Health Insurance and Care Terms

ACA (Affordable Care Act)

Federal law passed in 2010 to make health care coverage available to more people, expand Medicaid, and reduce health care costs

ADLs (Activities of Daily Living)

Routine activities that people tend to do every day without needing assistance, including eating, bathing, dressing, toileting, transferring (walking), and continence

Advanced Directive

Legal documents that allow you to spell out your decisions about end-of-life care ahead of time, giving a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on

Annual Limit

The maximum amount a health insurance plan will pay for covered healthcare services in a plan year

Appeal

A request for your health insurer or plan to review and reconsider a decision that denies a benefit or payment

Balance Billing

When a provider bills you for the difference between the provider's charge and the allowed amount. This can happen if you see an out-of-network provider

Beneficiary

A person who is eligible to receive benefits from a health insurance plan or policy

Catastrophic Coverage

A type of health insurance designed to protect an individual from significant medical expenses due to serious illness or injury. It typically features low monthly premiums and a very high deductible, meaning it covers extremely high costs but only after the insured has paid a substantial amount out-of-pocket

Charity Care

Free or reduced-cost medical care provided to patients who are unable to pay for their treatment due to financial hardship

CHIP (Children's Health Insurance Program)

Program that provides low-cost health coverage to children in families that earn too much to qualify for Medicaid

Claim

A request for payment that you or your health care provider submits to your health insurer when you receive items or services you believe are covered

Coinsurance

The percentage of costs of a covered service that the insured pays, after reaching the deductible

Conservatorship

A legal status where a court appoints a person or organization to manage the financial affairs and/or daily life of another adult who is deemed unable to manage their own affairs due to physical or mental limitations

Copayment

A fixed amount the consumer pays for a covered health care service

Deductible

The amount the consumer owes for covered health care services before their health insurance plan begins to pay

DNR (Do Not Resuscitate)

A legal order to not perform CPR or advanced cardiac life support if a patient's breathing or heartbeat stops

Durable Medical Equipment

Equipment and supplies ordered by a health care provider for everyday or extended use, including walkers, wheelchairs, and hospital beds

Employer-based insurance

Insurance provided by an employer to employees and their dependents, with costs often shared between employer and employee; also called group health insurance

Enrollment Periods

Specific times when you can sign up for Medicare or make changes to your coverage. This includes the Initial Enrollment Period, General Enrollment Period, and Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage

EOB (Explanation of Benefits)

A statement from your health insurance company explaining what medical treatments and/or services were paid for on your behalf, the amount billed, the payment amount covered, and what you may owe the provider

Fee-For-Service Plan

Health insurance payment plan that pays healthcare providers for each service performed

FSA (Flexible Spending Account)

A special tax-deferred savings account consumers use to save money to pay certain health care expenses

HDHP (High Deductible Health Plan)

A health insurance plan with lower monthly premiums and higher deductibles than traditional insurance plans

Health Care Power of Attorney

Specifically allows a person to make medical and health care decisions on behalf of another person if they become unable to make these decisions themselves

Health Insurance Marketplace

A web-based platform where individuals, families and small employers can shop for, and enroll in, private health insurance

HMO (Health Maintenance Organization)

A type of health insurance where medical services are covered in part or fully when the insured uses services that are delivered by providers who are part of the network. Care delivered by providers not in network is generally not covered by this insurance

Home Health Care

Health care services that can be provided in a patient's home for an illness or injury

Hospice

Care focused on providing comfort and support to terminally ill patients and their families, emphasizing pain relief and emotional support rather than curative treatments

HSA (Health Savings Account)

A savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. HSAs are often paired with high-deductible health plans

In-Network Provider

A healthcare provider who has a contract with your health insurance plan to provide services to you at a discount

Individual Mandate

A requirement in some states that all individuals must have health insurance

Insured

A person covered by an insurance policy

Lifetime Limit

The maximum amount a health insurance plan will pay for covered healthcare services during a person's lifetime

Long-Term Care

Services that include medical and non-medical care for people with chronic illnesses or disabilities

Medicaid

A joint federal and state program that provides healthcare coverage for individuals with limited income and resources. Eligibility varies by state

Medicare

The federal health insurance program for people 65 or older, and others with certain disabilities

Medicare Plan Finder

An online tool at Medicare.gov that allows you to find health and drug plans based on your specific needs

Medigap (Medical Supplement Insurance)

Private insurance plans that supplement Medicare

Open Enrollment

The period during which a health care plan or insurer accepts new applicants

Out-of-Network Provider

A healthcare provider who does not have a contract with your health insurance plan. Using an out-of-network provider usually requires you to pay a higher portion of the cost of care

Out-of-Pocket

The expenses for medical care that aren't reimbursed by insurance. This includes deductibles, copayments, and coinsurance, representing the amount you pay directly for services covered by your plan, excluding premiums

Outpatient Care

Medical services provided to patients who do not require hospitalization or admission to a healthcare facility

Palliative Care

Specialized medical care for people living with serious illnesses, focusing on providing relief from symptoms and stress

Part A

Type of Medicare that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. (Hospital Insurance)

Part B

Type of Medicare that covers certain doctors' services, outpatient care, medical supplies, and preventive services. (Medical Insurance)

Part C

A type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage Plans offer prescription drug coverage. (Medicare Advantage Plans)

Part D

Adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. (Prescription Drug Coverage)

PCP (Primary Care Provider)

A healthcare professional who serves as a patient's main healthcare provider

Policy coverage

A contract between a policyholder and an insurer that details the terms and conditions of coverage

Power of Attorney

A legal document that grants an individual the authority to manage the financial affairs and property of another person

PPO (Preferred Provider Organization)

A type of health insurance where care delivered by providers who are part of the network has a lower co-pay than care delivered by a provider who is not part of the network. Unlike an HMO, in a PPO services provided out-of-network will generally be paid for by insurance, but the consumer will pay more of the cost of care when the provider is not in the network

Pre-existing Condition

A medical issue or condition a patient has sought medical treatment for before enrollment in a new health insurance plan

Preauthorization

A decision by your health insurer or plan that a prescription, procedure, service, or equipment is medically necessary. Sometimes preauthorization is required for certain services before you receive them, except in an emergency

Premium

An amount paid to have an insurance policy

Preventative Services

Medical services aimed at disease prevention and early detection to maintain health, such as vaccinations and health screenings

Private insurance

Insurance offered by a company and not the government

Respite Care

Temporary relief for caregivers, offering them a break

Secondary Care

Specialist care that is typically accessed through a referral from a primary care provider

Skilled Nursing

A high level of medical care provided by trained individuals, such as registered nurses, under the supervision of a physician

Special Enrollment Period

A time outside the regular enrollment periods when you can sign up for or make changes to your health insurance plan due to certain life events, such as moving, losing other health coverage, getting married, or having a baby

SHIP (State Health Insurance Assistance Program)

A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare

Subsidy

Financial assistance offered by the government to help lower the cost of health insurance premiums

Tertiary Care

Highly specialized medical care, usually on referral from primary or secondary medical care personnel

Universal Coverage

A health care system in which all residents of a particular country or region have access to essential health services without suffering financial hardship as a result of paying for them