Health Insurance Dictionary

In the United States, we tend to recognize three major types of health insurance: employer-sponsored insurance, public insurance such as medicare and medicaid, and private health insurance. Each of these options has their own benefits. Health insurance can be a confusing topic, but HealthPlanOptionsToday is here to help you.

Below is a list of health insurance terms that we get asked about the most:

Certificate of coverage

A certificate of coverage is a legal and binding document between the health insurer and a group to provide benefits to eligible members. The certificate spells out the benefits, limitations, and exclusions in the health plan.

Co-insurance

The amount of medical costs the patient pays after reimbursing the health insurance plan deductible. Co-insurance is often a percentage of the cost and is solely defined in the health plan itself. It sometimes varies according to the type of service provided as well as the benefits enlisted.

Copayment

Also is known as “copay” for short. The copay is the amount a patient has to pay after paying the health insurance plan’s deductible. Co-insurance is usually a percentage of the cost of the service and is defined in the health plan. It sometimes varies according to the type of service provided.

Deductible

A deductible is a flat amount that a patient must pay each year for covered medical services before health insurance pays for the services.

Group Health Insurance

Health plans offered to groups by employers and professional and alumni associations. It is easier to get coverage for pre-existing conditions under a group health plan than an individual health insurance plan.

Health Insurance Exchange (marketplace)

One-stop shops for comparing and purchasing insurance are called “health insurance exchanges” or the health insurance “marketplace.” This does not necessarily only apply to the federal government’s marketplace, but also the smaller state-run exchanges that some states have as well. Health insurance plans sold through exchanges must meet certain federal quality standards.

HMO

HMO stands for “Health Maintenance Organization.” Members in most HMOs choose a primary care physician who makes necessary referrals to specialists and, if needed, will also facilitate hospital care. In most cases, members must receive non-emergency care from providers in a network. Other HMO plans may offer drastically reduced benefits for out-of-network providers.

Individual health insurance

People who do not have health insurance benefits through work or a professional association. These are termed: “Individual health insurance” plans, or “individual health insurance.” This is when they purchase the insurance through an individual health insurance market.

Long-term care

Long term care refers to personal care services that help people with a chronic illness or a disability that affects their daily routines and activities, such as bathing, dressing, and eating. Substantial long-term care services are not covered under most health plans, disability insurance, or Medicare. Coverage can be purchased through long-term health care insurance.

Medicaid

A Federal-and-State-funded health insurance program for low income children, the elderly, the blind, or the disabled is called “Medicaid,” and should not be mistaken for “Medicare.” Some states use their own rules for eligibility for Medicaid, while others provide Medicaid to people who are eligible for Supplementary Security Income (SSI) or Disability Income (SSDI). Learn More About Medicaid>>

Medicare

Federally administered health insurance for people 65 or older. Medicare coverage is also available to people under 65 with certain disabilities and to people of any age who have permanent kidney failure. Legal U.S. residents who have lived here for at least five years are eligible. Medicare Part A provides hospital coverage, and Medicare Part B helps pay for doctors’ services and outpatient care. Medicare prescription drug plans are known as Part D. Medicare Advantage Plans (Part C) provides all the benefits of Parts A and B (known as Original Medicare) plus some additional services.

Learn More About Medicare and Medicare Supplements>>

Open Enrollment

The period each year when employees can change insurance plans offered through their employer is called “open enrollment” and allows for a specific time frames to work in favor of certain benefits.

PPO

A PPO is a “Preferred provider organization” and is a type of health plan that includes a network of preferred providers. The doctors, hospitals, labs and other providers in the network maintain contact with the insurer or health plan administrator in order to provide care at discounted rates to members. Parents pay higher out-of-pocket costs to receive care outside of the network.

Pre-existing condition

A pre-existing condition is defined as something that was present prior to accepting the employer’s (or other form of health insurance policy) health insurance benefits. Individual insurance policies may exclude certain pre-existing conditions from coverage. Under healthcare reform, insurers are now able to exclude coverage for pre-existing conditions (beginning in 2014).

Short-term health insurance

Short-term health insurance policies offer temporary health insurance coverage. These policies (which usually range from one to six months in duration) provide in the case of a sudden health crisis.