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A to Z health care reform glossary

Here we offer an interactive A-to-Z guide to common health care reform terms. Special thanks to Kaiser Permanente and the United States Department of Labor’s Uniform Glossary of Health Coverage and Medical Terms for some of the content you’ll find here.

Advanced Premium Tax Credit

The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return. Also called premium tax credit.

Affordable Care Act (ACA)

The comprehensive federal health care reform law enacted in March 2010. Also known as “Obamacare” or “Health Care Reform.”

Benefits

The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in a health insurance plan’s coverage documents. See your plan’s Summary of Benefits and Coverage (SBC) or your plan’s Schedule of Benefits (SOB) for full details.

Benefit Year

The annual cycle for your health insurance plan. A “calendar year” cycle always starts in January and ends in December. A “plan year” cycle can start any month and runs for 12 consecutive months. Your plan’s deductibles, out-of-pocket maximums, visits, and other limits are tracked according to your plan’s benefit year.

Brand Name (Drugs)

A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.

Certified Applicant Counselor

An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers.

CHIP (Children’s Health Insurance Program)

Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.

Coinsurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

ConnectorCare

Qualified health plans for the subsidized health insurance market in Massachusetts.

Copayment (Copay)

A set amount (for example, $15) you pay for a covered health care service or prescription, usually when you get the service. The amount will vary by the type of coverage you have for that service.

Cost share

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.

Deductible

The amount you owe for health care services your plan covers before your health plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Some plans have a separate deductible for prescription drugs.

Dependent

A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.

Durable Medical Equipment

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.

Drug List

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.

Emergency Care

Life-threatening health problems that need immediate care. These problems can include chest pain, poisoning, or severe bleeding. If you think your medical problem is life threatening, always go to the nearest emergency room.

Emergency Medical Condition

An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Enrollment Assistants

An individual who is trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers.

Essential Health Benefits (EHBs)

The Affordable Care Act ensures health plans offered in the individual and small group markets offer a comprehensive package of items and services, known as Essential Health Benefits. Essential Health Benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Exchange (The health connector: www.mahealthconnector.org)

A resource for Massachusetts residents 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. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available.

Excluded Services

Health care services that your health insurance or plan doesn’t pay for or cover. See your plan’s Summary of Benefits and Coverage (SBC) or your plan’s Schedule of Benefits (SOB) for full details.

Full-time Employee

An employee who works an average of at least 30 hours per week (so part-time would be less than 30 hours per week).

Federal Poverty Level

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

Fee

Starting January 1, 2014, if someone doesn’t have a health plan that qualifies as minimum essential coverage, he or she may have to pay a fee that increases every year: from 1% of income (or $95 per adult, whichever is higher) in 2014 to 2.5% of income (or $695 per adult) in 2016. The fee for children is half the adult amount. The fee is paid on the 2014 federal income tax form, which is completed in 2015. People with very low incomes and others may be eligible for waivers.

Fee for Service

A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.

Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

Generic Drugs

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Grandfathered plan

A group health plan that’s had at least one person enrolled in it at all times since March 23, 2010, or that a subscriber had purchased on or before March 23, 2010, and meets other requirements. Grandfathered plans are subject to some ACA and exempt from others. The plan’s issuer may make changes to the coverage as long as they are within certain limits.

Grievance

A complaint that you communicate to your health insurer or plan.

Group Health Plan

In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Habilitative/Habilitation Services

Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Care

The prevention, treatment, and management of diseases and injuries, as well as the preservation of mental and physical health, through services offered by trained and licensed professionals (like doctors, dentists, and psychologists).

Health Care Reform

A general term for the major health policy changes put in place by the federal Affordable Care Act and any state laws passed to put it in place.

Health Insurance (also referred to as “coverage” or “plan”)

A contract that requires your health insurance issuer to pay some or all of your health care costs in exchange for a premium you pay.

Health Insurance Marketplace: Mahealthconnector.org

A resource for Massachusetts residents 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. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available.

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. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Health Plan Categories

Plans in the Marketplace are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.

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. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.

Health Savings Account (HSA)

A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Inpatient care

Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

Large Group Health Plan

In general, a group health plan that covers employees of an employer that has 101 or more employees. Until 2016, in some states large groups are defined as 51 or more.

Marketplace

A common nickname for the Health Insurance Marketplace(s). In Massachusetts, this is also called the Health Connector. It’s found at www.mahealthconnector.org

Medically necessary

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Minimum Essential Coverage

The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act (ACA). This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.

Navigator

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. These individuals and organizations are required to be unbiased. Their services are free to consumers.

Network

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

Open Enrollment Period

The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. For 2015 and later years, the Open Enrollment Period is October 15 to December 7 of the previous year.

Out-of-Network Provider

A facility, provider, or supplier who is not contracted with your health insurance plan to provide services to you under your plan.

Out-of-Pocket Expenses

The amounts you pay to providers for health care services you receive under the terms of your health care coverage, including copayments, coinsurance, and deductible payments, in contrast to the premium you pay each month for your health plan coverage. Also known as “cost share.”

Out-of-Pocket Maximum

The most you pay during a policy period (a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your plan doesn’t cover. Some health insurance plans don’t include all copays, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.

Pre-existing Condition

A medical condition that a person has before he or she applies for new health plan coverage.

Premium

The amount you and/or your employer pay (usually each month) for health plan coverage. Premiums do not count toward deductibles or out-of-pocket maximums.

Premium Tax Credit

The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

Prescription Drugs

Drugs and medications that, by law, require a prescription.

Preventive Care

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Includes activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

Primary Care

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. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Prior Authorization

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.

Provider

A physician, health care professional, or health care facility that is licensed, certified, or accredited to provide health care services and supplies as required by state law.

Qualified Health Plan

An insurance product that is certified by a Marketplace, provides Essential Health Benefits, follows established limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts) and meets other requirements. A qualified health plan will have a certification by each marketplace in which it is sold.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Rehabilitative/Rehabilitation 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. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Specialist

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. A non-physician specialist is a provider who has more training in a specific area of health care.

Small Employer

The ACA defines “small employer” differently for different purposes. An employer is considered a “small employer” eligible to purchase coverage at the exchange if the employer has 50 or fewer full-time equivalent employees. In 2016, an employer with 100 or fewer employees will be eligible to purchase coverage in the Exchange. Potential tax penalties for failure to provide coverage that meets the ACA standards does not apply to employers with 49 or fewer full-time equivalent employees.

Summary of Benefits and Coverage (SBC)

A plain-language summary of your benefits and coverage. In compliance with the ACA, every insurer must supply this document and a uniform glossary of common health terms to prospective members during open enrollment or upon request. It outlines the cost-sharing responsibilities specific to your plan such as annual deductible amount, copay amounts, co-insurance percentages, and out-of-pocket maximums.

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.

Vision or Vision Coverage

A type of health benefit that at least partially covers vision care, like eye exams and glasses.

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. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

Wellness Programs

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. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventive health screenings.

What is cost sharing?

Read about cost sharing in
A Guide to Your Health Care Costs