Glossary of healthcare terms

A

Adjudication

How an insurance company decides if it will pay for your doctor’s visit or medicine based on your health plan.

Affordable Care Act (ACA)

A law from 2010 that helps make healthcare easier to afford for people in the U.S. It’s also called Obamacare.

Allowable Charge

The highest amount your insurance pays for a service, no matter how much the doctor charges.

Allowed Amount

How much your insurance pays for your doctor visits and treatments.

Amount Billed

The price that a doctor or hospital says you owe for their services.

Annual Deductible

The total amount you need to pay each year before your insurance starts covering your medical costs.

Annual Enrollment Period (AEP)

A specific time of year when you can sign up or change your health plan, usually for Medicare.

Annual Limit on Cost Sharing

The highest amount you pay in a year for your medical services. After you reach this amount, your insurance pays for everything else for the rest of the year.

Appeal

When you ask your insurance company to rethink its decision about paying for a treatment or service.

ARHOME

A program in Arkansas that helps people get Medicaid coverage.

AutoPay

A feature that allows you to make your insurance payments automatically each month from your bank account or credit card.

B

Balance Billing

When a doctor or hospital charges you for services that your insurance doesn’t cover, especially if you visit a doctor outside their network.

Benefits

The services that your insurance plan will cover or pay for.

Brand-Name Drugs

Medicines made by a specific company that are usually more expensive than generic ones.

C

Chronic Conditions

Health problems like asthma or diabetes that last a long time.

Claim

A request that your doctor sends to your insurance asking them to pay for your care.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

A law that allows certain employees to keep their insurance even after they leave a job, but they have to pay for it themselves.

Coinsurance

The part of medical costs you pay after you’ve met your deductible. For example, if your insurance pays 80%, you pay 20%.

Copayment or Copay

A set amount you pay each time you visit a doctor or get a service.

Cost Sharing

The total money you pay for healthcare services, including the copays and deductibles, along with your monthly premium.

Cost-Sharing Assistance

Discounts that lower the amount you have to pay if you earn less money.

Coverage Start Date

The date when your health insurance begins. It's good to wait to see a doctor until this date to avoid extra charges.

Covered Person

Anyone who is included in your health insurance plan.

Covered Services

Medical services that your insurance will pay for.

D

Deductible

The amount you need to pay for healthcare before your insurance starts to help. You pay this gradually until you reach the total.

Dependent

A person, like your child or spouse, who is covered by someone else's health plan 26.

Diagnostic Test

Tests your doctor orders to find out why you might be feeling unwell, like if you have chest pain.

Durable Medical Equipment (DME)

Items like wheelchairs or crutches that doctors say you need for a long time.

E

Effective Date of Coverage

The actual day when your insurance starts working.

Emergency Medical Condition

A serious health problem that needs quick treatment to keep you safe.

Essential Health Benefits (EHB)

Services that all health plans must offer according to the ACA.

Exchange

A website where you can look at and buy different health insurance plans, also known as the Health Insurance Marketplace.

Exclusions

Services that your insurance won't pay for.

Explanation of Benefits (EOB)

A report from your insurance company that explains the medical services you received and what they cost. It’s important to know it’s not a bill.

F

Federal Poverty Level (FPL)

An income level set by the government that helps decide if you qualify for certain healthcare programs.

Flexible Spending Account (FSA)

An account through your job where you can save money to help pay for medical bills without paying taxes on it. If you don’t use it by the end of the year, you lose the leftover money.

Formulary

A list of prescription medicines that your health plan will pay for.

G

Generic Drug

This type of medicine works the same way as a brand-name drug, but it costs less money.

Grandfathered Health Plan

This is a health insurance plan that existed before the Affordable Care Act (ACA) started in 2010. These plans don’t have to follow some of the ACA rules.

H

Habilitation Service

These are healthcare services that help people learn new skills or keep skills they need to do everyday things.

Health Insurance Marketplace

This is a website where you can look at and buy different health insurance plans. It's also called the “Exchange.”

Health Reimbursement Account (HRA)

This is an account your employer creates for you to help pay for your medical expenses. The money in this account is put in by your employer, and you can't take it with you if you change jobs or health plans.

Health Savings Account (HSA)

This is a special bank account that lets you save and pay for healthcare costs without paying taxes on it. HSAs work with certain insurance plans that have high deductibles, and any money you don’t spend can roll over to the next year. You can keep this account even if you change jobs.

High Deductible Health Plan (HDHP)

This is a type of health insurance plan that has a higher amount you need to pay before it starts helping with costs. Because of this, the monthly payment for the plan is usually lower.

HIPAA (Health Insurance Portability and Accountability Act)

This is a law that helps keep your health information safe and private by limiting who can see it.

Health Maintenance Organization (HMO)

This is a type of health insurance plan where you choose one main doctor (called a primary care provider or PCP) who helps you get the care you need. If you want to see a specialist, you'll need a recommendation from your PCP. Usually, an HMO won’t help you pay for outside doctors that aren’t in the network.

I

Individual Health Insurance Plan

This is a health insurance plan you buy directly from a company or a website, instead of getting it from your job.

In-Network

This refers to doctors and hospitals that have agreed to work with your insurance and provide services at set prices.

Inpatient Services

These are medical services you get when you have to stay overnight in a hospital.

M

Medicaid

This is a government insurance program that helps provide health coverage for people who don’t have a lot of money, including families, children, pregnant women, older people, and people with disabilities.

Medicare

This is a federal health insurance program for people who are 65 years or older, certain younger people with disabilities, and those with severe kidney disease.

Member

This is a person who has health insurance coverage.

Metallic Health Plans

These are different categories of health insurance plans named after metals: Bronze, Silver, and Gold. The names show how costs are shared between you and your insurance plan.

N

Network

This is a group of doctors, hospitals, and other healthcare providers that have agreed to provide services to people who have insurance from a particular plan.

O

Off-Exchange Health Plan

This is a type of health insurance you can buy directly from a company, but it doesn't qualify for a money-saving program called a premium tax credit. If you want that tax credit, you need to get a plan from the Health Insurance Marketplace.

On-Exchange Health Plan

This is a health insurance plan you can buy from the government’s Health Insurance Marketplace website or through someone who helps with insurance. If you want to use a premium tax credit to save money, you have to choose one of these plans.

Open Enrollment Period (OEP)

This is a special time each year when you can sign up for health insurance or switch to a different plan if you buy your own insurance. If you already have a plan, you might have different dates to check for updates.

Out-of-Network

This term refers to doctors or hospitals that do not have an agreement with your health insurance plan to provide services at lower costs.

Out-of-Pocket Costs

These are the medical expenses that you have to pay yourself because your insurance doesn’t cover them. This includes things like deductibles, coinsurance, and copayments.

Out-of-Pocket Maximum (OOPM)

This is the most money you'll pay in a year for your medical costs. It doesn't include your monthly insurance payment, just the extra costs you have to cover.

Outpatient Services

These are medical services you receive without needing to stay overnight in the hospital.

Over the Counter (OTC)

These are medicines you can buy without needing a prescription from a doctor.

P

Plan

This refers to any health insurance coverage you have, whether you get it directly or through a job or group.

Pre-Existing Condition

This means a health issue or illness you had before you signed up for a new insurance plan.

Preferred Provider Organization (PPO)

This is a type of health insurance plan that lets you see any doctor or hospital without needing permission from your primary doctor. You usually pay less when you go to doctors that are in-network.

Premium

This is the monthly amount you pay to keep your health insurance active.

Premium Tax Credit

This is financial help that can lower your monthly insurance payment when you sign up for a plan through the Health Insurance Marketplace. How much you get is based on your income and family size.

Prescription Drugs

These are medications that a doctor orders for you to take.

Preventive Services

These are regular check-ups and tests that can help you stay healthy and catch any problems early.

Primary Care Provider (PCP)

This is the doctor you usually see for check-ups and health concerns. They help with most of your healthcare needs.

Prior Authorization

This is when your health insurance needs to approve a test, procedure, or medication before you can get it. They check to make sure it's really necessary.

Provider

This is anyone who gives healthcare, including doctors, nurses, and hospitals.

Q

Qualified Health Plan

This is a health insurance plan that meets the rules set by the Health Insurance Marketplace and the ACA (Affordable Care Act).

Qualifying Life Event

This is a big change in your life, like having a baby or getting married, that lets you switch your health insurance plan outside the regular sign-up time.

R

Referral

This is when your doctor gives you permission to see another doctor or specialist for more treatment.

Rehabilitation Services

These are healthcare services that help you recover or improve skills needed for daily life, especially after an illness or injury.

S

Special Enrollment Period (SEP)

This is a time when you can buy health insurance outside of the regular sign-up period because of a special life event.

Specialist

This is a doctor who focuses on one area of medicine, like a heart doctor or skin doctor.

Specialty Drug

These are medicines that need special care to handle and are often more expensive./dd>

Subsidy

This is financial help from the government to reduce the costs of health insurance for individuals and families. It can lower your monthly premium or other costs.

Summary of Benefits and Coverage (SBC)

This is a paper that lists what your health insurance plan covers and what benefits you get.

T

Telemedicine

This means having a doctor's appointment through a video call or a phone call.

U

Urgent Care

This is medical care that you need right away for a problem that isn't life-threatening but still needs attention.