Glossary
Aa
ACA
Affordable Care Act
Also known as: ACA
A federal law that made new rules about health care so that everyone can get health insurance. The Affordable Care Act is also known as Obamacare.
Bb
Benefit
Any care or service covered by your health insurance. Each insurance plan has different covered benefits.
For example, lab tests, surgery, drugs, or medical equipment.
Brand name drug
Drugs that are owned by the company who made them. They may cost more than generic drugs.
Cc
Claim
Also known as: Claims
A bill that your doctor submits to your insurance after you receive health care.
Claims
See Claim
Coinsurance
Coinsurance is a percent you pay for your health care costs, with your insurance plan paying the rest. This cost-sharing starts after you have reached your yearly deductible.
If your hospital bill is $1000 and you have a 20% coinsurance, you will pay $200 and your insurance will pay $800.
Copay
See Copayment
Co-pay accumulators & maximizers
If your insurance plan uses a co-pay accumulator, this might impact how much money you will have to spend for your medications. For example, if you go to a pharmacy and they pay for a portion of the drug cost, this might not be counted toward your out-of-pocket maximum. Reach out to your insurance plan to ask if they use co-pay accumulators and how this could affect your out-of-pocket costs.
For more information, Crohn’s & Colitis Foundation and Cystic Fibrosis Foundation have resources on this topic
Copayment
Also known as: Copay
Copayment is a fixed amount you pay each time you get health care services that are covered by your insurance.
For example, a plan might have a $10 copay for doctor visits and a $15 copay for prescription drugs.
CPT code
Also known as: CPT Codes, Current Procedural Terminology Code
A CPT Code is a specific number (or code) for a health care service or test. Your insurance company uses this code to find out the costs of the care or service you receive.
For example, a chest x-ray with one view has a CPT code of 71010. Your insurance company will use this code to figure out how much they will pay for this x-ray and how much you owe for the x-ray.
Dd
Deductible
The amount you have to pay out of your own pocket to pay for covered health care each year before your insurance will start sharing the cost. For most health care services, you pay 100% of your bills until you meet your plan's deductible. After that, you pay your part of the costs by paying coinsurance and copays.
If you have a yearly deductible of $1,000, you will have to pay full price every time you go to the doctor until you have spent $1,000 that year.
Dependent
Also known as: Dependents
A family member who will be covered by your plan. This may be a spouse or an unmarried child under the age of 26. If you cover dependents, your monthly bill (premium) might go up.
Dependents
See Dependent
Ee
Emergency care
Care you need right away for a problem that could be life- threatening.
Having a heart attack, being in a car accident, breaking a hip bone. This may or may not include the cost of ambulance rides.
EPO
Essential health benefits
Benefits that every plan has to give you according to the Affordable Care Act.
• Emergency services • Hospital stays • Lab services (like a blood draw) • Pregnancy care • Mental health and substance abuse treatment • Outpatient care (can be done in a medical center without an overnight stay) • Children's health care • Prescription drugs • Preventive care (like a flu shot) • Rehabilitative and habilitative services (help you maintain daily functioning or recover from an illness or accident) • Vision and dental care for children
Exclusive Provider Organization
Also known as: EPO
A plan where you can only see doctors, specialists, or hospitals in a plan's network, unless you have an emergency.
Explanation of Benefits
Also known as: EOB, EOB form
A statement from your health insurance company that explains which health care services you received, how much your insurance paid for each service, and how much you will have to pay.
Ff
Facility fees
A facility fee is a fee you have to pay on top of the costs for the health care service. This fee is added when you get care from a doctor at a place that is not owned by your doctor.
For example, if you go to a clinic that is owned by a hospital, you might be charged a facility fee plus a fee for your doctor and the health care service.
Flexible Spending Account (FSA)
A type of savings account that’s offered by some employers as a job benefit. You can save money in these accounts, for a calendar year, to use for medical care tax-free.
Formulary
A list of the prescription drugs your health insurance plan will cover. Some plans make you get a note from a doctor before you can use a drug that is not in this list. Others may make you pay more for drugs that aren't on their formulary.
Gg
Generic drug
Also known as: Generics
Drugs that cost less than brand-name drugs. Generic drugs have the same quality and strength as brand-name drugs. The Food and Drug Administration (FDA) tests them to make sure they are safe.
Generics
See Generic drug
Hh
HDHP
Health insurance
A way to pay for health care. You choose a plan and a pay a certain bill for it (premium) each month. You then share the cost of your health care with your insurance.
Health Maintenance Organization
Also known as: HMO
A kind of health plan where you must get approval to use doctors and hospitals outside of the plan.
Health Savings Account (HSA)
A type of savings account that comes with some health insurance plans. You can save money in these accounts to use for medical care tax-free. Your HSA travels with you – you can keep the account as you switch jobs or retire.
High Deductible Health Plan (HDHP)
Also known as: HDHP
This a type of health insurance plan that typically has a low premium and a high deductible. Some of these plan include health savings accounts where you can save money to use for medical care tax free.
Hospital stay
When you stay for the day or overnight in a hospital.
For example, having surgery or having an emergency and then staying at the hospital
Ii
In-network provider
Doctors or health care providers who work with your health insurance plan. It usually costs less to see providers who are in-network.
Mm
Medicaid
A health insurance program the government offers for low-income families and kids.
Medicare
A health insurance program the government offers for people over 65.
Nn
Network coverage
Health care from the doctors, hospitals, pharmacies, and other providers that are in-network, meaning they work with your insurance plan to offer health care. As a plan member, you’ll get care at a lower cost.
Oo
Out-of-network provider
Doctors or hospitals that do not work with your health insurance plan. You usually pay more to go to these providers.
Out-of-pocket costs
Your expenses for health care that your insurance plan won't pay back.
Out-of-pocket maximum
The most money you would have to pay in a year for health care, even if you got very sick. Your health insurance covers most costs after this amount, except for your monthly bill (premium). All Marketplace plans have a maximum out-of-pocket cost of $6,600 or less for an individual and $13,200 or less for a family (2015).
Pp
PCP
PPO
Pre-existing conditions
A health problem you had before you got your health insurance plan. Health insurance companies must cover the cost to care for the health problem. They also can't charge you more money because of the health problem.
Preferred Provider Organization
Also known as: PPO
A kind of health plan where you pay less if you use doctors and hospitals who work with that plan. You can go to doctors or hospitals who don't work with the plan, but you might pay more for the insurance itself and per visit to the doctor.
The amount you pay each month to have health insurance.
You might pay $50 each month to have health insurance.
Prescription drugs
Medicines a doctor orders to help treat an illness or health problem you have.
For example, this might be pills to lower your blood pressure, treat an ear infection, or to treat depression.
Preventive care
Medical care, such as screenings, that helps you stay healthy.
This includes things like getting shots like a flu shot, or getting a test to check for health problems like cancer, diabetes or depression.
Primary care office visit
Care to treat an injury or illness.
For example, seeing a doctor to treat an illness like asthma or treat high blood pressure.
Primary care physician
Also known as: PCP
Your main doctor who helps keep you healthy at well visits or check-ups, and who helps you with health problems when you are sick.
Rr
Referral
When your main doctor sends you to see another doctor for a specific kind of health problem.
For example, your main doctor (primary care physician) might make a referral for you to see a doctor to check your heart (cardiologist).
Ss
Sliding scale
Some hospital and clinics offer care on a sliding scale. This means they might lower your bills based on your income.
Ask your doctor, hospital or clinic if you can get care at a lower cost if you are having trouble paying your bills.
Specialist
A doctor who is an expert on a specific kind of health problem.
For example, a cardiologist treats heart problems; an oncologist treats cancer; a therapist treats depression, anxiety or addiction.
Specialty care office visit
Care given by a doctor who is an expert in a specific kind of health problem.
For example, if you visited an allergy doctor for allergy shots or a heart doctor (cardiologist) to treat a heart problem.
Tt
Tests and procedures
Care that helps your doctor find out what might be making you sick.
X-ray, blood tests, or ultrasounds
Uu
Urgent care
Care you can get at a clinic for a problem that needs to be treated right away but is not life-threatening.
Twisting your ankle, cuts that might need stitches, eye infection
Ww
Well visit
A yearly visit or check-up with your doctor to make sure you are healthy. It is also called preventive care. During this visit, you might receive a vaccine or screening to protect against a disease or find an illness before you start feeling sick. The Affordable Care Act says that this care should be free. You should always check with your doctor to see if the care you are getting is free for you or costs money.