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Glossary

A

Access
Accumulation Period
Actuary
Advance Premium Tax Credit (APTC)
Age Change
Agent and Broker (Health Insurance)
Allowed Amount
Ambulatory Setting
Annual Deductible Combined
Approved Health Care Facility or Program
Accident
Actively-at-work
Adjusted Gross Income (AGI)
Adverse Selection
Age Limits
Allied Health Personnel
Alternate Delivery System
Ancillary Fee
Annual Limit
Assignment of Benefits
Authorized Representative
Accountable Care Organization
Actual Charge
Administrative Services Only (ASO) Agreement
Affordable Care Act (ACA)
Age/Sex Factor
Allowable Charge
Alternative Medicine
Ancillary Products
Appeal
Attending Physician Statement (APS)
Accreditation
Actuarial Value
Admissions/1,000
Admits
Affordable coverage
Agent
Allowable Costs
Ambulatory Care
Ancillary Services
Application Fee
Attest/Attestation

B

Balance Billing
Benefit Package
Biosimilar Biological Products
Broker
Bed Days/1,000
Benefit Riders
Birthday Rule
Bronze Health Plan
Benefit Riders
Benefit Year
Board-certified
Benefit Level
Binding Receipt
Brand Name (Drugs)

C

Capitation
Case Management
Chemical Dependency Inpatient
Coinsurance
Conversion
Cost Sharing Reduction (CSR)
Care Coordination
Catastrophic Health Plan
Children’s Health Insurance Program (CHIP)
Community Rating
Co-op
Cost-sharing
Carrier
Centers for Medicare & Medicaid Services (CMS)
Chronic
Claim
Competitive Bidding
Coordination of Benefits (COB)
Creditable Coverage
Carry-over Provision
Certificate of Coverage
Certified Application Counselor
Chronic Disease Management
COBRA
Complication of Pregnancy
Copayment

D

Data Matching Issue (Inconsistency)
Department of Health and Human Services (HHS)
Drug List
Durable Medical Equipment (DME)
Date of Service
Dependent
Disability
Drug Maintenance List
Deductible
Dependent Coverage
Donut Hole, Medicare Prescription Drug
Drug Utilization Review (DUR)
Dental Coverage
Designated Mental Health Provider
Drug Formulary
Durable Medical Equipment (DME)

E

Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)
Eligible Expenses
Emergency Medical Transportation
Employer Contribution
Enrollment Period
Evidence of Insurability
Exclusive Provider Organization (EPO) Plan
Explanation of Benefits (EOB)
Effective Date
Eligibility Requirements
Eligible Immigration Status
Emergency Room
Employer or Union Retiree Plans
EPO(Exclusive Provider Organization)
Examination
Exemption Certificate Number (ECN)
Extended Coverage
Eligibility Assessment
Eligible Dependent
Eligible Person
Emergency Services
Employer Shared Responsibility Payment (ESRP)
ERISA (Employment Retiree Income Security Act of 1974)
Exchange
Exemption
Extension of Benefits
Eligibility Date
Eligible Employee
Emergency Medical Condition
Employee Contribution
Enrollee
Enrollment
Essential Health Benefits
Estimated Cost
Exclusions
Experimental or Investigational Procedures
External Review

F

Family and Medical Leave Act (FMLA)
Fictitious Business Name Statement
Fully Insured Job-based Plan
Federal Poverty Level (FPL)
Flexible Benefits Plan
Federally Qualified Health Center (FQHC)
Formulary
Fee For Service
Fee For Service
Full-Time Employee (FTE)

G

Gatekeeper
Grandfathered Health Plan
Guaranteed Issue
Generic Drugs
Grievance
Guaranteed Renewal
Gold Health Plan
Grievance Procedure
Grace Period
Group Health Insurance

H

Habilitative/Habilitation Services
Health Insurance Marketplace
Health Status
High-Risk Pool Plan (State)
Home Health Agency
Hospital Outpatient Care
Household
Health Care Workforce Incentive
Health Maintenance Organization (HMO)
High Deductible Health Plan (HDHP)
HIPAA (Health Insurance Portability and Accountability Act of 1996)
Home Health Care
Hospital Readmissions
Health Coverage
Health Plan Categories
Health Savings Account (HSA)
High Deductible Health Plan (HDHP)
HIPAA Eligible Individual
Hospice Care
Hospitalization Insurance
Health Insurance
Health Reimbursement Account (HRA)
Health Service Agreement
High-Cost Excise Tax
Home and Community-Based Services (HCBS)
Hospital Benefits
Hospitalization Insurance

I

In Person Assistance Personnel Program
In-network Coinsurance/Copayment
Integrated Delivery System
In-area Services
Indemnity Plan
Inpatient
Interest
Inconsistency (Data Matching Issue)
Individual Health Insurance Policy
Inpatient Care
Intermediate Care
Incontestable Clause
Infertility
Insurance Co-Op
IPA (Individual Practice Association)

J

Job-based Health Plan

L

Lab/X-Ray
Length of Stay (LOS)
Limited cost sharing plan
Lapse
Lifetime Limit
Long-Term Care
Large Group Health Plan
Lifetime Maximum
Lawfully Present
Limitations

M

Major Medical Insurance
Maternity Coverage
Medical Loss Ratio (MLR)
Medically Necessary
Medicare Hospital Insurance Tax
Member Survey Results
Minimum Essential Coverage (MEC)
Managed Care
Max Duration
Medical Necessity
Medicare
Medicare Part D
Member
Minimum value
Maternity (Inpatient)
Maximum Out-Of-Pocket Costs
Medical Savings Account (MSA)
Medicare Advantage (Medicare Part C)
Medicare Prescription Drug Donut Hole
Mental Health Inpatient
Modified Adjusted Gross Income (MAGI)
Maternity (Outpatient)
Medicaid
Medical Underwriting
Medicare Beneficiary
Medicare Supplement Insurance
Mental Health Office Visits
Multi-Employer Plan
Multi-State Plan

N

National Association of Insurance Commissioners (NAIC)
Nondiscrimination
National Drug Code (NDC)
Network Plan
Non-Preferred Provider
Navigator
Network Provider
Not Yet Accredited (Health Insurance Plan)
Network
New Plan
Notice

O

Obamacare-Affordable Care Act (ACA)
Out-of-network Care
Outpatient Surgery
Office Visit
Out-of-Network Coinsurance/Copayment
Over-the-counter (OTC) Drugs
Open Enrollment Period
Out-of-Pocket Costs
Out-of-pocket maximum/limit
Original Medicare
Out-of-Pocket Estimate
Outpatient

P

Partial Disability
Patient Protection and Affordable Care Act
Penalty
Physician Services
Plan Year
Policy Term
Pre-existing Condition
Preferred Provider Organization (PPO)
Prescription Drug Coverage
Primary Care
Provider
Partial Disability
Patient Protection and Affordable Care Act
Periodic Health Exam
Place of Service
Platinum Health Plan
Policy Year
Pre-existing Condition
Preferred Provider
Prescription Medication
Primary Coverage
Provider Write-off
Partial Hospitalization Services
Patient Protection and Affordable Care Act (PPACA)
Periodic Health Exam
Place of Service
Platinum Health Plan
Policy Year
Pre-existing Condition Exclusion
Premium Tax Credit
Preventive Care
Prior Authorization
Part-Time Employee
Patient-Centered Outcomes Research
Payment Bundling
Periodic OB-GYN Exam
Plan
Point of Service (POS) Plans
Practical Nurse
Pre-existing Condition Insurance Plan (PCIP)
Premium
Primary Care Physician (PCP)
Probationary Period

Q

Qualifying Event
Qualifying Health Coverage
Qualifying Life Event (QLE)
Quality Ratings

R

Rate Review
Rehabilitative/Rehabilitation Services
Rescission
Rating Process
Reinsurance
Respite Care
Reconstructive Surgery
Renewal
Rider (exclusionary rider)
Referral
Renewal Date
Risk Adjustment

S

Same-Sex Marriage
Secondary Care
Service Area
Small Business Health Options Program (SHOP)
Standard Industrial Classification (SIC) Codes
Subrogation
Supplemental Security Income (SSI)
Schedule C
Secondary Coverage
Short-Term Plans
Small Group Market
Specialist
State Continuation Coverage
Subscriber
Schedule K-1
Self-Funded Health Insurance Plan
Silver Health Plan
Special Enrollment Period (SEP)
Spousal Abandonment
State Health Insurance Assistance Program (SHIP)
Subsidized Coverage
Second Surgical Opinion
Self-Insured Plan
Skilled Nursing Care
Special Health Care Need
Stand-Alone Dental Plan
State Insurance Department
State Medical Assistance Office
Summary of Benefits and Coverage (SBC)

T

Tax Filing Requirement (for dependents)
Tertiary Care
Temporary Partial Disability
Total Cost Estimate (for health coverage)
Temporary Total Disability
Treatment Facility
TRICARE
Terminally Ill
Triage
TTY

U

Uncompensated Care
Usual, Customary and Reasonable (UCR) Charge
Underwriting
Utilization
Uniform Billing Code of 1992 (UB-92)
Utilization Management/Review
Urgent Care

V

Value-Based Purchasing (VBP)
Vision Coverage

W

Waiting Period
Wellness Programs
Waiver (Exclusion Endorsement)
Well-Woman Care
Waiver of Premium
Worker’s Compensation
Well-Baby/Well-Child Care

Z

Zero Cost Sharing Plan
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