreement with your insurance company to offer services at discounted rates, so your coinsurance costs will typically be higher with this provider.
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Out-Of-Network Copayment
Out-of-Network Copayment is a fixed amount that you pay for a healthcare service when you visit a provider who is not in your health insurance plan's network. This payment is typically made at the time you receive the service. For an out-of-network provider, you may need to pay a higher copay than with an in-network provider.
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Out-Of-Pocket Costs
Out-of-pocket costs are all the expenses you pay for healthcare services that aren't covered by your health insurance plan. These costs can include copayments, coinsurance, and deductibles, as well as other charges. Many insurance plans have an out-of-pocket maximum, which is the maximum amount you will have to pay for covered services in a policy period. Once you reach this limit, your insurance will cover 100% of the costs for covered services for the rest of the period.
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Out-Of-Pocket Maximum/Limit
The Out-of-Pocket Maximum (or Limit) is the most you will have to pay for covered health care services in a plan year. Once you reach this limit, your insurance plan will pay 100% of the costs for any additional covered services for the remainder of the year. Out-of-pocket costs include your deductible, copayments, and coinsurance for covered services but does not include your premiums or out-of-network care.
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Plan ID
A Plan ID is a unique identifier assigned to a specific health insurance plan that helps to differentiate one health insurance plan from another, even from the same insurer. This number typically appears on your health insurance card and helps healthcare providers verify your coverage. It is not the same as your Member ID.
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Plan Year
A Plan Year refers to the 12-month period during which your health insurance plan provides coverage. It typically runs for a full calendar year, but it may start and end on different dates depending on your plan or employer. Your benefits, coverage limits, deductibles, copayments, and out-of-pocket maximums reset at the beginning of each new plan year.
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Pre-Existing Condition
A pre-existing condition is any health condition or illness that you had before enrolling in a new health insurance plan. This could include conditions like high blood pressure, diabetes, asthma, cancer, arthritis, heart disease. Before the Affordable Care Act, insurance companies could deny coverage, exclude care for these conditions, or charge higher premiums. Some insurance plans require a waiting period before pre-existing conditions are covered.
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Preauthorization
Preauthorization (also known as prior authorization) is a process where your health insurance company requires you or your healthcare provider to get approval before a specific medical service, treatment, or prescription is covered under your plan. Your healthcare provider will submit a request to your insurance company before care is provided and receive an approval or denial from the company. If it is denied, you can pay for the care yourself, try alternative treatments or appeal the decision.
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Premium Tax Credit
A premium tax credit is a subsidy offered by the federal government to help lower-income individuals and families pay for their health insurance premiums when purchasing coverage through the Health Insurance Marketplace. If your income falls within the eligible range, you’ll receive a monthly reduction in your health insurance premium, which is directly applied to the cost of your plan. You must not be eligible for other affordable health insurance such as through your job or Medicaid.
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Prescription Drug Coverage
Prescription drug coverage is health insurance that helps pay for the cost of prescription medications. It may be a part of a broader health insurance plan or may be a separate policy specifically for medications. This coverage helps reduce the out-of-pocket expenses for prescriptions. Medicare Part C, Marketplace plans and employer-sponsored plans often include prescription drug coverage. Medicare Part D is a standalone prescription drug plan.
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Preventive Services
Preventive services are healthcare services aimed at preventing illnesses or health problems before they happen. These services help identify health risks early, promote healthier lifestyles, and can even prevent certain diseases from developing. They include well-baby and well-woman visits, immunizations and diabetes, cholesterol and blood pressure checks. Under the Affordable Care Act, many of these services are covered at no cost to you.
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Primary Care
Primary care refers to the basic healthcare services provided by a primary care provider (PCP) who is usually the first point of contact when you need medical care. It involves general healthcare management and ongoing care of your overall health, including preventive services, diagnosis, treatment of common illnesses, and management of chronic conditions. If you need specialized care, your PCP often refers you to specialists within your insurance network.
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Primary Care Physician
A Primary Care Physician (PCP) is a doctor who provides general medical care and is typically the first healthcare provider you see for most of your medical needs. The PCP is responsible for managing your overall health, offering preventive care, diagnosing and treating illnesses, and referring you to specialists when necessary. PCPs may be family medicine doctors, internists, pediatricians or geriatricians (doctors focusing on the health of elderly patients).
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Primary Care Provider
A Primary Care Provider (PCP) is a healthcare professional who provides general healthcare services, focusing on the overall health of patients. The PCP is often the first person you see for routine care, minor health issues, preventive services, and ongoing management of health conditions. The term "PCP" can refer to a variety of healthcare professionals, including doctors, nurse practitioners (NPs), and physician assistants (PAs).
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Prior Authorization
Prior authorization (also known as preauthorization) is a process where your health insurance company requires you or your healthcare provider to get approval before a specific medical service, treatment, or prescription is covered under your plan. Your healthcare provider will submit a request to your insurance company before care is provided and receive an approval or denial from the company. If it is denied, you can pay for the care yourself, try alternative treatments or appeal the decision.
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Qualifying Health Coverage
Qualifying Health Coverage refers to a health insurance plan that meets certain minimum standards set by the government. If you have qualifying health coverage, you are considered to have sufficient health insurance. You would not have had to pay a penalty for being uninsured or underinsured in the years leading up to 2019 when this penalty ended. Employer-sponsored group insurance, policies obtained through the Marketplace, Medicare, TRICARE and other plans fall into this category.
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Qualifying Life Event (QLE)
A Qualifying Life Event (QLE) is a major life change that allows you to make changes to your health insurance outside of the Open Enrollment Period. If you experience a QLE, you become eligible for a Special Enrollment Period (SEP), which typically lasts 60 days from the date of the event. Events such as divorce or death of the insured person, changing residence, having a baby or gaining U.S. citizenship qualify you for an SEP but there are many additional qualifying events.
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Referral
A referral is a written order from your primary care provider (PCP) that allows you to see a specialist or get certain medical services. Some health plans, especially Health Maintenance Organizations (HMOs), require a referral before they will cover specialist visits or advanced medical care. In PPOs, referrals are not required. To obtain a referral, see your PCP.
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Report a Life Change
Report a Life Change refers to the process of notifying your health insurance provider or the Health Insurance Marketplace about major changes in your life that could affect your coverage or financial assistance. If you experience a Qualifying Life Event (QLE) such as getting married, having a baby, changing your residence, or losing other health coverage (see the definition of Qualifying Life Event in this glossary for more) you must report the change within 30 to 60 days (depending on the type of change) to update your insurance plan or eligibility.
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Second Lowest Cost Silver Plan (SLCSP)
The Second Lowest Cost Silver Plan (SLCSP) provides a formula for the government to decide the amount of premium tax credits (subsidies) you qualify for when purchasing health insurance through the Health Insurance Marketplace (also known as the Affordable Care Act). Silver plans offer a middle-ground option with moderate monthly premiums and moderate out-of-pocket costs (like deductibles, copays, and coinsurance). The Second Lowest Cost is just that—the second cheapest plan of this type that is available in your area. The Marketplace calculations compare your expected contribution (based on your income) to the cost of this SLCSP. The amount over what your income would allow you to affordably pay is your premium tax credit or subsidy.
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Self-Employment Income
Self-Employment Income is the money you earn from working for yourself instead of being an employee of a company. If you operate a business, work as a freelancer, or do independent contract work, the money you make is considered self-employment income. This income must be reported to determine your eligibility for premium tax credits (subsidies) when obtaining health insurance through the Marketplace, eligibility for Medicaid or CHIP, or other savings.
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Self-Insured Plan
A self-insured plan, also called a self-funded health plan, is a type of health insurance where an employer pays for employees' healthcare costs directly, rather than buying a traditional insurance policy. The employer sets aside money to cover medical expenses for employees and pays for claims as they happen. Many self-insured employers hire a third-party administrator (TPA) to handle claims and provider networks, but the employer still covers the costs. Large employers, some small businesses, governments, school districts and unions may choose this plan.
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Service Area
A service area is the geographic region where a health insurance plan has its network of medical providers and where it covers medical services. Except for emergencies, HMOs and Medicare Advantage plans require you to get care in your service area.
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Silver Health Plan
A Silver Health Plan is one of the four levels of insurance in the Health Insurance Marketplace (Bronze, Silver, Gold, and Platinum). Each level indicates how costs are shared between you and the insurance company. Bronze, for example, has the lowest premium but highest out-of-pocket costs. Silver offers a balance of premium and out-of-pocket costs.
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Social Security Benefits
Social Security benefits are payments provided by the U.S. government to people who qualify, primarily through the Social Security Administration (SSA). These benefits are designed to provide financial support to individuals and families who experience certain life events, such as retirement, disability, or the death of a breadwinner. Benefits start as early as age 62, but the full retirement age is between 66 and 67, depending on the year you were born. Monthly payments are based on how much you earned during your working life.
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Special Enrollment Period (SEP)
A Special Enrollment Period (SEP) is a time when you can enroll in or make changes to your health insurance plan outside the regular Open Enrollment Period. SEPs are available under specific circumstances that qualify as major life events, such as marriage, divorce, having a baby, or moving to a new area. Typically, you have 30 to 60 days from the qualifying event to enroll in a health plan or make changes.
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Specialist
A specialist is a medical doctor or healthcare provider who has advanced training and expertise in a specific area of medicine or healthcare. Specialists focus on diagnosing, treating, and managing particular health conditions or diseases that require more in-depth knowledge than what a primary care physician typically possesses. Specialists include cardiologists, oncologists, pediatricians and dermatologists. In an HMO, it is generally necessary to get a referral from your Primary Care Physician before seeing a specialist.
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State Continuation Coverage with COBRA
State Continuation Coverage with COBRA is a way for individuals to continue their health insurance coverage after they lose their job or experience a change in employment status. This coverage is offered under two separate systems: The COBRA (Consolidated Omnibus Budget Reconciliation Act) or state continuation (also called mini-COBRA). By paying the full price of the premium, a former employee can retain their insurance for 18 to 36 months, depending on the situation. The length of coverage may be shorter under mini-COBRA.
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Summary of Benefits and Coverage (SBC)
The Summary of Benefits and Coverage (SBC) is a standardized, easy-to-read document that provides essential information about a health insurance plan. It’s designed to help individuals understand their coverage options so they can make informed decisions when choosing a health plan. It explains what services the plan covers, such as hospital visits, doctor's office visits, prescription drugs, preventive services, and emergency care. It also outlines cost-sharing details, like your deductible, copayments, and coinsurance. This document is available for individual and family plans as well as group employer health plans.
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Supplement
A supplement refers to a supplemental insurance plan, an additional type of coverage you can add along with your primary health insurance plan. It helps cover costs that the primary plan may not fully pay for, reducing out-of-pocket expenses for the policyholder. Supplemental policies include ones that cover copays, deductibles and coinsurance, medical expenses while traveling, dental, vision, critical illness, or accidents. Some people want these supplemental plans to provide more peace of mind.
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Tax Household
A tax household refers to a group of people who are considered together for tax purposes when filing a tax return. The household tax is important because the income of the household determines your eligibility for Medicaid, CHIP or certain types of financial assistance, like premium tax credits (subsidies) for health insurance coverage purchased through the Health Insurance Marketplace.
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Urgent Care
Urgent care refers to medical care for conditions that are not life-threatening but still require prompt attention. It’s a step between emergency care (for severe, life-threatening conditions) and regular doctor visits. Urgent care centers are designed to handle health issues that need quick treatment but don't necessarily require a visit to the emergency room. Most major medical plans, including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO) plans, include urgent care as a covered benefit.
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Waiting Period (Job Based Coverage)
A waiting period in job-based health coverage refers to the time between when you start a new job and when you're eligible to begin receiving health insurance benefits through your employer. Waiting periods for health insurance coverage are often 30, 60, or 90 days but can vary depending on the employer’s policy. Some employers may offer health insurance coverage as soon as you start your job.
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Well-Baby and Well-Child Visits
Well-Baby and Well-Child Visits are routine check-ups and health exams for infants, toddlers, and children that focus on preventing illness, monitoring growth and development, and ensuring they are reaching important milestones. These visits are typically covered by most health insurance plans, including those obtained under the Affordable Care Act (ACA), with no out-of-pocket costs for parents when using in-network providers. Well-baby visits extend through the first birthday and well-child visits continue until adolescence.
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Zero Cost Sharing Plan
A Zero Cost Sharing Plan is a type of health insurance plan where the insured individual doesn't have to pay any out-of-pocket costs for covered healthcare services. This means that the plan covers 100% of the costs for doctor visits, hospital stays, prescriptions, and preventive services, with no copayments, coinsurance, or deductibles required from the insured. These plans are often available through government programs like Medicaid, or as a result of special programs or subsidies, such as those offered under the Affordable Care Act (ACA) for low-income individuals and families.