Health Insurance Glossary

ACA (Affordable Care Act)

The 2010 law that expanded health coverage access and established consumer protections.

Acute Onset of Pre-Existing Condition

A sudden, unexpected flare-up of a known condition that some visitor plans cover.

Advance Premium Tax Credit (APTC)

A federal subsidy that reduces your monthly marketplace plan premium based on your income.

Allowed Amount

The maximum amount your insurer will pay for a covered service from an in-network provider.

Annual Enrollment Period (Medicare)

The October 15–December 7 window when Medicare beneficiaries can change their coverage.

Appeal (Claim Denial)

A formal process to challenge your insurer's decision to deny a claim or service.

Balance Billing

When an out-of-network provider bills you for the difference between their charge and your insurer's payment.

Bronze Plan

The lowest-premium ACA metal tier, covering roughly 60% of average healthcare costs.

Catastrophic Plan

A low-premium, very high-deductible plan available to people under 30 or with hardship exemptions.

CHIP (Children's Health Insurance Program)

A program providing low-cost health coverage to children in families that earn too much for Medicaid.

COBRA

A law allowing you to keep employer-sponsored insurance after leaving a job, at full cost.

Coinsurance

Your share of costs after meeting your deductible, expressed as a percentage.

Comprehensive Visitor Plan

A visitor insurance plan that covers a broad range of medical expenses, similar to regular insurance.

Coordination of Benefits

Rules that determine which insurer pays first when you're covered by more than one health plan.

Copay

A fixed amount you pay for a specific covered service at the time of care.

Cost-Sharing Reduction (CSR)

Extra savings on deductibles, copays, and out-of-pocket maximums for Silver plan enrollees with lower incomes.

Coverage Gap (Donut Hole)

A phase in Medicare Part D where you pay more for prescriptions until catastrophic coverage kicks in.

Creditable Coverage

Health coverage that meets minimum standards, preventing late enrollment penalties in Medicare.

Deductible

The amount you pay out-of-pocket before your insurance starts covering costs.

Dependent

A family member — typically a spouse or child — covered under your health insurance plan.

Dependent Care FSA

A pre-tax account for childcare and elder care expenses — separate from a medical FSA.

Dual Eligible

A person who qualifies for both Medicare and Medicaid, receiving benefits from both programs.

Durable Medical Equipment (DME)

Reusable medical items — like wheelchairs, CPAP machines, and blood glucose monitors — covered by insurance.

EOB (Explanation of Benefits)

A statement from your insurer explaining what was billed, covered, and what you owe.

EPO (Exclusive Provider Organization)

A plan with no referrals required but no out-of-network coverage except emergencies.

Essential Health Benefits (EHBs)

Ten categories of services that ACA-compliant plans must cover.

Extra Help (Low Income Subsidy)

A federal program that reduces Medicare Part D prescription drug costs for people with limited income.

Fixed Benefit Plan

A visitor insurance plan that pays a set dollar amount per service, regardless of actual cost.

Form 1095-A

A tax form from the Health Insurance Marketplace showing your coverage and any premium tax credits received.

Form 1095-B

A tax form confirming you had minimum essential health coverage during the year.

Form 1095-C

A tax form from large employers showing what health coverage they offered to employees.

Formulary

Your insurance plan's list of covered prescription drugs, organized by cost tiers.

FSA (Flexible Spending Account)

A tax-advantaged account for medical expenses that doesn't require an HDHP.

Gold Plan

A higher-premium ACA plan that covers roughly 80% of average healthcare costs.

Grace Period

A short window after a missed premium payment during which your coverage remains active.

HDHP (High-Deductible Health Plan)

A plan with lower premiums but a higher deductible, often paired with an HSA.

Health Insurance for Self-Employed

Coverage options for freelancers, independent contractors, and small business owners without employer coverage.

Health Reimbursement Arrangement (HRA)

An employer-funded account that reimburses employees for qualified medical expenses tax-free.

HIPAA

Federal law protecting the privacy and security of your health information.

HMO (Health Maintenance Organization)

A plan that requires you to use a specific network of doctors and get referrals for specialists.

HRA (Health Reimbursement Arrangement)

An employer-funded account that reimburses you for qualified medical expenses tax-free.

HSA (Health Savings Account)

A tax-advantaged savings account for medical expenses, available with HDHPs.

In-Network

Doctors and facilities that have a contract with your insurance plan, offering lower costs.

Indemnity Plan (Fee-for-Service)

A traditional plan letting you see any doctor and getting reimbursed a set amount per service.

Insurance Claim

A request submitted to your insurer to pay for a medical service you received.

IRMAA (Income-Related Monthly Adjustment Amount)

A Medicare surcharge added to your Part B and Part D premiums if your income exceeds certain thresholds.

Marketplace Plan

Health insurance plans sold through government-run exchanges under the ACA.

Medicaid

A joint federal-state program providing health coverage to low-income individuals and families.

Medicaid Expansion

The ACA provision that allowed states to extend Medicaid to adults earning up to 138% of the Federal Poverty Level.

Medical Evacuation

Coverage that pays to transport you to an appropriate medical facility or back home if medically necessary.

Medical Necessity

The standard insurers use to determine whether a service is appropriate and required for your condition.

Medicare Advantage (Part C)

Private insurance plans that bundle Parts A and B, often with extra benefits.

Medicare Part A

Hospital insurance covering inpatient stays, skilled nursing, and some home health care.

Medicare Part B

Medical insurance covering doctor visits, outpatient care, and preventive services.

Medicare Part D

Prescription drug coverage available as a standalone plan or bundled with Medicare Advantage.

Medicare Savings Programs (MSP)

State programs that help low-income Medicare beneficiaries pay their premiums, deductibles, and copays.

Medigap (Medicare Supplement Insurance)

Private insurance that covers the gaps in Original Medicare — deductibles, coinsurance, and copays.

Medigap Plan Types (A, B, D, F, G, K, L, M, N)

The standardized supplemental Medicare plans that help cover Original Medicare cost-sharing gaps.

Mental Health Parity

A federal law requiring insurers to cover mental health and substance use disorders no more restrictively than physical health conditions.

Network Adequacy

The requirement that an insurance plan's provider network has enough doctors and facilities to serve its members.

No Surprises Act

A 2022 federal law that protects patients from unexpected out-of-network medical bills.

Open Enrollment Period

The annual window when you can sign up for or change your health insurance plan.

Out-of-Network

Providers without a contract with your plan, typically resulting in higher costs or no coverage.

Out-of-Pocket Maximum

The most you'll ever pay in a plan year for covered services.

Platinum Plan

The highest-premium ACA plan, covering roughly 90% of average healthcare costs.

Policy Maximum

The maximum dollar amount your visitor insurance plan will pay for covered expenses.

POS Plan (Point of Service)

A hybrid plan requiring a PCP and referrals for specialists, but allowing some out-of-network care.

PPO (Preferred Provider Organization)

A flexible plan that lets you see any doctor without a referral, with lower costs in-network.

Pre-Existing Condition

A health condition you had before your insurance coverage started.

Premium

The monthly amount you pay to keep your health insurance coverage active.

Premium Tax Credit Eligibility

ACA subsidies that reduce marketplace plan premiums based on your household income and size.

Preventive Care

Routine health services — like annual checkups and screenings — covered at no cost under ACA plans.

Primary Care Physician (PCP)

Your main doctor who provides routine care and coordinates referrals to specialists.

Prior Authorization

Approval required from your insurer before receiving certain services or medications.

Provider Network

The group of doctors, hospitals, and facilities contracted with your insurance plan.

Qualifying Life Event

A major life change that triggers a special enrollment period outside of open enrollment.

Qualifying Life Event — Job Loss

Losing job-based health coverage triggers a Special Enrollment Period to get new insurance outside open enrollment.

Referral

A written authorization from your primary care doctor to see a specialist, required by some plans.

Short-Term Health Insurance

Temporary health coverage for gaps between plans — cheaper but with significant coverage limitations.

Silver Plan

The mid-tier ACA plan — the only tier eligible for cost-sharing reductions based on income.

Special Enrollment Period

A limited window to enroll in health insurance outside of open enrollment after a qualifying life event.

Specialist

A doctor with advanced training in a specific area of medicine, such as cardiology or dermatology.

Step Therapy

An insurer's requirement to try lower-cost medications before approving a more expensive drug.

Surprise Billing (No Surprises Act)

Unexpected medical bills from out-of-network providers — now largely prohibited by the No Surprises Act.

Telehealth

Healthcare delivered remotely via video, phone, or app — often at lower cost than an in-person visit.

TRICARE

Health insurance coverage for active-duty military members, veterans, and their families.

Turning 26 — Losing Parental Coverage

At 26, you age off your parent's health plan and must find your own coverage within 60 days.

Utilization Review

An insurer's evaluation of whether a healthcare service is medically necessary and appropriate.

Visa Insurance Requirement

Mandatory health insurance required by certain US visa types, particularly J-1 and J-2.

Visitor Health Insurance

Short-term medical coverage for non-US residents visiting the United States.

Waiting Period

A period after your coverage starts during which certain conditions are not yet covered.