Health Insurance Glossary & Definitions

Note that this list includes some general healthcare and insurance terms that may not be specific to health insurance. It’s always best to check with your insurance provider or healthcare professional for more information on specific terms and definitions related to your coverage.

If you would like to search this page for a specific word or phrase, on a Mac press the CMD (Command key) plus the letter F at the same time, or on a Windows based PC, press the CTRL (control Key) pls the letter F.

Affordable Care Act (ACA) – A comprehensive health care reform law enacted in March 2010 aimed at improving access, affordability, and quality of health care in the United States.
Allowed Amount – The maximum amount an insurance plan will cover for a specific service, procedure, or treatment.
Annual Deductible – The total amount a policyholder must pay for covered services within a calendar year before the insurance plan begins to pay for benefits.
Annual Limit – The maximum amount an insurance plan will pay for specific covered services or benefits within a calendar year.
Annual Open Enrollment Period – A specified time period each year when individuals can enroll in or change their health insurance plan.
Appeal – A formal request made by a policyholder or health care provider to an insurance company to review a decision or claim denial.
Application ID – A unique identifier assigned to an individual’s health insurance application when submitted through the Health Insurance Marketplace.
Attest/Attestation – The act of declaring that certain information provided on a health insurance application or other forms is true and accurate to the best of one’s knowledge.
Authorized Representative – A person designated by a policyholder to act on their behalf in matters related to their health insurance coverage or claims.
Actuarial Value – A measure used to estimate the percentage of total average costs for covered benefits that a health insurance plan will cover.
Adverse Benefit Determination – A decision by an insurer to deny, reduce, or terminate a benefit or coverage, or a failure to provide or make a payment in whole or in part for a benefit.
Ambulatory Care – Health care services provided on an outpatient basis, without the need for hospital admission.
Amendment – A change made to an insurance policy, often to clarify or modify coverage, benefits, or terms.
Ancillary Services – Additional services that support medical care, such as laboratory work, diagnostic imaging, and physical therapy.
Application ID – A unique identifier assigned to an individual’s health insurance application when submitted through the Health Insurance Marketplace.
Assignment of Benefits – An agreement by which a policyholder authorizes their insurance company to pay benefits directly to a health care provider.
Association Health Plan (AHP) – A health insurance plan sponsored by a trade or professional association for its members.
Attained Age – The age of an individual at a particular point in time, often used to determine eligibility for certain benefits or coverage.
Average Length of Stay – A measure of the average number of days a patient stays in a hospital for a specific condition or procedure.

Balance Billing – The practice of a healthcare provider billing a patient for the difference between the provider’s charges and the amount allowed by the patient’s insurance plan. Balance billing is not permitted for in-network providers.
Benefit Period – A specified length of time during which insurance benefits are paid, usually a calendar year.
Benefits – The health care items or services covered under an insurance plan, such as doctor visits, hospital stays, or prescription medications.
Benefit Package – The specific set of benefits and coverage levels offered by a health insurance plan, including deductibles, co-payments, and out-of-pocket maximums.
Benefit Year – A 12-month period during which an insurance plan’s benefits are in effect, often aligned with the calendar year.
Brand-Name Drugs – Prescription medications marketed under a trademarked name, typically more expensive than their generic equivalents.
Broker – A licensed professional who assists individuals and businesses in selecting and purchasing health insurance plans.
Bundled Payment – A single payment made to healthcare providers for all services related to a specific episode of care, such as a surgery or treatment, intended to encourage cost-effective and coordinated care.
Buy-Up Plan – An insurance plan option that offers higher levels of coverage and benefits for an additional cost, compared to a lower-cost, less comprehensive plan.
Business Health Options Program (SHOP) – A program created under the Affordable Care Act that allows small businesses to offer health insurance coverage to their employees through a state-based or federally-facilitated marketplace.

Capitation – A fixed payment made to a healthcare provider, typically a primary care physician, for each enrolled member under their care, regardless of the actual services provided. This payment model is common in Health Maintenance Organizations (HMOs).
Certificate of Creditable Coverage – A document provided by a health insurance company to a former policyholder, indicating the length of time they were covered under the plan. This certificate can be used to prove prior coverage when applying for new health insurance, which can help in avoiding waiting periods for pre-existing conditions.
Certificate of Insurance – A document issued by an insurer that provides evidence of an individual’s health insurance coverage. It contains important information, such as the policy number, coverage period, and types of benefits included in the plan.
Children’s Health Insurance Program (CHIP) – A state and federal program that provides low-cost health insurance coverage to children in families with incomes too high to qualify for Medicaid, but who cannot afford private insurance.
Chronic Condition – A long-term health problem that requires ongoing medical attention or treatment, such as diabetes, heart disease, or asthma.
Claim – A request submitted by a policyholder or health care provider to an insurance company for reimbursement for covered services or treatments.
COBRA (Consolidated Omnibus Budget Reconciliation Act) – A federal law that allows eligible employees and their dependents to temporarily continue their group health insurance coverage after a qualifying event, such as job loss or reduction in work hours.
Co-insurance – The percentage of the allowed amount for a covered service that a policyholder is responsible for paying, after the deductible has been met.
Community Rating – A system used by some health insurance companies to determine premium rates for a group, where all members of the group are charged the same premium, regardless of their individual health status, age, or other factors.
Comprehensive Coverage – Health insurance that covers a wide range of health care services, including preventive care, hospitalization, and outpatient services.
Continuation of Coverage – The extension of health insurance coverage beyond the original term of a policy, often through COBRA or other state-specific programs.
Conversion – The process of changing one type of health insurance policy to another, such as switching from a group plan to an individual plan after leaving a job.
Coordination of Benefits (COB) – The process of coordinating payments between two or more insurance plans when a policyholder has coverage from more than one source.
Cost-Sharing – The portion of health care costs that a policyholder is responsible for paying, including deductibles, co-payments, and co-insurance.
Covered Services – The specific health care services, treatments, and procedures that are included in an insurance plan and eligible for reimbursement.
Creditable Coverage – Health insurance coverage that meets certain federal and state requirements and can be used to reduce or eliminate waiting periods for pre-existing conditions when switching to a new health plan.

Deductible – The amount a policyholder must pay for covered services before the insurance plan begins to pay for benefits.
Dependent – A person who relies on another person, such as a spouse or parent, for financial support and is covered under that person’s insurance plan.
Dental Insurance – A type of insurance coverage that helps pay for the cost of dental care, including preventive services, routine checkups, and treatment for oral health issues.
Disability Insurance – A type of insurance that provides financial protection and replaces a portion of a person’s income if they become unable to work due to a qualifying disability or illness.
Drug Formulary – A list of prescription medications covered by an insurance plan, typically organized by tiers that indicate the level of cost-sharing for each drug.
Durable Medical Equipment (DME) – Medical equipment that is prescribed by a doctor for use by a patient at home, such as wheelchairs, oxygen tanks, or hospital beds, and is covered by an insurance plan under certain conditions.
Direct Primary Care (DPC) – A healthcare model in which patients pay a monthly fee directly to a primary care physician for access to comprehensive primary care services, often bypassing traditional insurance arrangements.
Denial of Claim – A decision by an insurance company to refuse payment for a submitted claim, typically due to a lack of coverage, policy exclusions, or other reasons.
Diagnosis-Related Group (DRG) – A system used by hospitals and insurance companies to categorize and determine payment for inpatient hospital services based on the patient’s diagnosis, age, and other factors.
Disease Management Program – A coordinated approach to managing chronic conditions, such as diabetes or heart disease, through education, monitoring, and support services provided by an insurance plan or healthcare provider.
Dual Coverage – A situation in which a person has health insurance coverage through two different sources, such as two job-based plans or a combination of job-based and individual coverage.
Drug Utilization Review (DUR) – A process used by insurance companies or pharmacy benefit managers to evaluate and monitor the use of prescription drugs, ensuring appropriate prescribing and minimizing potential drug interactions or overuse.

Effective Date – The date on which an insurance policy or coverage begins.
Eligibility – Criteria that must be met for an individual to qualify for and enroll in a health insurance plan.
Emergency Medical Condition – A medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, which would lead a prudent layperson with an average knowledge of health and medicine to reasonably expect that the absence of immediate medical attention could result in serious harm or endangerment to the individual’s health.
Emergency Room (ER) – A hospital facility that provides immediate medical care for patients with acute or life-threatening illnesses or injuries.
Employee Assistance Program (EAP) – A workplace program designed to help employees manage personal and work-related issues, often including mental health and substance abuse services, offered as part of an employee benefits package.
Employer-Sponsored Health Insurance – Health insurance coverage provided by an employer as part of an employee benefits package.
Enrollment Period – The time during which individuals can apply for, change, or renew their health insurance coverage. This period typically includes an open enrollment period for all eligible individuals and special enrollment periods for those who experience qualifying life events.
Essential Health Benefits (EHB) – A set of 10 categories of health care services that must be covered by most insurance plans under the Affordable Care Act (ACA). These categories include hospitalization, prescription drugs, maternity care, and mental health services, among others.
Exclusions – Specific services, treatments, or conditions that are not covered by an insurance plan.
Exclusive Provider Organization (EPO) – A type of managed care health insurance plan that requires policyholders to receive care from a network of specified providers, similar to an HMO, but usually without the need for referrals for specialist visits.
Explanation of Benefits (EOB) – A document sent by an insurance company to a policyholder explaining the details of a claim, including what services were covered and what costs the policyholder is responsible for.
Extended Care Facility – A health care facility that provides a range of medical and non-medical services to individuals who require ongoing assistance, such as nursing homes and assisted living facilities.

Fee-for-Service (FFS) – A traditional health care payment model in which providers are paid separately for each service or treatment they provide, rather than receiving a set payment for managing a patient’s care.
Fee Schedule – A list of predetermined fees for specific medical services, procedures, and treatments that an insurance company will pay to providers.
Flexible Spending Account (FSA) – An account that allows employees to set aside pre-tax dollars to pay for qualified medical expenses, subject to annual limits.
Formulary – A list of prescription medications covered by an insurance plan, typically organized by tiers that indicate the level of cost-sharing for each drug.
Free-Look Period – A period during which a policyholder can review and cancel a new insurance policy without penalty.
Fully Insured Plan – A health insurance plan in which the employer contracts with an insurance company to assume the financial risk and manage the claims process for the covered employees.
Family Deductible – The total amount that a family must pay out-of-pocket for covered services before the insurance plan begins to pay for benefits. This is different from an individual deductible, which applies to each person separately.
Family Health Insurance – A health insurance plan that covers the policyholder, their spouse, and dependents, providing coverage for a range of medical services and treatments.
Federal Poverty Level (FPL) – A measure of income level used by the U.S. government to determine eligibility for various assistance programs, including Medicaid and subsidies for health insurance premiums.
First Dollar Coverage – A feature of some health insurance plans where the plan begins to pay for covered services without the policyholder having to first meet a deductible or other cost-sharing requirement.
Fraud – Intentional deception or misrepresentation by an individual or entity in order to gain an unauthorized benefit, such as receiving payment for a service that was not provided or inflating the cost of a service.
Furlough – A temporary, unpaid leave of absence from work, which may impact an employee’s health insurance coverage, depending on the employer’s policies and the length of the furlough.

Gap Coverage – A type of insurance that covers the difference between the actual cash value of a medical service and the amount paid by the primary insurance plan, often used in conjunction with high-deductible plans.
Generic Drug – A medication that has the same active ingredients, strength, dosage, and form as a brand-name drug but is typically less expensive.
Grace Period – The period after a premium payment due date during which the policyholder can make the payment without losing coverage or incurring penalties.
Grandfathered Health Plan – A health insurance plan that existed before the Affordable Care Act (ACA) was signed into law and is exempt from certain ACA requirements, provided it does not make significant changes to its benefits or costs.
Group Health Insurance – Health insurance coverage provided to a group of people, typically through an employer or professional organization.
Guaranteed Issue – A requirement that insurance companies offer coverage to all applicants, regardless of their health status or pre-existing conditions.
Guaranteed Renewability – A provision in health insurance policies that ensures the policyholder’s right to renew the policy, as long as the premiums are paid on time and the insurer continues to offer the plan.
Guaranteed Replacement Cost – A type of health insurance coverage that pays the full cost to replace damaged or lost medical equipment or supplies, without taking depreciation into account.
Gynecological Exam – A routine medical examination of a woman’s reproductive system, typically covered by most health insurance plans as part of preventive care.
Gag Rule – A controversial provision in some managed care contracts that prohibits physicians from discussing certain treatment options or costs with their patients, which may limit the patient’s ability to make informed decisions about their health care.

Health Care Provider – A licensed professional, facility, or organization that delivers health care services, such as doctors, hospitals, pharmacies, and labs.
Health Insurance – A contract between an individual or group and an insurance company to help cover the costs of health care services in exchange for the payment of premiums.
Health Insurance Marketplace – A service that helps people shop for and enroll in affordable health insurance, also known as the “Exchange.”
Health Maintenance Organization (HMO) – A type of health insurance plan that typically requires policyholders to receive care from a network of specified providers and obtain referrals for specialist visits.
Health Reimbursement Account (HRA) – An employer-funded account that reimburses employees for qualified medical expenses.
Health Savings Account (HSA) – A tax-advantaged account used to pay for qualified medical expenses, available to individuals enrolled in a high-deductible health plan (HDHP).
High-Deductible Health Plan (HDHP) – A health insurance plan with a higher deductible than traditional insurance plans, often combined with a Health Savings Account (HSA) to help policyholders save for and manage their medical expenses.
Home Health Care – Medical care and support services provided in a patient’s home, usually for individuals who need ongoing care but do not require hospitalization or a nursing home stay.
Hospice Care – Specialized care and support services for terminally ill patients and their families, focused on providing comfort and maintaining the highest possible quality of life.
Hospital Indemnity Insurance – A supplemental insurance policy that provides a fixed cash benefit for each day spent in the hospital, regardless of the actual costs incurred.
Hospital Outpatient Care – Medical services and treatments provided in a hospital setting that do not require an overnight stay.
Hospitalization – Admission to a hospital for medical treatment or observation that requires an overnight stay.
Household Income – The combined income of all individuals living in a single household, often used to determine eligibility for health insurance subsidies and cost-sharing reductions.

In-network – Health care providers that have contracted with an insurance company to provide services to policyholders at negotiated rates.
Inpatient Care – Medical treatment that requires a patient to be admitted to a hospital or other healthcare facility for an overnight stay or longer.
Independent Practice Association (IPA) – A group of independent physicians who contract with an HMO to provide health care services to its members.
Indemnity Plan – A type of health insurance plan that allows policyholders to choose any doctor or hospital for care, with the insurance company reimbursing a percentage of the cost of services.
Individual Health Insurance – Health insurance coverage purchased by individuals, as opposed to group coverage provided by an employer or organization.
Individual Mandate – A requirement under the Affordable Care Act (ACA) that most individuals obtain health insurance or pay a tax penalty, repealed in 2019.
Inpatient Rehabilitation Facility (IRF) – A specialized facility that provides intensive rehabilitation services for patients recovering from illnesses, injuries, or surgeries that require ongoing care and therapy.
Insured – An individual who is covered by a health insurance policy.
Insurer – The insurance company that provides coverage and assumes financial responsibility for health care claims.
Internal Limitations – Caps or restrictions placed by an insurance plan on the coverage of specific services or treatments, such as limits on the number of visits, length of stay, or dollar amounts.
International Health Insurance – A type of insurance that provides coverage for medical expenses incurred while traveling or living outside one’s home country.
Interpreter Services – Language assistance provided by qualified interpreters for policyholders who do not speak English or have limited English proficiency, as required by certain insurance plans and regulations.
In-Usual, Customary, and Reasonable (UCR) Fees – The amount an insurance company determines is the average cost of a specific medical service or procedure within a particular geographic area, used to establish the allowed amount for out-of-network services.

Job-Based Health Insurance – Health insurance provided by an employer to its employees.
Joint Underwriting Association (JUA) – A state-operated organization that offers insurance coverage to individuals who are unable to obtain coverage in the private market.
Joint Venture – An agreement between two or more companies to work together on a specific project or initiative.
Jurisdiction – The geographical area or legal entity over which a court or regulatory body has authority.
Juvenile Diabetes – Also known as Type 1 diabetes, a chronic condition in which the pancreas produces little or no insulin, requiring lifelong insulin injections.
J-Code – A five-digit code used to identify and bill for injectable drugs administered in a physician’s office or hospital setting.
JCAHO (Joint Commission on Accreditation of Healthcare Organizations) – An independent organization that accredits and certifies healthcare organizations and programs in the United States.
Jargon – Technical language or terms used in a specific industry or profession that may be difficult for non-experts to understand.
Joint Replacement – A surgical procedure in which a damaged joint is removed and replaced with an artificial joint, such as a hip or knee replacement.
Jump Page – A web page that serves as a gateway to other content or resources on a website. In the context of health insurance, a jump page may be used to provide links to specific information about benefits, claims, or providers.

Kaiser Permanente – A healthcare organization that provides health insurance plans and medical care services to its members.
Kidney Dialysis – A medical treatment that removes waste and excess fluids from the blood when the kidneys can no longer perform this function.
Kinesiology – The study of human movement and physical activity.
Knock-for-Knock Agreement – A type of insurance agreement where each party agrees to cover its own losses in the event of an accident, regardless of who was at fault.
Key Person Insurance – A type of life insurance policy that covers the life of a key person in a business or organization. The purpose of this insurance is to provide financial protection to the business in case the key person dies or becomes disabled.
Knowledge-Based Authentication (KBA) – A security protocol that requires users to answer questions based on personal information to verify their identity when accessing an online service or account.
Ketogenic Diet – A high-fat, low-carbohydrate diet that can be used as a medical treatment for certain conditions, such as epilepsy.
Kidney Stones – Hard deposits of minerals and salts that form inside the kidneys and can cause pain and other symptoms.
Knowledge of Results (KR) – Feedback given to individuals about the outcome of their actions, which can be used to improve future performance.
Knee Replacement – A surgical procedure to replace a damaged or diseased knee joint with an artificial joint.
Kaiser Family Foundation – A non-profit organization that conducts research and analysis on healthcare policy issues and provides information and resources to policymakers, researchers, and the general public.
Karoshi – A term used in Japan to describe death from overwork or job-related stress.
Kyphoplasty – A minimally invasive surgical procedure to treat vertebral compression fractures, which involves injecting a special cement into the affected vertebrae to stabilize and strengthen them.
Kaiser HMO – A type of health insurance plan offered by Kaiser Permanente that requires members to receive medical care from providers within the Kaiser Permanente network.
Kickback – An illegal payment or incentive given to a healthcare provider in exchange for referring patients to a particular healthcare facility or service.
Key Rate – The interest rate set by the Federal Reserve Bank that influences other interest rates in the economy.
Kratom – A plant-based substance that is sometimes used as a natural remedy for pain, anxiety, and other conditions. Kratom is currently legal in most states but is banned in some.
Kinase Inhibitor – A type of medication used to treat certain types of cancer by blocking the action of enzymes called kinases, which are involved in cell growth and division.
Kegel Exercises – A series of exercises designed to strengthen the pelvic floor muscles, which can help improve bladder control and sexual function.
Knowledge Management – The process of creating, sharing, using, and managing knowledge and information within an organization to improve performance and achieve strategic objectives.

Lapse – A situation where a policyholder fails to pay their premium on time, and their policy terminates or lapses.
Lifetime Maximum – The maximum amount of money a health insurance policy will pay out over the course of the policyholder’s lifetime.
Long-Term Care (LTC) Insurance – A type of insurance that covers the costs of long-term care, such as in-home care, assisted living, and nursing home care.
Lump-Sum Payment – A one-time payment made by an insurer to a policyholder, usually in the case of a critical illness diagnosis or disability.
Limitations – Restrictions or exclusions listed in a policy that limit the coverage provided by an insurance policy.
Lifetime Benefit Period – The maximum length of time that an insurance policy will cover a policyholder’s medical expenses.
Level Premium – A premium that remains constant over the life of an insurance policy.
Loss Ratio – The ratio of claims paid out by an insurer to the premiums collected from policyholders.
Lab Work – Medical tests conducted in a laboratory, such as blood tests or urine tests.
Lien – A legal claim against a policyholder’s property or assets in order to satisfy a debt or obligation.
List of Covered Services – A document that outlines the medical services and treatments that are covered by an insurance policy.
Local Health Department – A government agency responsible for protecting public health and providing healthcare services to local residents.
Late Enrollment Penalty – A fee charged to individuals who enroll in health insurance coverage after the open enrollment period has ended.
Loss of Use – A provision in insurance policies that covers the cost of renting or replacing property that has been damaged or destroyed.
Long-Term Disability (LTD) Insurance – A type of insurance that provides income replacement for individuals who are unable to work due to a long-term disability.
Living Benefit Rider – A provision in an insurance policy that allows policyholders to access a portion of their death benefit while they are still alive if they are diagnosed with a terminal illness.
Limiting Charge – The maximum amount that a healthcare provider who does not accept assignment can charge a Medicare patient for a covered service.
Legal Guardian – A person appointed by a court to make legal and financial decisions for an individual who is unable to make these decisions for themselves.
Lock-In Provision – A provision in some insurance policies that requires policyholders to use a specific network of healthcare providers in order to receive coverage.
Liability – Legal responsibility for an event or action, which may result in financial damages or penalties.
Loss Control – Measures taken by an insurance company to minimize the frequency and severity of losses, such as offering safety training or risk assessments.

Mammogram – A screening test that uses low-dose x-rays to examine the breast tissue for any abnormalities or signs of breast cancer.
Maternity Coverage – Health insurance coverage that provides benefits for pregnancy, childbirth, and postpartum care.
Maximum Out-of-Pocket (MOOP) – The maximum amount of money an insured person is required to pay out of their own pocket for covered healthcare services during a given period, usually a year.
Medicaid – A joint federal and state program that provides health insurance coverage for low-income individuals and families.
Medicare – A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease.
Medicare Advantage – A type of Medicare health plan offered by private insurance companies that provides all Medicare Part A and Part B benefits and may offer additional benefits.
Medical Loss Ratio (MLR) – The percentage of premium dollars that an insurance company spends on healthcare services and quality improvement activities for its customers.
Medical Underwriting – The process of evaluating an individual’s health status and medical history to determine their eligibility for health insurance coverage.
Mental Health Parity – The requirement that health insurance plans provide equal coverage for mental health and substance use disorder services as they do for medical and surgical services.
MRI (Magnetic Resonance Imaging) – A diagnostic imaging test that uses a powerful magnetic field, radio waves, and a computer to produce detailed images of the body’s internal structures.

Narrow Network – A health plan that limits its network of healthcare providers to a smaller group of doctors, hospitals, and other healthcare facilities, in order to offer lower premiums.
National Provider Identifier (NPI) – A unique identification number assigned to healthcare providers by the Centers for Medicare & Medicaid Services (CMS).
Navigators – Individuals or organizations who are trained to help consumers understand their health insurance options and enroll in coverage through the Health Insurance Marketplace.
Network – A group of healthcare providers, such as doctors, hospitals, and clinics, that have contracted with a health insurance company to provide medical services to their policyholders.
Non-Preferred Provider – A healthcare provider who has not contracted with a particular health insurance company to provide medical services to their policyholders, resulting in higher out-of-pocket costs for policyholders who choose to use them.
Noncancellable – A type of health insurance policy that cannot be cancelled by the insurer as long as the policyholder continues to pay their premiums.
Nonprofit Health Insurance – Health insurance plans that are operated by nonprofit organizations, rather than for-profit companies.
Nurse Practitioner (NP) – A healthcare professional who has completed advanced training and education in order to provide primary care and other medical services to patients.
Nutritional Counseling – Counseling and education provided by a healthcare professional on nutrition and healthy eating habits to prevent or manage certain health conditions.
Nursing Home – A residential facility that provides care for elderly or disabled individuals who require ongoing medical and personal care.

Out-of-Network – A healthcare provider or facility that is not part of an insurance company’s network of providers. When a patient receives care from an out-of-network provider, they may be responsible for a higher percentage of the cost or the entire cost of the care.
Open Enrollment – A period of time, usually once a year, when individuals can enroll in or change their health insurance coverage without a qualifying event. During open enrollment, individuals can choose to enroll in a new plan or make changes to their existing plan.
Out-of-Pocket Maximum – The maximum amount an individual will be responsible for paying for covered healthcare expenses in a given year. Once an individual reaches their out-of-pocket maximum, their insurance company will typically cover the remaining costs for the year.
Office Visit – A visit to a healthcare provider’s office for medical care or consultation. Office visits may be covered by health insurance plans, depending on the plan’s coverage and the services provided.
Obamacare – The Patient Protection and Affordable Care Act (ACA), also known as Obamacare, is a federal law that was passed in 2010 with the goal of increasing access to healthcare and reducing healthcare costs for individuals and families.
On-Exchange – Health insurance plans that are sold on the state or federal Health Insurance Marketplace, as established under the Affordable Care Act.
Outpatient Care – Medical care or treatment that does not require an overnight stay in a hospital or healthcare facility. Outpatient care may include services such as diagnostic tests, surgery, or physical therapy.
Over-the-Counter (OTC) Medications – Medications that can be purchased without a prescription from a healthcare provider. Some health insurance plans may cover the cost of certain OTC medications, depending on the plan’s coverage.
Optional Benefits – Additional benefits that may be offered by a health insurance plan, such as dental or vision coverage. Optional benefits may be added to a plan for an additional cost.
Out-of-Area Coverage – Health insurance coverage that provides benefits for medical care received outside of an individual’s home area. Out-of-area coverage may be important for individuals who travel frequently or who live in areas with limited healthcare providers.

Payer – A health insurance company or government program that pays for healthcare services on behalf of the policyholder.
Policy – The written contract between the insurance company and the policyholder that outlines the terms and conditions of coverage.
Policyholder – The person who owns the insurance policy and is responsible for paying the premiums.
Pre-existing condition – A health problem that existed before the start of the insurance policy and may affect the cost or availability of coverage.
Premium – The amount paid by the policyholder to the insurance company for coverage.
Prescription drug coverage – Insurance coverage for the cost of prescription medications.
Preferred provider organization (PPO) – A type of health insurance plan that offers a network of healthcare providers who offer services at a discounted rate to plan members.
Primary care physician (PCP) – The doctor who provides basic medical care and coordinates referrals to specialists.
Preauthorization – The process of obtaining approval from the insurance company before receiving medical services or treatments.
Provider – A healthcare professional or facility that provides medical services to patients.
Pharmacy benefit manager (PBM) – A company that manages prescription drug benefits for health insurance plans.
Point-of-service (POS) plan – A type of health insurance plan that combines elements of an HMO and a PPO, allowing members to see both in-network and out-of-network providers.
Pre-tax dollars – Money set aside from an employee’s paycheck to pay for healthcare expenses, such as premiums and deductibles, before taxes are taken out.
Preventive care – Medical services intended to prevent illness or detect health problems early, such as immunizations, cancer screenings, and annual checkups.
Provider network – The group of healthcare providers that are contracted with an insurance company to provide services to plan members.

Qualified Health Plan (QHP) – A health insurance plan that meets the standards set by the Affordable Care Act (ACA) and is eligible for purchase on a health insurance exchange.
Quality Improvement Organization (QIO) – An organization that works to improve the quality of healthcare services provided to Medicare beneficiaries.
Qualified Medical Expense (QME) – A medical expense that is eligible for reimbursement through a health savings account (HSA) or a flexible spending account (FSA).
Quantity Limits – Limits set by an insurance plan on the amount of a medication that can be prescribed or dispensed within a certain period of time.
Quit-Smoking Programs – Programs that provide resources and support to individuals who want to quit smoking, often covered by health insurance plans.
QALY (Quality-Adjusted Life Year) – A measure of disease burden that takes into account both the quality and quantity of life lived with a particular health condition.
Quick Response (QR) Code – A two-dimensional barcode that can be scanned by a smartphone or other device to access information, such as medical records or insurance information.
Quiet Room – A designated space in a healthcare facility that is intended for patients and families to use for meditation, prayer, or relaxation.
Quality of Care – A measure of the effectiveness, safety, and patient-centeredness of healthcare services provided to patients.
Qualified Beneficiary – An individual who is eligible for continuation of health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Rate – The amount of money an insurance company charges for a particular health insurance policy.
Rating area – A geographic area used by insurance companies to determine the premiums they charge for health insurance policies. Rating areas are based on factors such as the cost of medical care and the health status of the population.
Reimbursement – The payment made by an insurance company to cover the cost of medical care. Reimbursement can be made directly to the healthcare provider or to the policyholder, depending on the policy.
Renewal – The process of extending a health insurance policy for another term. Renewal typically requires the policyholder to pay the premium for the next term.
Resident – A person who lives in a particular state or region and is eligible to purchase health insurance in that area.
Residual benefit – A benefit paid by an insurance company to a policyholder who has suffered a partial disability and is unable to work at full capacity.
Rider – An amendment to a health insurance policy that modifies the coverage or terms of the policy. Riders can be added to a policy at any time, subject to the approval of the insurance company.
Risk – The likelihood that an individual or group will require medical care and the potential cost of that care. Insurance companies use risk assessment to determine premiums and coverage.
Risk adjustment – The process by which insurance companies adjust premiums based on the risk level of a particular individual or group. Risk adjustment is intended to ensure that premiums are fair and reflect the actual risk of medical care.
Risk pool – A group of individuals or organizations that share the risk of healthcare costs. Risk pools are used by insurance companies to determine premiums and coverage based on the overall risk level of the pool.

SARS-CoV-2 – Severe Acute Respiratory Syndrome Coronavirus 2, the virus that causes COVID-19.
Second Opinion – A consultation with another doctor or medical professional for a second opinion on a diagnosis, treatment plan, or medical test.
Self-Funded Insurance – An insurance plan in which an employer assumes financial responsibility for the health claims of its employees.
Skilled Nursing Facility – A healthcare facility that provides 24-hour nursing care to patients who need rehabilitation, chronic care, or ongoing medical supervision.
Special Enrollment Period – A period during which individuals can enroll in health insurance outside of the open enrollment period due to a qualifying life event, such as losing health coverage, getting married, or having a baby.
Specified Disease Coverage – An insurance policy that provides coverage for a specific disease, such as cancer or heart disease.
State Children’s Health Insurance Program (SCHIP) – A federally funded program that provides low-cost health coverage to uninsured children whose families have low incomes.
Stop-Loss Insurance – Insurance that protects an employer from excessive claims expenses by limiting the amount an employer is responsible for paying for claims.
Subsidy – Financial assistance provided by the government to help individuals or families afford health insurance premiums.
Summary of Benefits and Coverage (SBC) – A document that provides a summary of the benefits, costs, and coverage limitations of a health insurance plan.

Third-party administrator (TPA) – A company that provides administrative services, such as claims processing and customer service, to self-insured employers or insurance companies.
Telemedicine – The use of technology, such as video conferencing or remote monitoring devices, to provide healthcare services to patients who are not physically present with their healthcare provider.
Tiered network – A health insurance plan that categorizes healthcare providers into different levels or tiers, with each tier representing a different cost-sharing arrangement for the insured individual.
Total maximum out-of-pocket (TMOOP) – The highest amount an individual will be required to pay for covered medical expenses in a given year. Once this amount is reached, the insurance plan will cover all remaining eligible expenses.
Treatment plan – A plan developed by a healthcare provider that outlines the recommended course of treatment for a patient’s medical condition.
Traditional indemnity plan – A type of health insurance plan that allows individuals to seek medical care from any provider, without restrictions or limitations.
Tax credits – Financial assistance provided by the government to help eligible individuals and families pay for health insurance premiums. The amount of the tax credit is based on income and other factors.
Temporary health insurance – Short-term health insurance coverage that is designed to provide temporary protection against unexpected medical expenses. This type of insurance is typically purchased by individuals who are in between jobs or waiting for employer-sponsored coverage to begin.
Termination of coverage – The ending of an insurance policy due to nonpayment of premiums, a change in coverage eligibility, or other reasons.
Travel insurance – Insurance coverage that provides protection for unexpected medical expenses incurred while traveling outside of one’s home country. This type of insurance may also provide coverage for trip cancellations, lost luggage, and other travel-related issues.

Urgent Care – A medical service that provides immediate care for illnesses or injuries that are not life-threatening, but still require prompt attention.
Utilization Review – The process of reviewing medical services to determine if they are medically necessary and appropriate.
Underwriting – The process of evaluating an individual’s health status, medical history, and other factors to determine the risk of insuring them and the cost of their coverage.
Usual, Customary, and Reasonable (UCR) – A method used by health insurance companies to determine the maximum amount they will pay for a particular medical service, based on what is considered a reasonable price in a particular geographic area.
Uninsured – Refers to individuals who do not have health insurance coverage.
Upcoding – The practice of billing for a more expensive medical service than was actually provided.
Unbundling – The practice of billing separately for individual components of a medical service that are typically billed together.
Umbrella Insurance – An additional type of insurance that provides additional liability coverage beyond the limits of an individual’s other insurance policies.
Unrestricted Network – A health insurance plan that allows policyholders to see any healthcare provider without needing a referral.
Unique Identifier – A code or number assigned to an individual or healthcare provider to identify them in electronic health records and insurance claims.

Value-Based Insurance Design (VBID) – A type of health insurance plan that adjusts cost-sharing and other benefits based on the value of the service or treatment being provided.
Vaccination – The process of administering a vaccine to protect an individual from a specific disease.
Vaccine – A substance containing a weakened or dead microorganism that stimulates the body’s immune system to produce antibodies against a particular disease.
Vision Care – Medical services that are related to the eyes and vision, including routine eye exams, eyeglasses, and contact lenses.
Voluntary Benefits – Optional employee benefits that an employer offers but are not required by law, such as dental insurance or vision insurance.
Valid Claim – A request for reimbursement of a medical expense that meets the terms and conditions outlined in the insurance policy.
Waiting Period – A specified period of time that an individual must wait after enrolling in a health insurance plan before coverage for certain services or treatments becomes effective.
Wellness Program – A program offered by an employer or health insurance plan that promotes healthy behaviors and lifestyles among employees or members.
Whole Life Insurance – A type of life insurance that provides coverage for an individual’s entire life and includes a savings component.
Well-Baby Care – Medical services that are provided to newborns and infants to monitor their growth and development, including regular checkups and vaccinations.

Waiting period – A specific amount of time that an individual must wait after enrolling in a health insurance plan before the coverage becomes effective.
Wellness program – A program or initiative that promotes healthy behaviors and habits, such as regular exercise or a balanced diet, to prevent illness and improve overall health.
Women’s health – A specific area of healthcare that focuses on the unique health needs and concerns of women, including reproductive health, breast cancer, and menopause.
Waiver of premium – A provision in a health insurance policy that allows the insured to stop paying premiums if they become disabled or otherwise unable to work.
Wrap-around coverage – A supplemental insurance policy that provides additional coverage for services not covered by a primary insurance policy, such as deductibles or copayments.
Workers’ compensation – A type of insurance that provides benefits to employees who are injured or become ill as a result of their job. These benefits may include medical expenses, lost wages, and rehabilitation services.
Whole life insurance – A type of life insurance that provides coverage for the insured’s entire life, as opposed to a term life insurance policy that only provides coverage for a specific period of time.
Withdrawal – The process of taking money out of a health savings account (HSA) or a flexible spending account (FSA) to pay for qualified medical expenses.
Wellness visit – A routine medical check-up that focuses on preventive care, such as immunizations, cancer screenings, and blood pressure checks. These visits are usually covered by health insurance plans at no cost to the patient.
Waiting period credit – A provision in a health insurance policy that allows an individual to count the time they were covered by a previous insurance plan towards the waiting period for a new plan.

X-ray – A diagnostic tool that uses radiation to produce images of bones and internal organs. X-rays are often used to diagnose and monitor a wide range of health conditions, including broken bones, pneumonia, and cancer.
X-ray technician – A healthcare professional who specializes in performing and interpreting X-ray images. X-ray technicians are also known as radiologic technologists.
Xenotransplantation – The transplantation of organs or tissues from one species to another. While this is an area of ongoing research, xenotransplantation is not currently a widely available or accepted form of medical treatment.
Xerostomia – A medical term for dry mouth, which can be caused by a variety of factors, including medication side effects, radiation therapy, and autoimmune diseases.
X-ray computed tomography (CT) – A medical imaging technique that uses X-rays and computer processing to produce detailed cross-sectional images of the body. CT scans are commonly used to diagnose and monitor a variety of health conditions, including cancer, heart disease, and stroke.
X-linked genetic disorders – Genetic disorders that are caused by mutations on the X chromosome. Because females have two X chromosomes while males have only one, X-linked disorders often affect males more severely than females. Examples of X-linked disorders include hemophilia and Duchenne muscular dystrophy.

Yearly Maximum – The maximum amount of money that a health insurance plan will pay for covered healthcare services in a given year.
Yeast Infection – A common infection that occurs when there is an overgrowth of yeast in the body, often in the vaginal area.
Yellow Fever – A viral infection spread by mosquitoes that can cause fever, chills, and yellowing of the skin and eyes.
Yoga – A mind-body practice that involves physical poses, breathing techniques, and meditation to promote relaxation and overall health.
Young Adult Coverage – A provision in the Affordable Care Act that allows young adults to stay on their parents’ health insurance plan until they turn 26 years old.
Yttrium-90 Radioembolization – A treatment for liver cancer that involves injecting tiny radioactive beads into the blood vessels that supply the tumor, cutting off its blood supply and destroying the cancer cells.

Zone rated – Refers to a method used by insurance companies to determine rates based on the risk level of the geographic location.
Zero-dollar copay – A type of insurance plan in which the insured pays nothing out of pocket for certain services or medications.
Zoster vaccine – A vaccine used to prevent shingles, a painful viral infection that affects the nerves.
Zip code rating – A method used by insurance companies to determine rates based on the risk level of the geographic location, specifically the zip code.
Zoonotic disease – A disease that can be transmitted from animals to humans, such as Lyme disease or West Nile virus.
Zolpidem – A medication used to treat insomnia, commonly known by the brand name Ambien.
Zone of danger – Refers to a situation where an individual is at risk of physical harm, and may be eligible for compensation under certain insurance policies.
Zafirlukast – A medication used to treat asthma and other respiratory conditions.
Zero sum game – A situation in which one party’s gain is equal to another party’s loss, often used in discussions about healthcare costs and insurance premiums.
Zygote intrafallopian transfer (ZIFT) – A fertility treatment in which a fertilized egg is transferred to the fallopian tubes.

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Health Insurance Glossary & Definitions

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Affordable Care Act (ACA) – A comprehensive health care reform law enacted in March 2010 aimed at improving access, affordability, and quality of health care in the United States.

Allowed Amount – The maximum amount an insurance plan will cover for a specific service, procedure, or treatment.

Annual Deductible – The total amount a policyholder must pay for covered services within a calendar year before the insurance plan begins to pay for benefits.

Annual Limit – The maximum amount an insurance plan will pay for specific covered services or benefits within a calendar year.

Annual Open Enrollment Period – A specified time period each year when individuals can enroll in or change their health insurance plan.

Appeal – A formal request made by a policyholder or health care provider to an insurance company to review a decision or claim denial.

Application ID – A unique identifier assigned to an individual’s health insurance application when submitted through the Health Insurance Marketplace.

Attest/Attestation – The act of declaring that certain information provided on a health insurance application or other forms is true and accurate to the best of one’s knowledge.

Authorized Representative – A person designated by a policyholder to act on their behalf in matters related to their health insurance coverage or claims.

Actuarial Value – A measure used to estimate the percentage of total average costs for covered benefits that a health insurance plan will cover.

Adverse Benefit Determination – A decision by an insurer to deny, reduce, or terminate a benefit or coverage, or a failure to provide or make a payment in whole or in part for a benefit.

Ambulatory Care – Health care services provided on an outpatient basis, without the need for hospital admission.

Amendment – A change made to an insurance policy, often to clarify or modify coverage, benefits, or terms.

Ancillary Services – Additional services that support medical care, such as laboratory work, diagnostic imaging, and physical therapy.

Application ID – A unique identifier assigned to an individual’s health insurance application when submitted through the Health Insurance Marketplace.

Assignment of Benefits – An agreement by which a policyholder authorizes their insurance company to pay benefits directly to a health care provider.

Association Health Plan (AHP) – A health insurance plan sponsored by a trade or professional association for its members.

Attained Age – The age of an individual at a particular point in time, often used to determine eligibility for certain benefits or coverage.

Average Length of Stay – A measure of the average number of days a patient stays in a hospital for a specific condition or procedure.

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Balance Billing – The practice of a healthcare provider billing a patient for the difference between the provider’s charges and the amount allowed by the patient’s insurance plan. Balance billing is not permitted for in-network providers.

Benefit Period – A specified length of time during which insurance benefits are paid, usually a calendar year.

Benefits – The health care items or services covered under an insurance plan, such as doctor visits, hospital stays, or prescription medications.

Benefit Package – The specific set of benefits and coverage levels offered by a health insurance plan, including deductibles, co-payments, and out-of-pocket maximums.

Benefit Year – A 12-month period during which an insurance plan’s benefits are in effect, often aligned with the calendar year.

Brand-Name Drugs – Prescription medications marketed under a trademarked name, typically more expensive than their generic equivalents.

Broker – A licensed professional who assists individuals and businesses in selecting and purchasing health insurance plans.

Bundled Payment – A single payment made to healthcare providers for all services related to a specific episode of care, such as a surgery or treatment, intended to encourage cost-effective and coordinated care.

Buy-Up Plan – An insurance plan option that offers higher levels of coverage and benefits for an additional cost, compared to a lower-cost, less comprehensive plan.

Business Health Options Program (SHOP) – A program created under the Affordable Care Act that allows small businesses to offer health insurance coverage to their employees through a state-based or federally-facilitated marketplace.

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Capitation – A fixed payment made to a healthcare provider, typically a primary care physician, for each enrolled member under their care, regardless of the actual services provided. This payment model is common in Health Maintenance Organizations (HMOs).

Certificate of Insurance – A document issued by an insurer that provides evidence of an individual’s health insurance coverage. It contains important information, such as the policy number, coverage period, and types of benefits included in the plan.

Children’s Health Insurance Program (CHIP) – A state and federal program that provides low-cost health insurance coverage to children in families with incomes too high to qualify for Medicaid, but who cannot afford private insurance.

Chronic Condition – A long-term health problem that requires ongoing medical attention or treatment, such as diabetes, heart disease, or asthma.

Claim – A request submitted by a policyholder or health care provider to an insurance company for reimbursement for covered services or treatments.

COBRA (Consolidated Omnibus Budget Reconciliation Act) – A federal law that allows eligible employees and their dependents to temporarily continue their group health insurance coverage after a qualifying event, such as job loss or reduction in work hours.

Co-insurance – The percentage of the allowed amount for a covered service that a policyholder is responsible for paying, after the deductible has been met.

Community Rating – A system used by some health insurance companies to determine premium rates for a group, where all members of the group are charged the same premium, regardless of their individual health status, age, or other factors.

Comprehensive Coverage – Health insurance that covers a wide range of health care services, including preventive care, hospitalization, and outpatient services.

Continuation of Coverage – The extension of health insurance coverage beyond the original term of a policy, often through COBRA or other state-specific programs.

Conversion – The process of changing one type of health insurance policy to another, such as switching from a group plan to an individual plan after leaving a job.

Coordination of Benefits (COB) – The process of coordinating payments between two or more insurance plans when a policyholder has coverage from more than one source.

Cost-Sharing – The portion of health care costs that a policyholder is responsible for paying, including deductibles, co-payments, and co-insurance.

Covered Services – The specific health care services, treatments, and procedures that are included in an insurance plan and eligible for reimbursement.

Creditable Coverage – Health insurance coverage that meets certain federal and state requirements and can be used to reduce or eliminate waiting periods for pre-existing conditions when switching to a new health plan.

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Deductible – The amount a policyholder must pay for covered services before the insurance plan begins to pay for benefits.

Dependent – A person who relies on another person, such as a spouse or parent, for financial support and is covered under that person’s insurance plan.

Dental Insurance – A type of insurance coverage that helps pay for the cost of dental care, including preventive services, routine checkups, and treatment for oral health issues.

Disability Insurance – A type of insurance that provides financial protection and replaces a portion of a person’s income if they become unable to work due to a qualifying disability or illness.

Drug Formulary – A list of prescription medications covered by an insurance plan, typically organized by tiers that indicate the level of cost-sharing for each drug.

Durable Medical Equipment (DME) – Medical equipment that is prescribed by a doctor for use by a patient at home, such as wheelchairs, oxygen tanks, or hospital beds, and is covered by an insurance plan under certain conditions.

Direct Primary Care (DPC) – A healthcare model in which patients pay a monthly fee directly to a primary care physician for access to comprehensive primary care services, often bypassing traditional insurance arrangements.

Denial of Claim – A decision by an insurance company to refuse payment for a submitted claim, typically due to a lack of coverage, policy exclusions, or other reasons.

Diagnosis-Related Group (DRG) – A system used by hospitals and insurance companies to categorize and determine payment for inpatient hospital services based on the patient’s diagnosis, age, and other factors.

Disease Management Program – A coordinated approach to managing chronic conditions, such as diabetes or heart disease, through education, monitoring, and support services provided by an insurance plan or healthcare provider.

Dual Coverage – A situation in which a person has health insurance coverage through two different sources, such as two job-based plans or a combination of job-based and individual coverage.

Drug Utilization Review (DUR) – A process used by insurance companies or pharmacy benefit managers to evaluate and monitor the use of prescription drugs, ensuring appropriate prescribing and minimizing potential drug interactions or overuse.

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Effective Date – The date on which an insurance policy or coverage begins.

Eligibility – Criteria that must be met for an individual to qualify for and enroll in a health insurance plan.

Emergency Room (ER) – A hospital facility that provides immediate medical care for patients with acute or life-threatening illnesses or injuries.

Employee Assistance Program (EAP) – A workplace program designed to help employees manage personal and work-related issues, often including mental health and substance abuse services, offered as part of an employee benefits package.

Employer-Sponsored Health Insurance – Health insurance coverage provided by an employer as part of an employee benefits package.

Enrollment Period – The time during which individuals can apply for, change, or renew their health insurance coverage. This period typically includes an open enrollment period for all eligible individuals and special enrollment periods for those who experience qualifying life events.

Essential Health Benefits (EHB) – A set of 10 categories of health care services that must be covered by most insurance plans under the Affordable Care Act (ACA). These categories include hospitalization, prescription drugs, maternity care, and mental health services, among others.

Exclusions – Specific services, treatments, or conditions that are not covered by an insurance plan.

Exclusive Provider Organization (EPO) – A type of managed care health insurance plan that requires policyholders to receive care from a network of specified providers, similar to an HMO, but usually without the need for referrals for specialist visits.

Explanation of Benefits (EOB) – A document sent by an insurance company to a policyholder explaining the details of a claim, including what services were covered and what costs the policyholder is responsible for.

Extended Care Facility – A health care facility that provides a range of medical and non-medical services to individuals who require ongoing assistance, such as nursing homes and assisted living facilities.

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Fee-for-Service (FFS) – A traditional health care payment model in which providers are paid separately for each service or treatment they provide, rather than receiving a set payment for managing a patient’s care.

Fee Schedule – A list of predetermined fees for specific medical services, procedures, and treatments that an insurance company will pay to providers.

Flexible Spending Account (FSA) – An account that allows employees to set aside pre-tax dollars to pay for qualified medical expenses, subject to annual limits.

Formulary – A list of prescription medications covered by an insurance plan, typically organized by tiers that indicate the level of cost-sharing for each drug.

Free-Look Period – A period during which a policyholder can review and cancel a new insurance policy without penalty.

Fully Insured Plan – A health insurance plan in which the employer contracts with an insurance company to assume the financial risk and manage the claims process for the covered employees.