Health Insurance Glossary
Health insurance terms, explained simply
Definitions from HealthCare.gov, paired with practical context so you can pick a plan that actually fits. Use search to find a term, or browse the full list below. Understand deductibles, premiums, copays, HMOs, PPOs, and everything in between.
Showing 24 of 256 health insurance terms
GeneralPenalty
A payment ("fee," "fine," "individual mandate") you made when you filed taxes if you didn't have health insurance that counted as…
GeneralAnnual deductible combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health…
GeneralLarge group health plan
In general, a group health plan that covers employees of an employer that has 51 or more employees. In some states large groups are defined…
GeneralPre-existing condition exclusion period (individual policy)
The time period during which an individual policy won't pay for care relating to a pre-existing condition. Under an individual policy,…
GeneralOut-of-network coinsurance
The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your…
GeneralUCR (usual, customary, and reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar…
ACA / MarketplaceCatastrophic health plan
Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but don't cover any benefits other than 3…
MedicareState Health Insurance Assistance Program (SHIP)
A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare.
GeneralMedically necessary
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted…
GeneralEmergency room care
Emergency services you get in an emergency room.
GeneralPrior 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…
GeneralCommunity rating
A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
GeneralState medical assistance office
A state agency in charge of the state's Medicaid program and can give information about programs in its state that help pay medical bills…
GeneralMedical loss ratio (MLR)
A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses…
GeneralCoinsurance
A percentage of the cost that you pay for each plan-covered service, like 20%.
GeneralIn Person Assistance Personnel Program
Individuals or organizations that are trained and able to provide help to consumers, small businesses, and their employees as they look for…
GeneralMember survey results
A survey conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) which asks health plan members to rate the care…
GeneralHospital outpatient care
Care in a hospital that usually doesn’t require an overnight stay.
GeneralGrace period
A short period after your monthly health insurance payment is due to pay all owed premiums to avoid losing coverage.
GeneralPrimary care
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors,…
GeneralNotice
An official form of communication that informs individuals about the status of their applications, their eligibility for programs, or other…
GeneralUrban Indian programs
Health programs available to American Indians and Alaska Natives living in urban areas.
GeneralPrescription drug coverage
Health insurance or plan that helps pay for prescription drugs and medications. All Marketplace plans cover prescription drugs.
GeneralUncompensated care
Health care or services provided by hospitals or health care providers that don't get reimbursed. Often uncompensated care arises when…
Showing 1–24 of 256 results
Common Questions About Health Insurance Terms
Health Insurance Definitions by State
Health insurance rules, marketplace plans, and Medicaid eligibility vary by state. Explore state-specific guides to understand how terms apply where you live.
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