Health insurance can be complicated, particularly when you encounter a variety of terms while searching for a suitable plan. This glossary briefly explains some of the most frequently searched phrases in health coverage. Certain terms may have additional details if you reside in Florida due to state regulations.
Affordable Care Act (ACA)
A federal law called the Affordable Care Act (ACA) was enacted to improve the quality and affordability of health insurance and decrease the number of uninsured individuals. The ACA has provided more insurance options for those seeking coverage in Florida.
Allowable Charge
The maximum amount an insurance plan will cover for a specified service.
Annual Deductible
The amount a policyholder must pay annually before their insurance plan starts covering certain costs.
Annual Limit
A cap on the benefits an insurer will pay in a year for certain coverages.
Benefits
This refers to the services and treatments that are covered or funded by an insurance policy.
Catastrophic Plan
Low-cost plans are available for those under 30 or with a hardship exemption. These plans cover major medical conditions and include up to 3 primary care visits per year.
Claim
A request made to an insurance company to cover a medical service.
Claim Form
A document completed to request compensation for medical services from an insurance provider.
Coinsurance
The percentage of costs for a covered health service paid by the patient after the deductible is met.
Complications of Pregnancy
Medical conditions due to pregnancy that require hospitalization, surgical procedures, or specialty care.
Consumer Directed Health Plan (CDHP)
Health plans that combine high deductibles with a health savings account or reimbursement arrangement.
Contracting Hospital
A hospital that has an agreement with a health insurer to provide services at pre-negotiated rates.
Coordination of Benefits
When more than one insurance plan covers an individual, this ensures no overpayment occurs.
Copay
A fixed amount the insured pays for covered services, often at the time of service.
Cost-Sharing Reduction (CSR)
Reducing out-of-pocket costs for policyholders with low incomes is especially relevant to those purchasing through the ACA marketplace in Florida.
Covered Person
An individual who is insured under a health insurance policy.
Covered Service
Any medical service that is included under an insurance plan.
Deductible
Amount paid out-of-pocket for care before insurance coverage begins.
Dental Coverage
Insurance specifically for dental services, such as cleanings, x-rays, and fillings.
Dependent
Someone who relies on another, typically a child or spouse, for insurance coverage.
Diagnostic Test
Medical tests performed to identify a disease or condition.
Durable Medical Equipment (DME)
Long-lasting medical equipment prescribed by a doctor for use at home.
Effective Date of Coverage
The date when insurance coverage begins.
Emergency Medical Care
Immediate treatment needed for a severe, unexpected health condition.
Emergency Medical Transportation
Services like ambulance transport necessary in emergencies.
Emergency Room Care / Emergency Services
Medical services obtained in an emergency room.
Employer Responsibility
Employers’ obligation under the ACA to provide health coverage to employees, with specific nuances in Florida’s state regulations.
Essential Health Benefits
Set of healthcare service categories that ACA-compliant plans must cover.
Exclusions
Specific conditions or circumstances not covered by an insurance policy.
Explanation of Benefits (EOB)
A statement from the insurance company detailing what has been paid, what the client owes, and why.
Family Coverage
Insurance that covers not only the primary insured but also eligible dependents.
Grandfathered Health Plan
Plans that were in existence before the ACA and may not be required to adhere to all ACA guidelines.
Grievance
A complaint or concern raised by a policyholder to their insurance company.
Group Plan
An insurance plan provided to a group, typically employees of a company.
Guaranteed Issue
A requirement that health plans must permit you to enroll regardless of health, age, gender, or other factors.
Habilitation Services
Services designed to help individuals acquire or improve skills necessary for daily living.
Health Insurance
A policy that covers medical expenses either in part or full.
Health Insurance Marketplace
An online platform for comparing and purchasing individual health insurance plans. In Florida, it’s a federally facilitated marketplace.
Health Maintenance Organization (HMO)
A type of health insurance plan that requires members to use care providers within a specific network and get referrals to see specialists.
HIPAA
Federal law designed to provide privacy standards to protect patients’ medical records and other health information.
In-network
Health care providers contracted with a health insurance company to provide services at discounted rates.
Individual & Family Out-of-Pocket Maximums
The most you have to pay for covered services in a plan year.
Individual Coverage HRA (ICHRA)
An account funded by employers to reimburse employees for health care expenses.
Individual Health Plan
A health insurance policy purchased by an individual.
Inpatient Services
Services where the patient is admitted to the hospital.
Insured Person
A person covered by a health insurance policy.
Lifetime Limit
The maximum amount an insurance plan will pay over the insured’s lifetime.
Marketplace
Another term for the Health Insurance Marketplace.
Maximum Out-of-pocket Limit
The maximum amount of money the insured will pay for covered services in a plan year.
Member<
An individual enrolled and covered by a health insurance plan.
Minimum Essential Coverage (MEC)
The type of coverage an individual needs to meet the shared responsibility requirement under the ACA.
Network
The facilities, providers, and suppliers your health insurer has contracted with to provide health care services.
Non-Contracting Hospital
Hospitals that do not have an agreement with an insurance provider.
Open Enrollment Period
A designated period during which individuals can enroll in or make changes to their health insurance plan.
Out of Network
Care provided outside of your health insurance plan’s network.
Out-of-Pocket Maximum
The most you could pay during a coverage period for your share of the costs of covered services.
Outpatient Services
Treatments that do not require an overnight hospital stay.
Participating Provider Option (PPO)
A type of health insurance plan where members pay less if they use providers from a designated network. Unlike HMOs, a referral isn’t needed to see a specialist.
Physician Services
Medical services rendered by doctors, such as consultations, check-ups, and surgical procedures.
Preauthorization
A decision by your health insurer that a health care service, medication, or equipment is medically necessary.
Premium
The amount paid, often monthly, for health insurance coverage.
Premium Health Insurance
A health insurance plan with higher monthly premiums but lower out-of-pocket costs when accessing care.
Premium Tax Credit
A tax credit to help eligible individuals and families with low or moderate income afford health insurance purchased through the Marketplace.
Preventive Care Services
Routine health care that includes screenings, services, and vaccinations to prevent diseases and health conditions.
Primary Care Physician (PCP)
A primary medical doctor who sees patients for general health concerns and provides referrals to specialists when necessary.
Prior Authorization
The requirement that a physician obtains approval from the health insurance plan to prescribe a specific medication or service.
Provider
A hospital, doctor, care practitioner, pharmacy, or any other individual or institution that provides medical care services.
Qualified Health Plan
An insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, and meets other requirements.
Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
An employer-sponsored health reimbursement arrangement available to eligible employees for medical expenses, including insurance premiums.
Referral
A recommendation from a primary care doctor for a patient to see a particular specialist or receive a specific service.
Special Enrollment Period
A time outside the usual open enrollment period during which an individual can enroll in a health plan due to specific qualifying life events, like marriage or birth.
State Continuation Coverage
Florida-specific provision allowing employees to continue their group health coverage under certain conditions, akin to COBRA but with state-specific guidelines.
Subsidy (Also Known As Premium Tax Credit)
Financial assistance from the federal government to help lower the monthly cost of health insurance.
Vision Insurance
Insurance coverage that helps pay for vision care, such as eye exams, prescription glasses, and contact lenses.
