Health Insurance Definitions
Advance Premium Tax Credit (APTC)
APTC lowers the cost of your monthly premium for insurance plans sold on Your Health Idaho. Individuals and families qualify for a tax credit based on income level, household size, and other factors. If at the end of the year, you’ve taken more premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return. If you’ve taken less than you qualify for, you’ll get the difference back.
An exemption that’s needed when applying for Catastrophic coverage for people 30 years or older whose coverage is unaffordable. Affordability exemptions are one type of exemption that someone can claim to qualify for Catastrophic Coverage, along with hardship exemptions.
You can qualify for an affordability exemption if the lowest-priced coverage is available to you, through either a Marketplace or job-based plan, which would cost more than 8.09% of your household income.
Affordable Care Act (ACA)
The comprehensive healthcare reform law was enacted in two parts in March 2010. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Healthcare and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” refers to the final, amended version of the law.
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference.
A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated healthcare costs for the rest of the year.
A request for your health insurance company or the Health Insurance Marketplace® to review a decision that denies a benefit or payment. If you disagree with a decision made by the Marketplace, you may be able to file an appeal. Small businesses can also appeal to Small Business Health Options Program (SHOP) decisions. If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Biosimilar Biological Products
The generic version of more complicated medications.
Brand Name (Drugs)
A drug sold by a drug company under a specific name or trademark that is protected by a patent. Brand-name drugs may be available by prescription or over the counter.
Bronze Health Plan
One of 4 plan categories (also known as “metal levels”) in the Health Insurance Marketplace®. Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. They can be a good choice if you usually use few medical services and mostly want protection from very high costs if you get seriously sick or injured.
Note: Bronze plan deductibles can be very high. This means you could have to pay thousands of dollars of health care costs yourself before your plan starts to pay its share.
A cafeteria plan is a separate written plan maintained by an employer for employees that meets the specific requirements and regulations of Section 125 of the Internal Revenue Code. It provides participants an opportunity to receive certain benefits on a pretax basis. Participants in a cafeteria plan must be permitted to choose among at least one taxable benefit (such as cash) and one qualified benefit.
Catastrophic Health Plan
Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but don't cover any benefits other than 3 primary care visits per year before the plan's deductible is met.
The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a Catastrophic plan, you must be under 30 years old OR qualify for a "hardship" or "affordability" exemption if you're over 30.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace.
Children's Health Insurance Program (CHIP)
Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.
Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply at any time. If you qualify, your coverage can begin immediately, any time of year.
A detailed statement of costs for healthcare services provided by a hospital or physician's office.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal act that requires group health plans to allow employees and certain dependents to continue group coverage for a specific time period following a qualifying event that causes a loss of coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
A non-profit organization in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state, or local level and can include doctors, hospitals, and businesses as member-owners. Co-ops will offer insurance through the Marketplace.
A fixed amount (for example, $15) for a medical visit or for medication that is covered under your health plan, that you pay usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.
After your deductible is met, co-insurance is the percentage of the cost you must pay for a medical service. Your health insurer or plan pays the rest of the allowed amount. Depending on your plan, your portion of the co-insurance could range from 10-40%.
Example of coinsurance with high medical costs
Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Total claim costs are $12,000.
Out-of-pocket maximum: $6,850
You'd pay all of the first $3,000 (your deductible).
You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).
So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.
If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.
Coordination of Benefits
A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, copayments, or similar charges, but it doesn't 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.
Cost-Sharing Reduction (CSR)
A discount that lowers the amount you pay out-of-pocket for things like deductibles, co-insurance, and co-payments. To qualify for a CSR your income must be within a certain range and you must enroll in a Silver-level health plan.
Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high-risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.
The amount you must pay for health care services before your health insurance company will start paying benefits. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your deductible for covered healthcare services that are subject to the deductible. The deductible may not apply to all services.
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a Marketplace health plan or by itself through a separate dental plan.
Department of Health and Human Services (HHS)
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
A limit in a range of major life activities. This includes activities like seeing, hearing, walking, and tasks like thinking and working. Because different programs may have different disability standards, please check the program you're interested in for its disability standards. The list of activities mentioned above isn't exhaustive.
Two people of the same or opposite sex who live together and share a domestic life, but aren't married or joined by a civil union.
Durable Medical Equipment (DME)
Equipment and supplies are ordered by a healthcare provider for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
The date your policy’s coverage begins.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Employee Assistance Program (EAP)
A mental health counseling program designed to identify an individual's or family's problem(s) and provide short-term counseling to help achieve a resolution.
Employee Retirement Income Security Act (ERISA)
A broad-reaching law that establishes the rights of pension plan participants, standards for the investment of pension plan assets, and requirements for the disclosure of plan provisions and funding.
Employer-Shared Responsibility Payment (ESRP)
The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to their full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.
Employer Tax Credit
A federal tax credit designed to encourage small employers to provide healthcare coverage to employees. Employers pay at least half of the cost of single coverage for employees to qualify.
Another term for the Health Insurance Marketplace®, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance.
The Marketplace is accessible through websites, call centers, and in-person assistance.
When you fill out a Marketplace application, you’ll find out if you qualify to save money when you enroll in a medical insurance plan. You’ll also find out if you qualify for Medicaid and the Children’s Health Insurance Program (CHIP).
Whether you qualify for these programs depends on your expected income, household members, and other information.
Health care services that your health insurance or plan doesn’t pay for or cover.
If you’re 30 and older and want Catastrophic coverage, you must qualify for a "hardship" or "affordability" exemption.
For plan years 2018 and earlier, other kinds of exemptions were granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances to avoid paying a fee that’s no longer required.
Explanation of Benefits (EOB)
A form that lists the services you or your providers submitted to a healthcare insurer for coverage. These forms are not bills, but explain the result for each service submitted.
Essential Health Benefit (EHB)
Essential health benefits must include items and services within at least the following 10 general categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services.
Family and Medical Leave Act (FMLA)
A federal law that guarantees up to 12 weeks of job-protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.
Federal Poverty Level (FPL)
A measure of income issued every year by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
The 2023 federal poverty level (FPL) income numbers below are used to calculate eligibility for Medicaid and the Children's Health Insurance Program (CHIP). 2022 numbers are slightly lower and are used to calculate savings on Marketplace insurance plans for 2023.
Fee for Service
A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.
Flexible Benefits Plan
A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans, and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage. Also known as a Cafeteria plan or IRS 125 Plan.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
Full-Time Employee (FTE)
Any employee who works an average of at least 30 hours per week for more than 120 days in a year. Part-time employees work an average of less than 30 hours per week.
Flexible Spending Account (FSA)
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices.
You decide how much to put in an FSA, up to a limit set by your employer. You aren't taxed on this money.
If money is left at the end of the year, the employer can offer one of two options (not both):
You get 2.5 more months to spend the leftover money.
You can carry over up to $500 to spend the next plan year.
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
One of 4 health plan categories (or “metal levels”) in the Health Insurance Marketplace®. Gold plans usually have higher monthly premiums but lower costs when you get care. Gold may be a good choice if you use a lot of medical services or would rather pay more upfront and know that you’ll pay less when you get care.
A short period — usually 90 days — after your monthly health insurance payment is due. If you haven't made your payment, you may do so during the grace period and avoid losing your health coverage.
The grace period for health insurance is usually 90 days if both of the following are true:
You have a Marketplace plan and qualify for advance payments of the premium tax credit.
You’ve paid at least one full month's premium during the benefit year so far.
Grandfathered Health Plan
An individual health insurance policy purchased on or before March 23, 2010. These plans weren’t sold through the Marketplace but by insurance companies, agents, or brokers. They may not include some rights and protections provided under the Affordable Care Act.
Plans may lose “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose whether it considers itself a grandfathered plan. (Note: If you’re in a group health plan, the date you joined may not reflect the date the plan was created. New employees and family members may be added to existing grandfathered group plans after March 23, 2010).
Group Health Plan
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
A provision where all eligible persons who apply for coverage and meet certain conditions are automatically issued an insurance policy.
A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Except in some states, guaranteed renewal doesn't limit how much you can be charged if you renew your coverage.
Health care services help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
An exemption that’s needed when applying for Catastrophic coverage for people 30 and older who faced a "hardship" that prevented them from getting insurance. Hardship exemptions are one type of exemption that someone can claim to qualify for Catastrophic coverage, along with affordability exemptions.
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Insurance Marketplace (Exchange)
A competitive marketplace where consumers can compare healthcare coverage benefits and costs.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers. The AS provisions also address the security and privacy of health data to improve the efficiency and effectiveness of the nation's healthcare system by encouraging the widespread use of electronic data interchange.
Health Maintenance Organization (HMO)
A managed care plan that requires members to utilize a primary care physician from its network. Plan benefits don’t apply if a member visits a provider outside the HMO network. Under an HMO, the primary care physician refers patients to other specialists and providers within the network as needed. These plans don’t usually include deductibles, but most plans require a small copayment per visit.
Health Plan Categories
Levels of plans in the Health Insurance Marketplace®: Bronze, Silver, Gold, and Platinum. Categories (sometimes called “metal levels”) are based on how you and your insurance plan split costs. Categories have nothing to do with quality of care. (“Catastrophic” plans are available to some people.)
For each plan category, you’ll pay a different percentage of the total yearly costs of your care, and your insurance company will pay the rest. Total costs include premiums, deductibles, and out-of-pocket costs like copayments and coinsurance.
Each category may include several types of plans and provider networks, like health maintenance organizations (HMOs) and preferred provider organizations (PPOs).
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the arrangement.
Health Savings Account (HSA)
A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your overall healthcare costs. HSA funds generally may not be used to pay premiums.
High Deductible Health Plan (HDHP)
A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.
For 2022, the IRS defines a high-deductible health plan as any plan with a deductible of at least $1,400 for an individual or $2,800 for a family. An HDHP’s total yearly out-of-pocket expenses (including deductibles, copayments, and coinsurance) can’t be more than $7,050 for an individual or $14,100 for a family. (This limit doesn't apply to out-of-network services.)
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
The Marketplace generally considers your household to be you, your spouse if you’re married, and your tax dependents. Your eligibility for savings is generally based on the income of all household members, even those who don’t need insurance.
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.
Individual Coverage Health Reimbursement Arrangement (ICHRA)
A type of Health Reimbursement Arrangement that reimburses medical expenses, like monthly premiums, and requires eligible employees and dependents to have individual health insurance coverage or Medicare Parts A (Hospital Insurance) and B (Medical Insurance) or Part C (Medicare Advantage) for each month they are covered by the individual coverage HRA. An employer can offer an individual coverage HRA instead of other job-based insurance that meets requirements for affordability and minimum value standards.
Employees and dependents with an individual coverage HRA offer qualify for
premium tax credits only if the employer’s offer doesn’t meet minimum standards for affordability, and they opt out of individual HRA coverage.
Individual Health Insurance Policy
Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.
Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
A non-profit entity in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state, or local level, and can include doctors, hospitals, and businesses as member-owners.
Job-Based Health Plan
Coverage that is offered to an employee (and often his or her family) by an employer.
A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.
Limited Cost-Sharing Plan
A plan that is available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders regardless of income or eligibility for premium tax credits. People enrolled in this type of plan:
Don’t pay co-payments, deductibles, or coinsurance when getting care through an Indian healthcare provider
Do need a referral from an I/T/U when getting essential health benefits through a Marketplace plan to avoid paying co-payments, deductibles, or coinsurance
Can get limited cost sharing with a plan at any metal level on the Marketplace
Don't need to have their income verified in order to enroll
Services that include medical and non-medical care are provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term support and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term support and services at any age. Medicare and most health insurance plans don’t pay for long-term care.
Long-term disability is an insurance plan that often works in tandem with a short-term disability to provide income for long-term illnesses and injuries. Once short-term disability benefits are exhausted, a long-term disability policy continues to provide the employee with some income until they can return to work.
Maximum Allowable Charge (MAC)
The maximum allowance is the lesser part of the billed charge or the amount established by the carrier as the highest level of compensation for a covered service. The carrier may pass on all charges above the maximum allowable charge to the insured.
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.
Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states.
You can apply anytime. If you qualify, your coverage can begin immediately, any time of the year.
Medical Loss Ratio (MLR)
An ACA required financial measurement where an insurer must use at least 80 cents of every premium dollar to pay medical claims or sponsor activities that improve the quality of healthcare. (large employers at 85 cents of every dollar)
A process used by insurance companies to try to figure out your health status when you're applying for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits.
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
A federal health insurance program for people 65 and 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).
Medicare Advantage (Medicare Part C)
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Part D
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.
Minimum Essential Coverage (MEC)
The Affordable Care Act requires people to have adequate and affordable healthcare coverage. If your coverage meets the minimum essential definition, then you don’t have to pay a fee for being uninsured. All plans sold through Your Health Idaho meet MEC.
A standard of minimum coverage that applies to job-based health plans. If your employer’s plan meets this standard and is considered “affordable,” you won’t qualify for a premium tax credit if you buy a Marketplace insurance plan instead.
A health plan meets the minimum value standard if both of these apply:
It’s designed to pay at least 60% of the total cost of medical services for a standard population
Its benefits include substantial coverage of physician and inpatient hospital services
Modified Adjusted Gross Income (MAGI)
The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children's Health Insurance Program (CHIP). MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.
For many people, MAGI is identical to or very close to adjusted gross income.
MAGI doesn’t include Supplemental Security Income (SSI).
MAGI does not appear as a line on your tax return.
The facilities, providers, and suppliers your health insurer or plan have contracted with to provide health services. If a provider or service is out-of-network, it will likely cost you more.
A health plan that contracts with doctors, hospitals, pharmacies, and other health care providers to provide members of the plan with services and supplies at a discounted price.
A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can't be charged more because of your health status. Job-based plans can restrict coverage based on other factors such as part-time employment that aren't related to health status.
The annual period on an insurance plan when members can enroll or make changes to their coverage for the coming plan year.
The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
A fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
Any covered service performed by a noncontracting (out-of-network) provider.
Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
Your monthly premiums
Anything you spend for services your plan doesn't cover
Out-of-network care and services
Costs above the allowed amount for a service that a provider may charge
The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.
For the 2023 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $9,100 for an individual and $18,200 for a family.
Out-of-Pocket Limit (OOP)
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This does not include your premium, balance-billed charges or health care your health insurance plan doesn’t cover.
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).
Platinum Health Plan
One of 4 categories (or “metal levels”) of Health Insurance Marketplace® plans. Platinum plans usually have the highest monthly premiums of any plan category but pay the most when you get medical care. They may work well if you expect to use a great deal of health care and would rather pay a higher premium and know nearly all other costs are covered.
Point of Service (POS) Plans
A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Premium Tax Credit
A tax credit you can use to lower your monthly insurance payment (called your “premium”) when you enroll in a plan through the Health Insurance Marketplace®. Your tax credit is based on the income estimate and household information you put on your Marketplace application.
Federal poverty levels (FPLs) & premium tax credit eligibility
Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan. Note: If your income is at or below 150% FPL, you may qualify to enroll in or change Marketplace coverage through a Special Enrollment Period.
Income above 400% FPL: If your income is above 400% FPL, you may now qualify for premium tax credits that lower your monthly premium for a 2022 Marketplace health insurance plan.
You can use all, some, or none of your premium tax credit in advance to lower your monthly premium.
If you use more advance payments of the tax credit than you qualify for based on your final yearly income, you must repay the difference when you file your federal income tax return.
If you use less premium tax credit than you qualify for, you’ll get the difference as a refundable credit when you file your taxes.
You can buy health insurance through other sources, but the only way to get a premium tax credit is through the Health Insurance Marketplace®.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications. All Marketplace plans cover prescription drugs.
A health problem like asthma, diabetes, or cancer you had before the date that new health coverage starts.
Routine health care includes screenings, check-ups, and patient counseling to prevent illnesses, diseases, or other health problems.
The amount that must be paid for your health insurance. Premiums are usually paid monthly, but may sometimes be paid quarterly or yearly.
Preferred Provider Organization (PPO)
A healthcare benefit arrangement designed to supply services at discounted costs by providing incentives for members to use designated healthcare providers. In this plan, members pay less when visiting a healthcare provider within the designated network of physicians and specialists. Members are free to use providers outside the PPO network but will share a greater portion of the final charges.
General medical care is provided directly to a patient without a referral from another physician. Primary care focuses on preventive care and the treatment of routine injuries and illnesses.
Primary Care Physician/Provider (PCP)
A physician serves as a group member's first contact with a plan's healthcare system. In Idaho, PCPs must include (at a minimum) family practice and general practice physicians, general internists, pediatricians, obstetricians, and gynecologists.
Approval from a health plan may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
A person or entity (such as a hospital) that is licensed, where required, to provide covered services as defined in the policy.
Small employers who don't offer group health coverage to their employees can help employees pay for medical expenses through a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA). If your employer offers you a QSEHRA, you can use it to help pay your household's health care costs (like your monthly premium) for qualifying health coverage.
Qualified Health Plan (QHP)
An insurance plan that is certified by Your Health Idaho and the Idaho Department of Insurance, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.
Qualified High Deductible Health Plan (QHDHP)
A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.
Qualified Dental Plan (QDP)
A dental insurance plan helps pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan or through a “stand-alone” dental plan.
Qualifying Life Event (QLE)
A change in your life that can make you eligible for a Special Enrollment Period, allowing you to enroll in health coverage outside of Open Enrollment. Examples of qualifying life events are moving to a new state, changes in your income, a loss of employer coverage, and changes in your family size (for example, if you marry or have a baby). Refer to your plan document for specific criteria.
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the 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.
The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Rider (Exclusionary Rider)
A rider is an amendment to an insurance policy. Some riders add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy).
Type of plan is usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan's service area.
Silver Health Plan
One of 4 categories of Health Insurance Marketplace® plans (sometimes called “metal levels”). Silver plans fall about in the middle: You pay moderate monthly premiums and moderate costs when you need care. Important: If you qualify for “cost-sharing reductions” (or “extra savings”) you can save a lot of money on deductibles, copayments, and coinsurance when you get care — but only if you pick a Silver plan.
Silver plans are the most common choice of Marketplace shoppers.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Small Business Health Options Program (SHOP)
The Small Business Health Options Program (SHOP) helps small business owners provide medical and/or dental insurance to their employees. Some smaller employers qualify for tax credits if they enroll in SHOP insurance.
A small business can offer SHOP health and/or dental insurance to their employees if they:
Have between 1 and 50 full-time equivalent (FTE) employees. Note: The business must have at least one full-time equivalent employee other than owners, partners, or their family members.
Offer coverage to all full-time employees
Enroll at least 70% of the employees offered insurance (with some exceptions)
Small business owners can use an agent or broker to enroll in SHOP insurance or work with their insurance company. There’s no limited enrollment period for SHOP, so they can apply, pick plans, and enroll employees any time of year.
Special Enrollment Period (SEP)
A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In order to qualify for a Special Enrollment Period, you must experience a Qualifying Life Event (QLE).
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Short-Term Disability (STD)
Provides short-term (up to 26 weeks) income protection if you become disabled from a covered injury or illness. STD benefits are 60% of your pre-disability income.
A physician specialist that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Stand-Alone Dental Plan
A type of dental plan offered through the Marketplace that’s not included as part of a health plan. You may want this if the health coverage you choose doesn’t include dental, or if you want different dental coverage.
State Insurance Department
A state agency that regulates insurance and can provide information about health coverage in its state.
Stop Loss Insurance
A type of insurance coverage that allows provider organizations or self-funded groups to place a dollar limit on their liability for paying claims. Stop loss insurance requires the insurer issuing the insurance to reimburse the insured organization for claims that exceed a specific yearly maximum.
Summary of Benefits & Coverage (SBC)
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
Supplemental Security Income (SSI)
A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren't the same as Social Security retirement or disability benefits.
The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents.
Total Cost Estimate (for health coverage)
The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage.
Generally, your total cost is your premium + deductible + out-of-pocket costs + any copayments/coinsurance.
The combined deductible (the amount you pay for covered services before your health plan begins to pay) and out-of-pocket payments made by a member in a benefit period before the insurer covers specified benefits at 100 percent of the maximum allowance.
A health care program for active-duty and retired uniformed service members and their families.
UCR (usual, customary, and reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.
Value-Based Purchasing (VBP)
Linking provider payments to improved performance by health care providers. This form of payment holds healthcare providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.
A health benefit that at least partially covers vision care, like eye exams and glasses. All plans in the Health Insurance Marketplace® include vision coverage for children. Only some plans include vision coverage for adults.
If adult vision coverage is important to you, check the details of any plan you’re considering.
If your plan doesn’t include adult vision coverage, you can buy a “stand-alone” vision plan to reduce your vision care expenses. The Marketplace doesn’t offer stand-alone vision plans.
Waiting Period (job-based coverage)
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
Well-Baby and Well-Child Visits
Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exams and measurements, vision and hearing screening, and oral health risk assessments.
A program intended to improve and promote health and fitness that's usually offered through the workplace, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.
A state-mandated insurance program that helps cover healthcare costs and lost wages for qualified employees and their dependents if the employee suffers a work-related injury or disease.
Zero Cost-Sharing Plan
A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is between 100% and 300% of the federal poverty level and qualify for premium tax credits. People enrolled in this type of plan:
Don’t pay co-payments, deductibles, or coinsurance when getting care from an Indian healthcare provider or when getting essential health benefits through a Marketplace plan
Don’t need a referral from an Indian healthcare provider when getting essential health benefits through a Marketplace plan
Can get zero cost sharing with a plan at any metal level on the Marketplace
Must agree to have their income verified in order to enroll