Health Insurance Glossary | Cover Missouri

Affordable Care Act (ACA), also known as Obamacare

A law passed in 2010 that made many changes in how Americans get health insurance. It created a website, the Health Insurance Marketplace, as a new way to buy health insurance.

Affordable coverage

A term used to describe an employer-offered insurance plan where an employee’s share of the premium (for his/her own coverage, not dependents’) is no more than a certain percentage of the employee’s annual household income. The percentage is set by the IRS each year. If your employer offers affordable coverage that provides minimum value, you can’t get a tax credit to help pay for your premiums.

Appeal

A request to your health insurance company to change a decision it has made about your coverage. For example, you may file an appeal if the company cancels your coverage or decides to not pay health care services you think should be covered.

Assisters

People (see “Certified Application Counselors” and “Navigators”) who provide free help to consumers enrolling in the Health Insurance Marketplace.

Benefit year or coverage year

A year of health insurance coverage. For example, a plan starting January 1 will end December 31. At the end of the benefit year, you re-enroll and begin paying out-of-pocket costs to meet your plan deductible again.

Benefits

The health care services or items, such as medicines or medical equipment, your health insurance plan covers.

Brand name prescription drug

This is a medicine sold under a specific name by the company that makes it. Your doctor may prescribe a brand name drug and the pharmacy may give you a generic version of this medicine. Generic medicines are often cheaper than brand name medicines.

Bronze health plan

A Bronze health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Bronze plans usually have lower monthly costs, but higher out-of-pockets. They usually cover about 60% of your health plan costs. You would have to pay the other 40%.

Catastrophic coverage

An insurance plan in the Health Insurance Marketplace that offers limited coverage for health care services. This plan is only available to adults under age 30 or adults who get a hardship waiver for a life situation that kept you from getting health insurance, for example, recent death of a close family member.

Certificate of coverage

Tells you the period of time you will be covered by your health plan. It acts as a contract, spelling out your Health Insurance Marketplace plan benefits and provides useful information regarding costs and care.

Certified Application Counselor (CACs)

People who provide free help to consumers enrolling in the Health Insurance Marketplace. CACs work at local community organizations, hospitals, or health centers.

CHIP (Children’s Health Insurance Program)

A program funded by the state and federal government to provide health coverage to children (and, in some states, pregnant women) in families who earn too much money to qualify for Medicaid but cannot afford to buy health insurance. In Missouri, CHIP is part of the MO HealthNet for Kid’s program.

Claim or insurance claim

A request for payment that you or your health care provider send to your health insurance company when you visit a doctor, hospital, or pharmacy.

COBRA coverage

If you lose your job, you can temporarily keep your employee health insurance – but you must pay all of the monthly premiums yourself, including the share the employer used to pay.

Coinsurance

Your share of the cost for health care services after you have paid your deductible each year (see “Deductible”). Once you reach your deductible, the insurance plan will start sharing the cost of health care with you. For example, if you go for a doctor visit that costs $100, your share may be $20 and your insurance plan’s share may be the remaining $80.

Co-payment

A fixed amount you may pay at the time you receive a health care service – for example, you may pay $15 when you go for a doctor visit.

Cost-sharing reductions

Money the government pays to help cover out-of-pocket health care costs for people who qualify. People qualify based on their yearly income and enrolling in a Marketplace Silver plan. Find other rules about qualifying for cost-sharing reductions at healthcare.gov.

Cost-sharing reduction

Money the government pays to help cover out-of-pocket health care costs for people who qualify. People who qualify, in general, are those who enroll in a Marketplace Silver plan and have a yearly income that is from 100 percent to 250 percent of the Federal Poverty Level (FPL). Other rules for qualifying for cost-sharing reductions are shown at www.healthcare.gov.

Deductible

The amount you must pay out of your own pocket for your covered health care services each year – for example, $1,000. Once you reach your deductible, your insurance plan will begin sharing the cost with you (see “Coinsurance”).

Dependent

A child or other person who you claim on your taxes for a personal exemption tax deduction.

Dental coverage

Insurance that helps pay for basic or preventive dental services, such as teeth cleaning, x-rays, and fillings.

Drug tier

Levels or categories of drugs preferred by your insurance company. Drugs are divided into tiers based on their cost. For example, Tier 1 often includes generic drugs that have the lowest cost, Tier 2 often includes preferred brand-name drugs that cost more, and Tier 3 often includes nonpreferred brand-name drugs that have the highest cost.

Emergency care

Health care services you get in the emergency room (ER) at a hospital.

Employer shared responsibility payment (ESRP)

The Affordable Care Act requires some employers with 50 or more full-time employees (or equivalents) to offer health coverage that meets certain standards or pay a tax called the Employee Shared Responsibility Payment.

Employer-sponsored insurance plan

Insurance you get through your job. Employers that offer an insurance plan pay a share of their employees’ monthly premiums.

Essential health benefits

The 10 kinds of health care services most insurance plans must now cover, including care to help prevent disease, care for children, emergency care, prescription drugs, and more.

Excluded services

Health care services that are not covered and not paid for by your insurance plan.

Exclusive provider organization (EPO)

A type of health insurance plan that only pays for in-network health care services or for out-of-network care in an emergency.

Explanation of benefits (EOB)

A written explanation your insurance company sends to you after you get a health care service. The EOB shows how much money the insurance company paid and how much money you must pay (if any) for the covered health care service or item. The EOB is not a bill. If you owe any money, you will get a bill from your health care provider.

Federal Poverty Level (FPL)

A measurement of how much a person or family needs to earn so they can pay for food, clothing, housing, and other necessary things. The government decides what the FPL is for each year. You can find the current FPL here.

Federally qualified heath center (FQHC)

Community health centers or clinics that provide low-cost health care in areas that don’t have enough doctors to serve the people living there.

Federally recognized tribe

A federally recognized tribe is any Indian or Alaska Native tribe, band, nation, pueblo, village, or community recognized by the federal government.

Formulary or drug formulary

A list of the prescription medicines or drugs that are covered under your insurance plan. Most plans use a formulary that groups the drugs into tiers, or levels, to control costs. Your plan may pay less for the drugs in some tiers.

Full-time employee

A person who works an average of 30 hours a week is considered a full-time employee.

Full-time equivalent (FTE) employee

A full-time employee or a combination of part-time employees whose hours add up to full time. The Affordable Care Act has a formula to calculate how many FTE employees a business has.

Gold health plan

A Gold health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Gold plans usually have higher monthly costs, but lower out-of-pockets. They usually cover about 80% of your health plan costs. You would have to pay the other 20%.

Generic prescription medicine

A generic prescription is a medicine sold without a brand name. Generic medicines usually cost less than brand name medicines but work the same way. The order from your doctor may say the brand name drug and note that it is okay to fill the prescription with a generic form of the medicine.

Grace period

A period that begins after an insured person does not pay his or her insurance premium. For plans in the Marketplace, your benefits will reduce or stop after 30 days of a grace period, and your coverage will be cancelled after 90 days, unless you begin paying your premium again.

Grandfathered health plan

As used in connection with the Affordable Care Act: A group health plan that was created, or an individual health insurance policy that was bought, on or before March 23, 2010. Grandfathered plans do not have to meet the new standards required under the Affordable Care Act.

Grievance

A complaint that you communicate to your health insurance company if it won’t pay for covered medical services or specialists or takes any other action that you believe hinders your ability to get quality health care. Learn more at: http://insurance.mo.gov/consumers/complaints/index.php.

Group Health Plan

A health insurance plan offered by an employer or an employee organization that provides health coverage to employees.

Habilitative or habilitation services

Health care that helps you keep, learn, or improve skills and ability to function for daily living. Some examples are speech therapy and physical therapy.

Hardship exemption

Circumstances that make it hard for a person to purchase health insurance coverage. Examples are homelessness, domestic violence, or bankruptcy.

Health insurance

Health insurance helps you pay for medical care and can protect you from high health care costs, like emergency room visits or hospital stays. Having health insurance gives you access to preventive care and provides a safety net when unexpected medical emergencies happen. Health insurance coverage is a contract with a health insurer.

Health Insurance Marketplace

An online marketplace where you can buy a Qualified Health Plan (Bronze, Silver, Gold, and Platinum) or Catastrophic coverage from private insurance companies.

Health maintenance organization (HMO)

A type of health insurance plan that contracts with a specific network of health care providers and only pays for health care that is received from those providers.

Health plan categories

Missouri Marketplace health plans are divided into four plan categories: Bronze, Silver, Gold, or Platinum. Plan categories are based on how you and the insurance company will share costs. Bronze and silver plan will generally have lower monthly costs, but higher out-of-pockets. Silver and platinum plans usually cost more each month, but have lower out-of-pocket costs.

Health savings account (HSA)

A savings account available to people who enroll in a high deductible health plan. The money you put into the account can only be used to pay for qualified medical expenses, such as doctor visits or medicines. The advantage to you is that the money you put into the account is not taxed by the federal government.

High deductible health plan

An insurance plan that has a higher deductible than most insurance plans – for example, $3,000.

HIPAA, Health Insurance Portability and Accountability Act

The Privacy Rule, a Federal law, that gives you rights over your health information and sets rules and limits on who can look at and receive your health information. When you go to a doctor’s office or other health provider, you may need to read about HIPAA and sign a statement saying you understand it.

Household income

The total amount of money earned or received by you, your spouse, and dependents you claim on your taxes. Find full rules on what qualifies as income at www.irs.gov.

In-network providers

Health care providers, including doctors, hospitals, and other suppliers, who contract with your insurance plan to give health care services to you at a lower cost. In-network providers are also called “preferred” providers.

Inpatient care

Health care services that require you to stay overnight in a hospital or other health care facility. Care that does not require an overnight stay is called “outpatient” care.

Insurance card

A wallet-sized card with information about your health plan, such as your name and policy number. It proves you have health coverage. You will need to show your health insurance card when you visit the doctor, hospital, emergency room, or other places to get health care services.

Lifetime limit

A limit on the total lifetime benefit payments some insurance companies will pay for a person’s health care – for example, $1 million. An insurance company may also limit benefit payments for a specific type of health care, such as organ transplants or certain types of surgery. After the insurance company has reached the lifetime limit on your benefit payments, it will no longer pay any money for your health care benefits.

Short-term, limited duration plans may have lifetime limits. Under the Affordable Care Act, most Qualified Health Plans cannot use lifetime limits on most benefits.

Managed care

Managed care is a system in which people get most or all of their Medicaid services from an organization under contract with the state. Managed care companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state.

Medicaid

A government health insurance program for Americans who have low incomes or disabilities. In Missouri, this program is called “MO HealthNet” for adults, and “MO HealthNet for Kids” for children up to age 19.

Medicaid expansion

Under the Affordable Care Act, the federal government offered money to help each state pay for and expand Medicaid coverage to more people.

Medicaid gap

A gap in government financial help for adults living in states that did not expand Medicaid. Adults who fall into the Medicaid gap make too much money to get Medicaid, but don’t make enough money to get financial help to buy Marketplace insurance plans.

Medicare

A government health insurance program for Americans who are age 65 or older, certain younger people with disabilities, and people who have end-stage renal disease (kidney failure).

Medicare Part D donut hole

The donut hole is a gap in Medicare prescription coverage, where the plan does not cover medicine costs until you have spent a certain amount out of pocket. Once you reach the out-of-pocket limit, the plan will help pay for covered medicines again. Under the Affordable Care Act, the donut hole is being phased out as discounts for brand name and generic prescription drugs are introduced and other adjustments are made. In 2020, the coverage gap will close.

Minimum value coverage

A value set by the Affordable Care Act for employer-sponsored plans. Learn more about calculating minimum value coverage at: www.irs.gov.

Missouri Health Insurance Marketplace (also called Marketplace)

A website (healthcare.gov) where you can shop for health insurance plans. The plans you see on the Marketplace website are owned and operated by insurance companies, not the Marketplace. The Affordable Care Act (also known as Obamacare or ACA) created the Marketplace as a way to buy health insurance.

Navigators

People who are certified to provide free help to consumers enrolling in the Health Insurance Marketplace. Find a Navigator in your area at findlocalhelp.covermissouri.org.

Obamacare

See Affordable Care Act.

Open enrollment period

A period of time when you can enroll in or change a health insurance plan in the Marketplace. Find dates for open enrollment at healthcare.gov.

Out-of-network provider

Health care providers, including doctors and hospitals, who have not contracted with your insurance plan. Out-of-network providers are also called “nonpreferred” providers. You’ll pay more for their services.

Out-of-pocket costs, also known as cost sharing

Money that you pay for covered health care services yourself, out of your own pocket. These costs include deductibles, co-payments, and coinsurance. They do not include monthly premiums and may not include costs for services you get outside your provider network.

Out-of-pocket maximum

A limit on your out-of-pocket costs – for example, $5,000. After you have reached your out-of-pocket maximum for the year, your insurance company will pay 100% of your covered essential health benefits. Out-of-pocket maximum costs differ from plan to plan.

For example, your deductible may or may not count toward your out-of-pocket maximum. Check the Summary of Benefits and Coverage (SBC) for your insurance plan to see which out-of-pocket costs count toward your out-of-pocket maximum.

Outpatient care

Health care services that do not require you to stay overnight in a hospital or other health care facility. Care that requires an overnight stay is called “inpatient” care.

Over-the-counter (OTC)

Over-the-counter are medicines you can buy without a prescription.

Part-time employee

An employee who works, on average, less than 30 hours a week for an employer.

Pre-authorization or pre-certification

Permission you may need to get from your insurance company before you use certain health care services, including treatments, prescription drugs, or medical equipment. If you do not get permission before you use these services (except for an emergency), the company may not cover these costs. Also called “prior authorization” or “prior approval.”

Pre-existing condition

A health problem you had before your health insurance started. Health insurance companies can’t refuse to cover you or charge you more just because you have a pre-existing condition.

Preferred provider organization (PPO)

A type of health insurance plan that gives you a choice to get health care services in-network or out-of-network, although it will pay less for out-of-network services.

Premium

The cost you pay for your health insurance. Premiums may be paid by you, your employer, or a combination of both. It is usually paid monthly.

Premium tax credit

Money the government pays to help cover monthly premium payments for people who qualify. People who qualify, in general, are those who enroll in a Marketplace plan and have a yearly income that is between 100% and 400% of the Federal Poverty Level (FPL). Other rules for qualifying for tax credits are shown at healthcare.gov. To see how much you could save, use the tax credit estimator.

Premium tax credits help make health care more affordable by lowering the cost you pay for your health insurance plan each month, which is called your premium. Premium tax credits can be taken now or later.

Prescription drugs

Medicines that are prescribed, or ordered, by your doctor or other health care provider. Medicines that you can buy without a prescription, like Tylenol, are called “over-the-counter” medicines.

Preventive care

Routine health care that includes screenings, check-ups, and patient counseling to help prevent illnesses, disease, or other health problems. Many preventive care services are covered at no cost under the Affordable Care Act.

Primary care doctor

A doctor who gives care for common health problems and for preventing illness. He or she can help you get access to special care services if you need them.

Primary care visit

A visit to a primary care doctor, nurse, nurse practitioner, or physician assistant to get preventive care or treatment for a common illness like the flu.

Private health insurance company

A private health insurance company is a business that offers health insurance plans that are not owned by the government. Health insurance companies can be nonprofit or for-profit businesses.

Provider

A medical professional or a hospital or other medical facility that provides health care services.

Qualified Health Plan

An insurance plan that provides the 10 essential health benefits and meets other standards put forth by the Affordable Care Act. The Bronze, Silver, Gold, and Platinum plans sold in the Health Insurance Marketplace are qualified health plans.

Qualifying life event

A change in your life that can make you eligible for a Special Enrollment Period so that you can enroll in a Marketplace health insurance plan outside of open enrollment. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).

SHOP (Small Business Health Options Program)

A health insurance program for small businesses (50 or fewer full-time equivalent employees) that want to offer health or dental insurance to their employees.

Short-term, limited duration (STLD) health insurance plans

Plans that provide coverage for a limited amount of time – the contract lasts less than one year and may be renewed for up to three years at most. They do not have to follow the rules of the Affordable Care Act, so these plans may not cover pre-existing conditions or all 10 essential health benefits and may put limits on how much they’ll pay for covered health care.

Sliding scale

A system that adjusts the cost of health care services depending on how much you can pay. Costs are lower for people who make less money.

Small business

A business that has 50 or fewer full-time equivalent (FTE) employees. Small businesses can get health insurance for their employees through the SHOP.

Small business tax credit

Money that the government pays to businesses that have 25 or fewer employees to help cover the employer share of premium payments. Businesses that qualify must pay at least 50% of employees’ premiums. Find rules for qualifying for small business tax credits at healthcare.gov.

Special Enrollment Period

A period of time outside of open enrollment when some people can enroll in or change an insurance plan in the Marketplace. In general, you may get a Special Enrollment Period when you have a qualifying life event (see “Qualifying life event”).

Special care doctor or specialist

A doctor who gives health care for a specific medical problem – for example, a foot doctor or heart doctor. A doctor who gives care for common illnesses or injuries is called a primary care doctor.

Summary of Benefits and Coverage (SBC)

A written summary of a health insurance plan that shows its costs and benefits. When you are shopping for health insurance, you can compare the costs and benefits of different plans by reading their SBCs. When you enroll in a health insurance plan, your insurance company will send you the SBC for your plan.

Tax credits

Money the government pays to help cover monthly premium payments for people who qualify. People qualify based on their yearly income. Find rules for qualifying for tax credits at www.healthcare.gov.

Urgent care

Care for an illness, injury, or condition serious enough that you would seek care right away, but not so severe that you would go to the emergency room.

Wellness programs

Programs intended to improve and promote health and fitness that are usually offered through your job. Wellness programs allow your job to offer you discounts, gym memberships, cash rewards, or other perks for participating. Examples of wellness programs include programs to help you stop smoking, loss weight, or get health screenings.