Welcome to our Simple Insurance Glossary!
Navigating insurance terminology can be complicated. That’s why we’ve created this easy-to-understand glossary explaining over 200 common insurance terms.
Our goal is to help you understand the essential meaning of common insurance language in plain English, not complex legalese. We cover important topics like health insurance, Medicare, disability, life insurance and more.
Please note this glossary aims to simplify key terminology only. Always refer to your specific insurance policy documents for details applicable to your exact coverage, costs, benefits and procedures.
What you need to know
- Insurance regulations and plan specifics can vary by state. Verify information for where you live.
- Those outside the U.S. – This glossary focuses on American insurance terminology and systems which differ internationally.
- Explanations cover typical scenarios but exceptions exist. Contact us if you need clarification on anything.
- We define bread-and-butter insurance terms in everyday language. Let us know if you need a less common term explained.
- Some industry jargon remains for accuracy. Tell us if you need clearer definitions.
Our goal is to provide friendly explanations of insurance language to boost your confidence and understanding. Please give us feedback so we can improve this resource. We’re glad you’re here and hope you find this helpful!
Glossary
A
Accidental Death and Dismemberment Insurance
Pays your family if you die or lose a body part in an accident.
Accountable Care Organization (ACO)
A group of doctors that coordinates care to improve quality and lower costs.
Activities of Daily Living (ADLs)
Basic daily tasks like eating, bathing, dressing. Help with ADLs is covered by long-term care insurance.
Acute Care
Medical care for sudden, severe conditions like a heart attack or bad injury.
Advance Beneficiary Notice of Noncoverage (ABN)
A notice saying Medicare won’t pay for a certain service or item. Lets you decide to get it and pay yourself.
Administrative Services Only (ASO)
The insurance company handles paperwork but the employer pays the claims.
Adjudicate
The insurance company processes claims to decide whether to pay them.
Advance Coverage Decision
A notice from your Medicare Advantage plan saying whether they will cover a certain service.
Affordable Care Act (ACA)
Also called Obamacare, this law changed health insurance rules and coverage.
Agent
A person who helps you choose and enroll in health insurance plans.
Aggregate Deductible
With a family plan, the whole family’s costs go toward meeting the deductible before insurance pays.
Allowable Charge
What an in-network provider bills for a service, usually lower than without insurance.
Allowable Expense
What an in-network provider bills for a service, usually lower than without insurance.
Allowed Amount
The maximum dollar amount an insurance plan will pay for a covered service.
Ambulatory Care
Medical care you can get without being admitted to a hospital.
Amount You Owe
deductibles, copays, coinsurance.
Ancillary Care
Extra health services like physical therapy that support diagnosing or treating you.
Anniversary Date
The date your health plan renews each year.
Annual Deductible
The amount you pay out of pocket for health care each year before insurance starts paying.
Annual Election Period
The time to make changes to your Medicare Advantage or Part D plan – Oct 15 to Dec 7.
Annual Limit
A cap on how much your plan will pay toward a benefit like prescriptions. You pay the rest.
Annual Out-of-Pocket Maximum
The most you pay for covered care in a year. Then insurance covers 100%.
Annual Plan Premium
How much you pay each year in total premium costs. You usually pay monthly.
Appeal
Asking your insurance company to reconsider a coverage decision you disagree with.
Assignment
Your doctor agrees to be paid by Medicare and can’t bill you for more.
Authorize
Getting approval from your insurance company before getting some services.
B
Balance Billing
When an out-of-network doctor bills you the difference between their charge and what your insurance paid them.
Behavioral Care Services
Mental health and substance abuse treatment services.
Behavioral Health Services
Mental health and substance abuse treatment services.
Beneficiary
Anyone covered by an insurance plan – you, spouse, children.
Benefits Coordination and Recovery Center
A company that coordinates information on your insurance coverage from different sources.
Benefits Summary
Highlights key benefits covered by your health plan.
Brand Name Drug
A prescription medicine sold under a trademarked name. Often more expensive than generic.
Broker
Helps employers choose group health plans to offer employees.
Bronze Health Plan
Offers low premiums but you pay more when you get care – covers about 60% of costs.
C
Cadillac Tax
The upcoming 40% tax on high-cost employer health plans.
Cancer Insurance
Supplemental insurance that pays extra if you get cancer.
Carryover
Flexible spending accounts letting you roll over some of the money to the next year.
Catastrophic Coverage
Part D prescription coverage with low costs once you spend over $5000 per year.
Catastrophic Health Insurance
Bare bones insurance that only pays for major care and emergencies.
Centers of Excellence
Top ranked hospitals for quality and cost efficiency.
Centers for Medicare and Medicaid Services (CMS)
The federal agency that runs Medicare, Medicaid and the Marketplace.
Certificate of Coverage
Details what services your health insurance does and doesn’t cover.
Certificate of Creditable Coverage
Proof you had previous health insurance to avoid pre-existing condition exclusions.
Certification
Needing approval from your insurance before getting certain services.
Chemical Dependency
Using alcohol or drugs in a way that is harmful to your health or life.
Children’s Health Insurance Program (CHIP)
Government health coverage for low-income children.
Claim
A request to your insurance company to pay for services you received.
Claim Status
Where your claim is in the process
Claims Review
Insurance company checking a claim to decide whether to pay.
Coinsurance
You and your insurance company share costs
Complaint
Telling your insurance company you have a problem with their service or decision.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Law letting you keep employer health coverage after leaving a job.
Consumer-Driven Health Plan (CDHP)
A plan with a tax-free account to help pay medical expenses.
Contract
Your health plan document outlining your coverage details.
Contract Year
The 12 month period your plan covers you before renewal is needed.
Contributory
Employees pay part of the premium for health or life insurance from their employer.
Convenience Care Clinic
Walk-in clinics in pharmacies and stores for minor illnesses and preventive care.
Conversion Option
Option to convert group insurance to an individual policy if you lose eligibility.
Coordination of Benefits (COB)
How plans coordinate payments when you’re covered by more than one plan.
Copay
A set amount you pay at the time of a doctor visit, usually $10-$50.
Cost Sharing
Payments you make like deductible, copay and coinsurance.
Cost Sharing Reduction (CSR)
Discounts that lower copays and other costs if you qualify based on income.
Coverage Determination (Part D)
Decision on what benefits you have under your Part D prescription plan.
Coverage End Date
The last date your health plan will provide coverage before ending.
Coverage Gap
With Medicare Part D, this is when coverage stops after reaching the initial limit before catastrophic.
Coverage Plan
The health insurance policy describing what services are covered.
Coverage Start Date
When your new health insurance policy goes into effect.
Creditable Coverage
Health insurance you had previously that counts toward reducing pre-existing condition exclusion periods.
Creditable Prescription Drug Coverage
Drug coverage that’s as good as Medicare’s so you don’t pay a penalty if you join Part D late.
Critical Illness Insurance
Pays cash benefits if you get cancer, heart attack, stroke or other critical illness.
Custodial Care
Help with daily living activities like eating, bathing, dressing. Not covered by Medicare.
Customer
Anyone covered by a health insurance plan.
Customer ID
Unique number assigned to you to identify you to providers and insurance companies.
D
Date Claim Incurred
With disability insurance, when the disabling injury happened.
Date Claim Received
When the insurance company gets the claim.
Date Last Worked
With disability insurance, the last day at work before the injury.
Date of Claim
With disability insurance, when the disabling injury occurred.
Date of Disability
With disability insurance, when the disabling injury occurred.
Date of Service
Day you received medical services.
Date Posted
Day a spending account withdrawal is recorded.
Date Processed
Day the insurance company finishes adjudicating the claim.
Death Benefit
Cash payout to your beneficiaries with life insurance when you die.
Deductible
What you pay for care before insurance starts paying
Deemed Status
Medicare-approved credentials that providers/suppliers have to show they meet requirements.
Demonstrations
Medicare projects testing improvements in coverage and care.
Denied Claim
An insurance claim the company will not pay.
Dental Health Maintenance Organization (DHMO)
Dental HMO plan that covers in-network dentists.
Dental PPO
Dental plan with network dentists but allows other dentists at higher cost.
Department of Health and Human Services (HHS)
Federal agency overseeing CMS which runs Medicare/Medicaid.
Dependent
Family member covered under your health plan
Dependent Care Flexible Spending Account (FSA)
FSA to pay for eligible child care expenses with pre-tax dollars.
Dependent Care Reimbursement Account
Account to pay for eligible child care expenses with pre-tax dollars.
Diagnostic Care
Tests and services to help diagnose your condition.
Diagnostic Tests
Tests to help diagnose your condition.
Direct Access Plan
Insurance plan that lets you see specialists without referrals.
Disability Benefit
Insurance that pays part of your income if you’re too injured/sick to work.
Disability Insurance
Insurance that pays part of your income if you’re too injured/sick to work.
Disenrollment
Choosing to leave a health plan you currently have.
Dispense as Written
When the Doctor requires the brand name drug instead of a generic substitute.
DME Medicare Administrative Contractor
Private company handling Medicare bills for medical equipment.
Drug Formulary
List of prescription medications covered by an insurance plan.
Drug Levels
How drugs are categorized in tiers that determine your out-of-pocket costs.
Drug List
List of prescription medications covered by an insurance plan.
Drug Tiers
How drugs are categorized in tiers that determine your out-of-pocket costs.
Duplicate Coverage
When you’re covered twice by group health plans as employee + spouse.
Durable Medical Equipment
Provider-prescribed items like wheelchairs, hospital beds, walkers.
E
Eligibility
Meeting requirements to enroll in an insurance plan.
Eligible Dependent
Family member who meets rules to be covered under your insurance plan.
Eligible Medical Expenses
Costs you can pay for with a Health Savings Account (HSA) or Flexible Spending Account (FSA).
Embedded Deductible
With family insurance, each person’s costs go toward their deductible before the plan pays.
Emergency Care
Immediate care for serious conditions like heart attack, stroke, serious injury.
Emergency Room Care
Immediate care for serious conditions like heart attack, stroke, serious injury.
Emergency Services
Immediate care for serious conditions like heart attack, stroke, serious injury.
Employee Assistance Program (EAP)
Employer program giving access to counselors and resources.
Employee Census
List of all employees used to get a group health plan quote.
Employee Enrollment Period
Window when employees can enroll in company health benefits.
Employer Contribution
How much your employer contributes toward your health premiums.
Enhanced Direct Enrollment
Applying for coverage directly through an insurance company website, not Healthcare.gov.
Enroll
Sign up for health insurance coverage.
Enrollee
Person who signs up for health insurance coverage.
Essential Health Benefits
Services health plans must cover like doctor visits, ER care, prescriptions.
Evidence of Coverage
Health plan document detailing covered services, rights, processes.
Excepted Benefits
Separate additional coverage like dental, vision, cancer.
Excess Charge
Difference between what Medicare approves and a doctor’s higher charge.
Exchange
The Health Insurance Marketplace to buy coverage and get financial help.
Excise Tax
The upcoming 40% “Cadillac Tax” on high-cost employer health plans.
Exclusionary Rider
Statement clarifying something your policy doesn’t cover.
Exclusions and Limitations
Services not covered or covered only in limited circumstances.
Exclusive Provider Organization (EPO)
A managed care plan that only covers in-network providers except emergencies.
Expenses Requiring Verification
Spending account claims that need documentation for reimbursement.
Experimental Procedures
Unproven emerging treatments that insurance may not cover.
Explanation of Benefits (EOB)
Summary of what providers billed, plan paid, your costs.
Extension of Benefits
Group coverage continues past termination date due to disability.
External Review
Independent review of an insurance company’s coverage denial that you dispute.
Extra Help
Medicare’s low-income program helping to pay drug plan costs.
F
Face Amount
Death benefit amount your beneficiary gets from life insurance.
Family and Medical Leave Act (FMLA)
Law giving 12 weeks of job-protected leave for health/family.
Family Deductible
Whole family’s costs go toward meeting deductibles before insurance pays.
Federal Financial Assistance
Help paying premiums and out-of-pocket costs if you qualify based on income.
Flexible Benefits Plan
Employer plan where you choose what coverage you want.
Flexible Coverage Plan
Employer plan where you choose what coverage you want.
Flexible Spending Account (FSA)
Special account to use pre-tax dollars on eligible health costs.
Formulary
List of prescription medications covered by an insurance plan.
Fully Insured
Employer contracts with insurer to cover health costs
G
Generic Drug
Version of brand drug with same ingredients but usually lower cost.
Gold Health Plan
Covers around 80% of costs
Grace Period
The time you can pay a late premium and keep your coverage.
Grandfathered Health Plan
Plans existing before the ACA that don’t have to meet all requirements.
Grandfathered Status
Health plans existing before the ACA that don’t have to meet all requirements.
Group Certificate
Document for group plan explaining covered services.
Group Coverage
Health plan an employer provides employees.
Group Health Coverage
Health plan an employer provides employees.
Group Health Insurance
Health plan bought by employer for employees.
Group Health Plan
Health plan an employer provides employees.
Group Insurance
Insurance an employer provides employees
Group Life Insurance
Life insurance policy an employer provides employees.
Group Universal Life Insurance
Employer life insurance policy that accumulates cash value.
Guarantee Issue Amount
Highest amount of life insurance you can get without a health check.
Guaranteed Issue Rights
Right to buy Medicare Supplement (Medigap) policies without exclusions in certain situations.
Guaranteed Renewal
Health plans must renew your policy if you keep paying premiums.
Guaranteed Renewable
Medigap policies that can’t be terminated if you keep paying premiums.
H
Health Benefit Plan
The health insurance policy describing what services are covered.
Health Care
General medical services
Health Care Facility
Places you get care like hospitals, clinics, labs.
Health Care Marketplace
State insurance marketplace to buy coverage and get financial help.
Health Care Professional
Doctor, nurse, technician or other licensed medical provider.
Health Care Reform
Improvements in health care access, affordability, quality
Health Care Services
General medical services
Health Care Spending Account
Special account to use pre-tax dollars on eligible health costs.
Health Coverage
Health insurance or plan that helps you pay for medical expenses.
Health Insurance
Coverage that helps pay your medical and health care expenses.
Health Insurance Carrier
Company offering health insurance plans.
Health Insurance Marketplace
State insurance marketplace to buy coverage and get financial help.
Health Insurance Portability and Accountability Act (HIPAA)
Set rules for protecting patient privacy.
Health Maintenance Care
Preventive care to maintain health and catch problems early.
Health Maintenance Organization (HMO)
Managed care plan that covers care from in-network providers only, except emergencies.
Health Plan
Insurance policy that covers medical services.
Health Proxy
Person legally designated to make health decisions if you’re unable.
Health Reimbursement Account (HRA)
Employer-funded account to help employees pay health expenses.
Health Savings Account (HSA)
Tax-advantaged account to pay for medical expenses.
Heart Attack and Stroke Insurance
Supplemental coverage providing cash benefits if you have a heart attack or stroke.
High Deductible Health Plan (HDHP)
Plan with high deductibles but often lower premiums.
Home Health Care
Health services like nursing care provided in your home. Limited Medicare coverage.
Hospice Care
End-of-life palliative care focusing on comfort instead of cure. Covered by Medicare.
Hospital Care Insurance
Supplemental coverage to help pay copays, deductibles for a hospital stay.
Hospital Indemnity Insurance
Supplemental coverage to help pay copays, deductibles for a hospital stay.
I
Identification (ID) Card
Card you show providers to confirm insurance coverage.
Immunizations Without Cost Share
Plans must cover approved immunizations without out-of-pocket costs.
Independent Reviewer
Independent third party that reviews Medicare appeals.
Individual Deductible
Your own costs go toward your deductible before the plan pays.
Individual Insurance Marketplace
State insurance marketplace to buy individual coverage and get financial help.
Individual Plan
Health coverage you buy directly instead of getting from an employer.
Initial Coverage
Prescription drug coverage up to a set limit before you enter the coverage gap.
Initial Coverage Limit
Spending limit before you enter the coverage gap with Part D prescription coverage.
Initial Enrollment Period
First time to sign up for Medicare when you turn 65.
In-Network
Providers that contract with your insurance plan to provide discounted rates. You pay less.
In-Network Hospital
Hospital contracted with your insurance plan
In-Network Pharmacy
Pharmacy contracted with your insurance plan
In-Network Provider
Doctor or facility contracted with your insurance plan –
Inpatient
Getting admitted to a hospital for care rather than outpatient.
Inpatient Prospective Payment System (IPPS)
Hospitals contracted to accept set Medicare payment rates.
Insurance Card
Card you show providers to confirm insurance coverage.
Insured
Covered by an insurance plan.
Insurer
Company that offers insurance plans.
Investigational Procedures
Unproven emerging treatments that insurance may not cover.
L
Late Applicant
Waiting too long to sign up for health benefits at a new job.
Late Enrollment Penalty
Added cost if you delay enrolling in Medicare Part D.
Late Entrant
Waiting too long to sign up for health benefits at a new job.
Legend Drug
Medication requiring a prescription.
Letter of Medical Need
Letter showing services were medically necessary.
Level Amount
Same benefit amounts for all employees in a group plan.
Life Insurance
Covers a payment to beneficiaries when you die.
Lifetime Limit
Cap on total benefits your insurance will pay over your lifetime.
Lifetime Reserve Days
Extra hospital days Medicare covers when you go over the limit.
Limited Medical Plans
Plans offering minimal coverage mainly preventive care.
Long-Term Care
Services like nursing homes and home health aides for chronic conditions.
Long-Term Disability Insurance
Replaces income if you can’t work for an extended time due to injury or illness.
M
MA-PD Plan
Medicare Advantage plan combining Part C and Part D drug coverage.
Mail Service Pharmacy
Pharmacy that mails medications to your home.
Mail-Order Pharmacy
Pharmacy that mails medications to your home.
Maintenance Medication
Medication you take regularly for chronic conditions.
Managed Behavioral Health
Plans managing mental health and substance abuse services.
Managed Care
Using coordination to reduce costs like HMOs and PPOs.
Maximum Allowance
Highest dollar amount a plan will cover for a service based on average costs.
Maximum Amount
Cap on how much your plan will pay toward a benefit like prescriptions.
Maximum Benefit Period
Longest time disability insurance will pay benefits.
Maximum Benefits Amount
Cap on how much your plan will pay toward a benefit like prescriptions.
Maximum Coverage Period
Longest time disability insurance will pay benefits.
Maximum Out-of-Pocket
Most you have to pay in a year before insurance covers 100%.
Maximum Plan Benefit Coverage
Cap on how much your plan will pay toward a benefit like prescriptions.
Maximum Reimbursable Charge
The most an insurance plan will pay an out-of-network provider.
Medicaid
Government health coverage for low-income people.
Medical Equipment
Provider-prescribed items like wheelchairs, hospital beds, walkers.
Medical History
Your conditions, prescriptions, procedures
Medical Necessity
Proof services were necessary and appropriate for diagnosis.
Medically Necessary
Proof services were necessary and appropriate for diagnosis.
Medicare
Federal health insurance program for seniors 65+ and some younger disabled people.
Medicare Administrative Contractor
Company that processes Medicare claims.
Medicare Advantage
Medicare plans offered by private insurers that combine Part A, Part B and often Part D.
Medicare Advantage Plan
Private plan that combines coverage of Part A, Part B and often Part D.
Medicare Annual Enrollment Period
Time to change Medicare Advantage and Part D plans
Medicare-Approved Amount
Maximum Medicare will pay for a covered service.
Medicare-Approved Supplier
Provider certified by Medicare to provide services or medical equipment.
Medicare Beneficiary
Person enrolled in Medicare.
Medicare Cost Plan
Medicare Advantage plan that lets you use out-of-network providers.
Medicare Health Plan
Any private Medicare Advantage plan or prescription plan.
Medicare Medical Savings Account Plan
Medicare Advantage plan combining high deductible insurance with a savings account.
Medicare Part A
Hospital/inpatient coverage.
Medicare Part B
Outpatient/doctor visit coverage.
Medicare Part C
Medicare Advantage plans offered by private insurers.
Medicare Part D
Outpatient prescription drug coverage offered by private plans.
Medicare Preferred Provider Organization (PPO) Plan
Medicare Advantage PPO with in-network discounts and out-of-network options.
Medicare Prescription Drug Plan
Stand-alone private insurance plan just for Part D drug coverage.
Medicare Private Fee-for-Service Plan
Medicare Advantage plan where you can see any provider if they agree to treat you.
Medicare Savings Program
Medicaid program that helps pay Medicare costs if you have limited income.
Medicare Select
Medigap policy requiring you to use certain hospitals to get full coverage.
Medicare Special Needs Plan
Special Medicare Advantage plan for certain groups of people like institutionalized or dual eligibles.
Medicare Specialist
Person who helps you choose Medicare coverage options.
Medicare Summary Notice
Summary of services billed, plan payments, your costs for Parts A and B.
Medicare Supplement Insurance
Supplemental coverage to fill gaps in Original Medicare.
Medicare Supplement Plan
Supplemental coverage to fill gaps in Original Medicare.
Medigap
Supplemental coverage to fill gaps in Original Medicare.
Member
Person covered by a health insurance plan.
Member Handbook
Document explaining plan coverage and processes.
Member ID
Unique number to identify you on your insurance card and coverage.
Member Liability
Your share of costs
Member Representative
Person legally designated to make health decisions on your behalf.
Member Responsible Amount
Your share of costs
Mental Health
Your emotional and psychological well-being.
Mental Health Services
Services like therapy and counseling to support mental health.
Mini-Med Plans
Plans offering minimal coverage mainly preventive care..
N
National Committee for Quality Assurance (NCQA)
Nonprofit that reviews and accredits health plans
Necessary Treatment
Proof services were necessary and appropriate for diagnosis.
Network
The doctors, clinics and hospitals contracted with an insurance plan.
Network Pharmacies
Pharmacies contracted with a prescription insurance plan.
Non-Contributory
Employer pays the full cost of group life insurance premiums.
Non-Formulary Drug
A drug not on your plan’s covered drug list. Needs approval.
Non-Participating Provider
Doctor or hospital not contracted with your insurance network.
Non-Preferred Provider
Doctor or hospital not contracted with your insurance network.
Non-Preferred Pharmacy
Pharmacy not contracted with your prescription insurance plan.
Non Qualified Amount
Expense you can’t pay for with an HSA or FSA.
Non Qualified Expense
Expense you can’t pay for with an HSA or FSA.
O
Obamacare
Nickname for the Affordable Care Act (ACA) health reform law.
Open Access Plan
Insurance plan that lets you see specialists without referrals.
Open Enrollment Period
Time you can enroll in or change health plans outside qualifying events.
Optional Supplemental Benefits
Extra benefits Medicare Advantage plans can choose to cover.
Organization Determination
Decision made by Medicare Advantage plan about coverage.
Original Medicare
Traditional fee-for-service Medicare
Out-of-Area Benefits
Coverage for providers outside your insurance network area.
Out-of-Network
Doctors, clinics and hospitals not contracted with your insurance plan. You pay more.
Out-of-Pocket Costs
Your expenses for deductibles, copays and coinsurance.
Out-of-Pocket Maximum
Limit on how much you pay before insurance covers 100%.
Outpatient
Medical care without being admitted
Over-the-Counter Drugs
Medications you can buy without a prescription.
P
Paid-to-Date
Current balance of what’s been spent from an HSA or FSA.
Participating Hospital
Hospital contracted with your insurance plan
Participating Pharmacy
Pharmacy contracted with your insurance plan
Participating Provider
Doctor or facility contracted with your insurance network.
Patient Advocate
Person legally designated to make health decisions on your behalf.
Patient Liability
Your share of costs
Patient Protection and Affordable Care Act (PPACA)
The ACA health reform law.
Pended Claim
Claim awaiting more information before it can be processed.
Pending Transactions
Spending account actions that are still being processed.
Personal Health Record
Information about your health history and care.
Personally Identifiable Information (PII)
Data that can identify you
Pharmacy
Place to fill prescriptions
Plan
Health coverage policy describing what services are covered.
Plan Certificate
Document detailing covered services in your health plan.
Plan Documents
Documents like policy, handbook explaining your coverage.
Plan Exclusions and Limitations
Services not covered or covered only in limited circumstances.
Plan Features
Overview of a health plan
Plan Level
Categories of Marketplace plans
Plan Maximum
Cap on how much your plan will pay toward a benefit like prescriptions.
Plan Premium
Main cost
Plan Sponsor
Employer, union, or group that offers a group health plan.
Plan Summary
Overview document on a health plan’s covered services.
Plan Year
The 12 month period your health plan covers you before renewal.
Platinum Health Plan
Highest premiums but lowest costs when you need care
Point of Service Plan
Hybrid plan combining in-network discounts with out-of-network options.
Policy
Your health plan document listing covered services, exclusions, processes.
Portable
Ability to keep group health coverage if you leave your job.
Post-Acute Care
Care needed after discharge from a hospital stay.
Power of Attorney
Legal document authorizing someone to act on your behalf.
Pre-Existing Condition
Illness or condition diagnosed before getting insurance.
Pre-Existing Condition Exclusions
Conditions insurance won’t cover because you had them before enrolling.
Preauthorization
Getting approval from insurance before getting certain services.
Precertification
Getting approval from insurance before getting certain services.
Preferred Care Provider
Doctor/facility contracted with insurance plan
Preferred Drug List
Drugs covered at lower out-of-pocket costs by a plan.
Preferred Pharmacy
Pharmacy contracted with insurance plan
Preferred Provider Organization (PPO) Plan
Network plan that allows out-of-network care at higher costs.
Premium
Main cost for insurance
Premium Tax Credit
Financial assistance to help pay premiums based on income.
Premium Waiver
Option to stop paying premiums for employer coverage if disabled.
Prepaid Dental Plans
Managed dental care plans
Prescription
Doctor’s note allowing you to get a specific medication.
Prescription Drug
Medication that legally requires a prescription.
Prescription Drug Coverage
Part of your insurance that covers prescription medications.
Prescription Medication
Medication that legally requires a prescription.
Prevailing Charge
Typical cost of a medical service in a geographic area.
Preventive Care and Services
Routine care to prevent or catch illnesses early
Primary Care
Basic health care usually from a family medicine, general practice or internal medicine doctor.
Primary Care Provider
Doctor providing basic health care and referrals.
Prior Authorization
Getting approval from insurance before getting certain services.
Prior Creditable Coverage
Health insurance you had before used to reduce waiting periods.
Private Fee-for-Service Plan
Medicare Advantage plan where any provider can be used if they agree to treat you.
Programs of All-Inclusive Care for the Elderly (PACE)
Special Medicare/Medicaid managed care plans.
Prosthesis
Artificial replacement for a missing body part like an arm, leg or tooth.
Protected Health Information
Private patient health data like diagnoses and treatment plans.
Provider
Any licensed health professional
Provider Directory
Insurance plan’s list of doctors and facilities in its network.
Provider Network
Doctors, clinics, hospitals contracted with an insurance plan.
Purchaser
Employer or organization that buys group insurance for employees.
Q
Qualified Disabled and Working Individuals (QDWI) Program
Program helping pay Part A premiums if you have limited income/resources.
Qualified Health Plan
Plans certified to be offered on the Health Insurance Marketplace.
Qualified Individual Program
Program helping pay Part B premiums if you have limited income/resources.
Qualified Medicare Beneficiary Program
Program helping pay Original Medicare costs if you have limited income/resources.
Qualified Amount
Eligible expense for paying with an HSA or FSA.
Qualified Expense
Eligible expense for paying with an HSA or FSA.
Qualifying Life Event
Major life change allowing a special enrollment period to change plans.
Quality Improvement Organizations (QIOs)
Groups that work to improve Medicare quality.
Quality Ratings
Star ratings on the Marketplace based on plan quality and performance.
Quantity Limit
Cap on the amount of a drug you can get in a certain time period.
R
Reasonable Charge
Typical cost of a medical service in a geographic area.
Recurrent Disability Provision
Disability insurance continues without interruption if you return to work but can’t continue.
Referral
Formal recommendation from your PCP to see a specialist.
Reimbursement
Getting paid back for an eligible health care expense from an HSA or FSA.
Renewal
Signing up again for the same health plan.
Residual Coverage
Disability insurance that replaces part of your income if you can only work part time.
Respite Care
Temporary institutional care for dependent family members to provide relief.
Retail Pharmacy
Pharmacy located in a store or other retail setting.
Return-to-Work Incentive
Disability coverage encouraging and supporting going back to work part or full time.
Rider
Addition or amendment to an insurance policy.
Rollover Funds
HSA/FSA funds that can roll over year to year.
Routine Care
Basic health care like doctor visits, preventive screenings.
Rx
Prescription.
S
Schedule of Benefits
Chart summarizing covered services and cost shares in a health plan.
Secondary Care
Specialized medical care you get referred to by your PCP.
Secondary Payer
When another insurance pays first before Medicare, Medicaid etc.
Section 125 Plan
Pretax deduction for health premiums and qualified expenses.
Self-Funded Plan
Employer pays claims, insurer handles admin functions.
Self-Insured Plan
Employer pays claims, insurer handles admin functions.
Service Area
Geographic area where an insurance plan operates and covers members.
Short-Term Disability Insurance
Coverage replacing income for short term disability.
Short-Term Health Insurance
Temporary insurance for gaps between coverage.
Short-Term Rehabilitation
Post-illness therapy helping you to regain function.
Silver Health Plan
Mid-range premiums and costs
Skilled Care
Daily nursing and rehabilitative care usually in a facility.
Small Business Health Insurance
Plans for small companies (under 50 employees).
Small Business Health Options Program (SHOP)
Gives small employers access to group plans.
Small Employer Plan
Group coverage for businesses under 50 employees.
Small Group Plan
Group coverage for businesses under 50 employees.
Special Election Period
Time outside open enrollment when Medicare enrollment is allowed.
Special Enrollment Period
Time outside open enrollment you can enroll after certain life events.
Special Needs Plan
Special Medicare Advantage plan for certain groups of people.
Specialist
Doctor focusing on a specific part of the body or type of illness.
Specialty Drug
High-cost prescription drug that needs special handling.
Specified Low-Income Medicare Beneficiary Program
Program helping pay Part B premiums if you have limited income/resources.
Sponsor
Employer, union or group providing a health plan.
Staff Model HMO
HMO where the doctors work directly for the insurance company.
Stand-Alone Dental Plan
Separate dental plan since dental isn’t covered under many medical plans.
Standard Medicare Drug Coverage
Minimum required prescription drug coverage under Part D.
Standing Referral
Referral from your PCP valid for multiple specialist visits without getting a new one each time.
Start Date
First day your health coverage goes into effect.
State Health Insurance Assistance Program (SHIP)
Provides local Medicare counseling.
State Insurance Department
Regulates insurance providers in your state.
State Medical Assistance Office
Administers Medicaid in your state. Can help apply.
State Survey Agency
State agency reviewing Medicare/Medicaid participating providers/facilities.
Step Therapy
Program that requires trying less expensive drugs first.
Stop-Loss Coverage
Employer coverage for claims exceeding a high threshold.
Subscriber
Person (often the employee) who enrolls in a health plan.
Subscriber Card
Insurance card with your plan info that you show providers.
Substance Abuse
Harmful drinking or drug use.
Substance Use Disorder
Illness from alcohol or drug abuse/misuse.
Summary of Benefits and Coverage
Summary of a plan’s covered services and cost shares.
Summary Plan Description
Document on health plan benefits, processes and rights.
Supplemental Insurance
Extra coverage beyond your basic insurance plan.
Survivor Benefit
Life insurance payment that goes to your beneficiary when you die.
T
Telemedicine
Remote health services via technology for minor acute conditions.
Term Life Insurance
Life insurance covering a set period of time.
Therapeutic Alternative
Different medication that treats the same condition.
Third-Party Administrator
Company contracted to administer group benefits.
Traditional Plan
Type of plan that lets you see any licensed provider but you pay more out-of-pocket.
Transaction Date
When an HSA or FSA withdrawal or deposit happens.
Transition of Care
Temporary coverage from non-network providers after switching plans.
Transitional Care
Temporary coverage from non-network providers after switching plans.
TRICARE
Military health benefits program.
TRICARE For Life
Extra coverage for military retirees with Medicare.
True Out-of-Pocket Costs
Your total costs for Medicare Part D drugs.
U
Urgent Care
Walk-in clinics for immediate care when your doctor isn’t available.
Usual, Customary and Reasonable Charge
Typical cost of service in a geographic area.
V
Vision Coverage
Extra insurance to get routine eye exams and glasses/contacts.
Voluntary Benefits
Additional coverage you can choose
W
Waiting Period
Time between starting a job and being eligible for health benefits.
Waiver of Premium
Option to stop paying premiums for employer coverage if disabled.
Whole Life Insurance
Lifelong life insurance policy that builds cash value.
Worker’s Compensation
Benefits if you’re injured or ill because of your job.