Understanding Health Insurance Terminology

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The Affordable Care Act (ACA), also known as Obamacare, is a U.S. federal law enacted on March 23, 2010, to expand healthcare access, improve quality, and regulate insurance markets.

These are life insurance benefits paid to the policyholder before death, typically in cases of terminal illness or critical health conditions.

A report from a physician, hospital, or medical facility detailing a patient's medical history. Insurance companies often request this during underwriting to assess an applicant’s health risks.

Group health plans that employer groups or associations offer to provide affordable coverage for their employees, regulated under the Department of Labor.

A global health services company based in Bloomfield, Connecticut, and Philadelphia, Pennsylvania, offering medical, dental, disability, life, and accident insurance, primarily through employers and groups.

A cost-sharing agreement where the insured pays a percentage of medical expenses after meeting their deductible, with the insurer covering the rest.

The negotiated price between an insurance company and a healthcare provider for a specific service, typically lower than standard rates, in exchange for increased patient volume.

A fixed fee that an insured individual pays for healthcare services (e.g., doctor visits or prescriptions), with the insurance company covering the rest.

When an insurance company denies coverage to an applicant due to medical history or risk factors during underwriting.

The amount an insured individual must pay out-of-pocket before insurance coverage begins. Plans with lower deductibles typically have higher premiums.

A program where members pay a monthly fee to receive discounted rates on medical services from participating providers, but it is not traditional insurance.

A health insurance plan where members must use in-network providers for care, except in emergencies. There are no out-of-network benefits.

A set of mandatory healthcare services required under the ACA. Enrolling in a plan with MEC status helps avoid penalties for lacking health coverage.

An insurance policy that pays benefits without requiring the insured to meet a deductible first.

A type of supplemental insurance that pays a fixed cash amount for specific illnesses or medical events, regardless of actual healthcare costs.

A health plan that requires members to use in-network providers and often mandates a Primary Care Physician (PCP) to coordinate care. There is no coverage for out-of-network care except in emergencies.

A traditional insurance model where patients choose any doctor or hospital and pay upfront. The insurer then reimburses a portion based on reasonable and customary charges, with no provider network restrictions.

A former ACA requirement that most Americans maintain health insurance coverage or pay a penalty. This penalty has been eliminated at the federal level but still exists in some states.

A patient who is admitted to a hospital for treatment and stays overnight or longer.

A health plan with lower coverage limits than major medical insurance, often including critical illness or hospital cash plans. These do not meet ACA requirements for comprehensive coverage.

A comprehensive health insurance plan that covers significant medical expenses, including hospitalization, surgery, and long-term treatment.

A faith-based cost-sharing program, not traditional insurance, where members contribute funds to cover each other's medical expenses. These plans are not regulated like traditional insurance.

A group of doctors, hospitals, and healthcare providers contracted with an insurance company to provide care at negotiated rates.

Another name for the Affordable Care Act (ACA).

A patient who receives medical treatment without being admitted to a hospital.

A hybrid health plan combining elements of HMO and PPO plans. Members choose a Primary Care Physician (PCP) but can seek out-of-network care at a higher cost.

A flexible health plan that allows members to see both in-network and out-of-network providers, though out-of-network care costs more.

A medical condition diagnosed before an individual's health insurance coverage begins. Under the ACA, insurers cannot deny coverage for pre-existing conditions.

The monthly payment an individual or employer makes to maintain health insurance coverage.

A doctor who serves as the main healthcare provider for routine check-ups, treatment, and referrals to specialists.

A penalty under the ACA’s individual mandate for not maintaining minimum essential coverage (MEC), though this has been eliminated at the federal level.

A temporary health insurance plan providing limited coverage for short-term gaps (typically less than a year). These plans do not meet ACA requirements and often exclude pre-existing conditions.

A life insurance policy that provides coverage for a specific period and pays a death benefit if the insured passes away during that term.

A 2017 Congressional bill intended to repeal and replace parts of the ACA, often referred to as TrumpCare.

The risk assessment process used by insurance companies to determine eligibility, pricing, and coverage for applicants based on medical history and other factors.

(Note: This I intended to be quick reference guide only. This is not legal or medical advice. This is not a comprehensive glossary of terms used in the industry, nor are these legal definitions. See your policy for a full description of all plans, plan features, benefits, exclusions limitations, etc.)