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Health Insurance Glossary
A
Affordable Care Act (ACA): The ACA is a comprehensive health care reform law enacted in March 2010 that expanded access to affordable healthcare by protecting people with pre-existing conditions from being denied health insurance coverage.
Agent: An insurance agent or broker is a person or business able to help you enroll in a Qualified Health Plan (QHP) through Healthcare.gov and apply for help to make coverage more affordable. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling people into an issuer’s plans. Some brokers may only be able to sell plans from specific health insurers.
Aid to the Aged, Blind, or Disabled (AABD) Program: A cash assistance program offered through the Illinois Department of Human Services to assist the elderly, blind or disabled with financial help or medical care.
All Kids: The Children’s Health Insurance Plan (CHIP) in Illinois. This program provides comprehensive health coverage for children up to age 18, including doctor visits, hospital stays, prescription drugs, vision care, dental care and medical devices like eyeglasses and asthma inhalers. Monthly premiums vary on a sliding scale based on annual household income.
Ambulatory Services: Outpatient care you get without being admitted to a hospital for an overnight or long-term stay. This is one of the 10 Essential Health Benefits covered by all ACA Marketplace plans.
Appeal: A request for your health insurer or plan to review a decision or a grievance again.
Application Counselors: Specially trained professionals that are available to help answer your questions and find coverage for you, your family or your business. In-person professionals, such as navigators, brokers, or agents provide free, confidential enrollment help in your language and your community.
B
Beneficiary: A person eligible for or receiving benefits under an insurance policy or plan.
Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s documents. In Medicaid or All Kids, covered benefits and excluded services are defined in state program rules.
Brand Name (Drugs): A drug sold by a drug company under a specific name or trademark and is protected by a patent. Brand name drugs may be available by prescription or over the counter.
Broker: An insurance agent or broker is a person or business able to help you enroll in a Qualified Health Plan (QHP) through Healthcare.gov and apply for help to make coverage more affordable. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling people into an issuer’s plans. Some brokers may only be able to sell plans from specific health insurers. Bronze Health Plan: See "Health Plan Categories"
C
Certified Application Counselor: See "Navigator"
Chronic Disease Management: An integrated approach to managing chronic illness, which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease.
Coinsurance: A type of cost-sharing where you pay a percentage of the total price for a covered health care service, like a lab test, and your insurer pays the rest. The percentage varies for different health care services depending on the health plan you choose.
Copay: A fixed amount that you pay for health care services covered by your plan, like a doctor visit, usually paid when you receive care.
Cost Sharing: The amount of costs covered by your insurance that you pay out of your own pocket. Cost sharing generally includes deductibles, coinsurance and copays, but does not include premiums, balance billing amounts for non-network providers or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
D
Deductible: The amount you pay before your insurance provider will begin paying for most health care services covered by your health plan. Some insurance providers will pay for services before you meet the deductible, so it is important to confirm the details of your coverage plan with the insurance company.
Disability: A condition that limits an individual in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working. Different programs may have varying disability standards, so check the program you are interested in to learn more about its disability standards. The list of activities mentioned above isn’t exhaustive.
E
Emergency Services: Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Services are usually received in an emergency room at the hospital.
Employer Sponsored Coverage: See Job-based Health Plan
Essential Health Benefits: A set of 10 health care services that must be covered by all Healthcare.gov and Medicaid plans. The 10 Essential Health Benefits include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Exchange: See Health Insurance Marketplace
F
Federal Poverty Level: A measure of income level determined annually by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine your eligibility for certain programs and benefits.
Fee: See penalty
Financial Help: Tax credits or subsidies provided by the federal government that could help lower the cost of your health coverage through Healthcare.gov if you qualify.
Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This could also be called a drug list.
Full-Time Employee: An employee who works an average of at least 30 hours per week. Employees who work less than an average of 30 hours per week are considered part-time employees.
Fully Insured Job-based Plan: A health plan purchased by an employer from an insurance company.
G
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.
Gold Health Plan: See Health Plan Categories
Grandfathered Health Plan: A group or individual health plan that was created or purchased on or before March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise people how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010.
H
Habilitative/Habilitation Services: See Rehabilitative/Rehabilitation Services
Health Coverage: Same as Health Insurance. A health coverage contract that requires your health insurer to pay some or all of your health care costs in exchange for a monthly fee, called a premium.
Health Insurance: Same as Health Coverage. A health coverage contract that requires your health insurer to pay some or all of your health care costs in exchange for a monthly fee, called a premium.
Health Insurance Marketplace: A service where individuals, families, and small businesses can compare health plans for coverage and affordability, and enroll in or change a health plan. The Marketplace provides financial help for those that qualify through premium tax credits, and provides Information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). Get Covered Illinois Navigators offer free enrollment assistance and help connect you to coverage at Healthcare.gov where consumers can enroll in a health plan.
Health Plan Categories: Plans in Healthcare.gov are primarily separated into four health plan categories based on the percentage the plan pays of the average overall cost of health services. These categories include Bronze, Silver, Gold, and Platinum. The plan category you choose affects the total amount you will 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).
Hospice Services: Services to provide comfort and support for people in the last stages of a terminal illness. Support services are also provided to the families of hospice patients.
Hospital Outpatient Care: Care in a hospital that usually doesn’t require an overnight stay.
Hospitalization: Health care provided in a hospital that requires admission as an inpatient and usually requires an overnight stay.
I
Individual Health Insurance Policy: Policies for people that aren’t connected to job-based insurance. Individual health insurance policies are regulated under state law.
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.
J
Job-based Health Plan: Health coverage, also known as employer-sponsored coverage, that is offered to an employee (and often his or her family) by an employer.
M
Marketplace: See Health Insurance Marketplace
Medicaid: A state-administered health coverage program for low-income families and children, pregnant women, the elderly, people with disabilities and other adults. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. Medicaid coverage is often available for little or no cost.
Medicare: A health coverage program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Mixed Status: Families with members having different immigration and citizenship statuses. Mixed status families can apply for coverage through Medicaid or the Marketplace for eligible family members. Only individuals who are eligible to apply will be asked to verify immigration status. Individuals and families who are U.S. citizens or are lawfully present in the United States may buy insurance through Healthcare.gov. Adults who are U.S. citizens or qualified immigrants may be eligible for Medicaid at little to no cost. Some undocumented pregnant women and children may qualify for Illinois’ Moms & Babies and All Kids based on household income.
Moms & Babies: Moms & Babies is a government program that provides health coverage for pregnant women and their babies. Moms & Babies covers women while they are pregnant and for 60 days after the baby is born. It also provides coverage for the first year of the baby’s life if the mother was covered by Moms & Babies when the baby was born. Moms & Babies does not have premiums or co-payments. You can qualify for Moms & Babies if you are pregnant and meet the income requirements. You do not need to be a citizen, legal immigrant, or have a Social Security number to get Moms & Babies.
N
Navigator: Individuals that are trained and able to provide help to consumers, small businesses, and their employees as they look for health insurance options through Healthcare.gov, including helping them complete eligibility and enrollment forms. Navigators might also be called Certified Application Counselors. These individuals and organizations are required to be unbiased. Their services are free to consumers.
Network: The health facilities, providers and suppliers your health insurance company or plan has contracted with to provide health care services.
O
Open Enrollment Period: A yearly period when eligible individuals can enroll in a new health plan or make changes to their existing health coverage. The Open Enrollment Period for the Health Insurance Marketplace is November 1 through January 15 each year. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain qualifying events. (See Special Enrollment Period and Qualifying Life Event) You can apply for Medicaid or All Kids at any time of the year.
Out-of-Pocket Costs: Your expenses for medical care that are not reimbursed by your insurance company. This includes deductibles, coinsurance and copayments for covered services and all costs for services that are not covered by your insurance company.
P
Plan: A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Plan Year: A 12-month period of health coverage under a group health plan. To find out when your plan year begins, you can check your plan documents or ask your employer. For individual health coverage plans this 12-month period is called a “policy year”.
Platinum Health Plan: See Health Plan Categories
Policy Year: A 12-month period of health coverage under an individual health coverage plan. To find out when your plan year begins, you can check your plan documents or ask your insurance company.
Pre-Existing Condition: A health problem or condition that you had before you enrolled in your new health coverage plan. This includes any medical issues that you face prior to the start date of your health coverage.
Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Premium Tax Credit: A form of financial help available on Healthcare.gov to lower the cost of your coverage. Eligibility for premium tax credits is determined by your income.
Prescription Drug Coverage: Health coverage that helps pay for prescription drugs and medications.
Prescription Drugs: Drugs and medications that by law require a prescription.
Prevention: Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.
Preventive Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Q
Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period, meaning you can enroll or make changes to your plan outside of the Open Enrollment Period in Healthcare.gov.
R
Recipient Identification Number (RIN): The ID number on your Medicaid medical card. You must give your RIN to your health provider or pharmacy when you seek medical attention.
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.
S
Silver Health Plan: See Health Plan Categories
Special Enrollment Period: "Outside Open Enrollment, you can enroll in a private insurance plan only if you have certain life events that give you a Special Enrollment Period. To buy a Healthcare.gov plan outside the Open Enrollment Period, you must have a Qualifying Life Event, such as getting married, having a baby, moving to an area that offers different health plan options, or involuntarily losing access to other health coverage. Most Healthcare.gov Special Enrollment Periods last 60 days from the date of the qualifying life event. Also, job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other job-based health coverage.
Subsidized Coverage: A health coverage plan that is paid for in part by the federal government or your employer. The amount of the subsidy, or financial help, is determined by your income and eligibility on Healthcare.gov.
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A division of the Illinois Department of Insurance