Click on the term below to find the definition.
This refers to medical care availability based on proximity, transportation options, types of medical facilities, etc.
Advanced Premium Tax Credit
This is federal money offered to help mid- to lower-income Americans pay for health coverage for their families. You have to qualify to get subsidy money based on income levels determined by the Federal Government. If you think you may qualify, you can check poverty and income levels here. Keep in mind, if you are covered by group health insurance or Medicaid, you will not qualify for these subsidies.
Affordable Care Act (ACA)
You have probably heard this referred to as "health care reform". Officially, it’s the Patient Protection and Affordable Care Act and U.S. Congress passed it in 2010. Some benefits that were key to the act include extending health care coverage to Americans without insurance or with pre-existing conditions and adding efficiencies to the health care system.
Somebody you would see who is licensed to sell health insurance to individuals.
The individual who receives insurance benefits.
This refers to specifically what your health plan will pay for — an annual physical, lab work, etc. What your insurance covers depends on the plan you have and your benefits documents will list the items covered and the items you may be responsible for paying for.
This is an independent insurance salesperson who is licensed as an agent and as a broker. They typically represent particular insurers. However, they some times function as a broker. This means they will search the entire insurance market in order to find a plan that will maximize protection and minimize cost for the applicant.
When a request is filed to the health plan to pay for a patient’s health care services, this is called a claim.
The pre-determined out-of-pocket fee you pay for certain health care services such as a trip to the emergency department.
The amount you must pay for your covered health care services before your insurance starts to pay.
This is typically a husband, wife or unmarried child who depends on the person who is the policyholder for their health care coverage.
Eligibility (also Subsidy Eligibility)
In order to receive Federal Government monies to help pay for your health coverage, you need to qualify — usually based on household income. If you qualify, you receive the money in the form of a subsidy or cost-share reduction linked directly to your insurance company on your behalf.
Essential Health Benefits
Starting in 2014, it is mandatory that a specific set of health care service categories are covered by certain health plans.
Exchange, Health Insurance Exchange (also Marketplace)
An online site where individuals and small businesses shop and buy health plans. All plans included in the Marketplace must offer a standard level of medical services and health care coverage.
Federal Poverty Level (FPL)
This is used to see if you qualify for federal subsidies and to determine how much help you need paying for health coverage based on your household income. Every year, The Department of Health and Human Services issues new FPL levels.
Health Care Tax Credit
This is money issued to you through a new tax credit. It lowers your health plan premium only if you are purchasing insurance through the Marketplace Exchange. You can use the credit right at time of purchase to lower your personal cost. However, you must qualify for this credit.
Health Insurance Exchange
You will also hear this referred to as the "health insurance marketplace". It’s where state and federal exchanges will offer you a choice of qualified plans from private health insurers.
Only certain health care providers and facilities are contracted to provide health services to a health plans members. These providers and facilities are referred to as “in network”.
One of several ACA reforms that may affect you the most. It requires that every American have health coverage that meets a minimum value standard. And if you don’t, you could pay a penalty.
Financial help from the federal government to help pay for health insurance costs.
Mandate (also Individual Mandate)
One of several ACA reforms. Since January 1, 2014, most Americans and legal residents are required to have minimum essential health benefits.
Marketplace (also Exchange)
Refers to the state and federal health insurance exchanges as a whole.
Government-funded health insurance for low-income Americans.
This is government-funded health insurance for Americans over 65. It also benefits those with specific conditions and permanent disabilities.
Trained and able to help consumers, small businesses and their employees look for health coverage options through the Marketplace, these individuals or organizations have 5 services to provide to customers. Under law, they are required to: educate people about available health plans, give unbiased information about plan enrollment, available tax credits and cost-sharing, help people enroll in plans, to refer people having issues with their coverage or premium assistance to a program or agency that can help and to provide help in the appropriate language or cultural context.
Your health insurer or plan will contract with certain facilities, providers and suppliers to provide you with health care services.
During this time period, you can enroll in a health insurance plan through the Marketplace.
Out Of Network
Facilities, providers and suppliers your health insurer or plan has not contracted with to provide health care services.
Before insurance will pay 100% of expenses, this is the maximum amount a person needs to pay for their health care.
If you choose not to have health care coverage, this is the amount you will need to pay.
How much you pay for insurance protection of a specified risk for a specified amount of time.
Primary Care Provider
The one health care provider who an individual sees for their overall health care needs. This health care provider can refer the patient to specialists if necessary.
A practitioner — i.e. a doctor — or entity — i.e. a hospital — that provides health care services.
Qualified Health Plan (QHP)
A federal or state marketplace certified insurance coverage plan that provides both essential health benefits and affordable health care coverage. The Federal Marketplace only sells Qualified Health Plans.
Qualifying Life Event
You may qualify for a special health coverage enrollment period if you experience a life event such as moving to a new state, a change in income or a change in family size.
Money offered from the federal government to help mid- to lower-income Americans and their families pay for health coverage. You must qualify to receive subsidy money and this depends on income levels set by the Federal Government. Check poverty and income levels here. Remember, you will not qualify for subsidy money if you get employer health insurance, Medicare or Medicaid.