You are currently viewing Ultimate Guide to Health Insurance Terms

Ultimate Guide to Health Insurance Terms

At Woligo, we believe it’s essential for everyone to understand the components of health insurance. That’s why we created this guide – to help you navigate the world of health insurance so you can maximize your benefits. 

Accident insurance helps provide financial protection for those who may become injured or deceased due to an unexpected accident. The insurance benefits help cover out-of-pocket medical expenses and other bills that emerge while healing from your injury. It works alongside your primary health insurance plan, making payable benefits directly to your pocket instead of the medical facilities that are treating you.

An adjusted gross income (AGI) is your total income for the tax year, minus certain deductions you’re allowed to take.

The Affordable Care Act, also known as Obamacare, is a comprehensive health care reform law signed by President Barack Obama in 2010.

For a full-time employee, coverage is considered affordable if the lowest cost self-only health plan is 9.61% or less of the employee’s household income.

An annual limit is the maximum amount of benefits your insurance company will pay in a plan year. Annual limits could be placed on a dollar amount of covered services or the number of visits covered for a particular service. You would be responsible for any expenses that exceed your plan’s annual limit.

Balance billing is when a provider bills you for more than the covered amount by your insurance company. For example, if a doctor charges you $75 and the allowed amount through your insurance policy is $50, you may be billed for the remaining $25 not covered by your insurance.

Benefits are the health care items or services covered under a health insurance plan.

A brand name drug is a drug sold by a pharmaceutical company under a specific name or trademark and protected by a patent. A generic name drug is typically a cheaper version with the same ingredients as a brand name drug.

A bronze health plan is one of four health 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.

A claim is a request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Coinsurance is the percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

A co-payment is a fixed amount ($20, for example) you pay for a covered health care service before OR after you’ve paid your deductible, depending on the plan.

COBRA is a federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

A cost-sharing reduction is a discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. In the Health Insurance Marketplace®, cost-sharing reductions are often called “extra savings.” If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

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Woligo’s licensed agents are here to help answer your questions about health insurance.

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(888) 633-5229

A deductible is how much you have to spend for covered health services before your insurance company pays anything (except free preventive services).

A dental discount plan offers discounted rates for cleanings, X-rays, crowns, fillings, and other dental services. Woligo’s dental discount plan has connections with dental providers around the U.S. and is just one of the many benefits of their well-being discount plan.

A dependent is a child or other individual for whom a parent, relative, or another 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.

Disability insurance helps replace a portion of your income if you become disabled and cannot work due to a qualifying injury or illness. This insurance covers critical illnesses, including heart attack, stroke, cancer, organ failure, cognitive impairment, and serious injuries that lead to an inability to work.

Essential health benefits (EHB) are a set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services. Plans must offer dental coverage for children. Dental benefits for adults are optional.

An Exclusive Provider Organization (EPO) is a managed care plan where services are covered, as long as you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Family and Medical Leave Act (FMLA) is 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 is 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.

A flexible savings account (FSA) is 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.

A full-time employee (FTE) is 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 fewer than 30 hours per week on average.

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Generic drugs are prescription drugs with the same active-ingredient formula as a brand name drug, but typically costs less.

A Gold health plan is one of four health plan categories (also known as “metal levels”) in the Health Insurance Marketplace. Gold plans usually have higher monthly premiums but lower costs when you get care.

A grandfathered health plan is an individual health insurance policy purchased on or before March 23, 2010, when the Affordable Care Act was signed into law. 

Group health insurance, in general, is a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Guaranteed renewal is 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 Maintenance Organization (HMO) is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. 

A Health Savings Account (HSA) is 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 health care costs. HSA funds generally may not be used to pay premiums.

A high-deductible health plan (HDHP) is 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.

Hospice services are services to provide comfort and support for persons in the last stages of a terminal illness and their families.

In-network coinsurance is 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.

An in-network copayment is 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.

An individual health insurance policy is a policy for people that aren’t connected to job-based coverage.

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Long-term care insurance provides services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term care can be provided at home, assisted living, or nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

The marketplace is shorthand for the “Health Insurance Marketplace®,” a shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010.

Medicaid is an 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.

Medical underwriting is 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. However, qualifying health plans under the Affordable Care Act to not use medical underwriting.

Medicare is 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).

Metal levels are the four health plan levels in the Health Insurance Marketplace – bronze, silver, gold, and platinum. Metal levels are based on how you and your plan split the costs of your health care. They have nothing to do with the quality of care.

Minimum essential coverage is any insurance plan that meets the Affordable Care Act requirement for having health coverage that is “affordable” and provides “minimum value.”

Minimum value is a standard of minimum coverage that applies to job-based health plans. 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; and its benefits include substantial coverage of physician and inpatient hospital services.

A non-preferred provider is a provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Obamacare is a nickname for the Affordable Care Act (ACA) or the comprehensive health care reform law enacted in March 2010.

Open enrollment is the yearly period in the fall when people can enroll in a health insurance plan for the next calendar year.

Out-of-network coinsurance is 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.

Out-of-network payment is 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.

Out-of-pocket costs are expenses for medical care that are not reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren’t covered.

Out-of-pocket maximum is the most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.

The plan year is 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”).

The platinum health plan is one of four health plan categories (also known as “metal levels”) in the Health Insurance Marketplace. Platinum plans usually have the highest monthly premiums but the lowest costs when you get care.

A pre-existing condition is a health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.

Prior authorization is the approval from a health plan that 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 Preferred Provider Organization (PPO) is a type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

Premium

A premium is the amount you must pay for your health insurance. It is usually paid on a monthly, quarterly, or years basis.

A premium tax credit is 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.

Prescription drugs

Prescription drugs are drugs and medications that by law require a prescription to obtain.

Preventive care is routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary care physician

A primary care physician is a physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) that directly provides or coordinates a range of health care services for you.

Still have questions?
We are here to help!

Woligo’s licensed agents are here to help answer your questions about health insurance.

Call now:
(888) 633-5229

Primary care provider

A primary care provider is a physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed by state law, that provides, coordinates, or helps you access a range of health care services.

Qualifying life event (QLE) is a change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period. 

There are four basic types of qualifying life events.

Loss of health coverage
Examples: Losing existing health coverage, including job-based, individual, and student plans, or turning 26 and losing coverage through a parent’s plan.

Changes in household
Examples: Getting married or divorced, having a baby or adopting a child,

Death in the family

Changes in residence
Examples: Moving to a different ZIP code or county, A student moving to or from the place they attend school

Other qualifying events
Examples: Changes in your income that affect the coverage you qualify for, Becoming a U.S. citizen, Leaving incarceration (jail or prison), AmeriCorps members starting or ending their service

A qualified health plan is a insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.”

A referral is 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.

A referral is 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.

A rider, or an exclusionary 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). In most states, an exclusionary rider is an amendment permitted in individual health insurance policies that permanently excludes coverage for a health condition, body part, or body system. After September 2010, under the Affordable Care Act, exclusionary riders couldn’t be applied to coverage for children. Since 2014, no exclusionary riders have been permitted in any health insurance.

The Small Business Health Options Program (SHOP) helps small business owners provide their employees medical and/or dental insurance. Some smaller employers qualify for tax credits if they enroll in SHOP insurance.

The silver health plan is one of four health plan categories (also known as “metal levels”) in the Health Insurance Marketplace. Silver plans usually have moderate monthly premiums and moderate costs when you get care.

A special enrollment period is when you can enroll for coverage outside of an annual enrollment period if you’ve experienced a qualifying life event such as losing health coverage, moving, getting married, having a baby, or adopting a child.

Social security survivors benefits are Social Security benefits based on your record (if you should die) that are paid to your widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22; children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22; and parents if you provided at least one-half of their support. An ex-spouse could also be eligible for a widow/widower’s benefit on your record. A special one-time lump sum payment of $255 may be made to your spouse or minor children.

Subsidized coverage is health coverage available at reduced or no cost for people with incomes below certain levels. Examples of subsidized coverage include Medicaid and the Children’s Health Insurance Program (CHIP).

Summary of benefits and coverage is 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.

Telehealth services include on-demand access to phone or video appointments with medical professionals, 24 hours a day, seven days a week. And if you don’t need a full appointment, you can still get your basic healthcare questions answered using a secure website. Telehealth is just one of the benefits that come with Woligo’s Well-Being Discount Plan.

Urgent care is 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.

A waiting period is 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. However, qualifying health plans under the Affordable Care Act cannot have waiting periods longer than 90 days.

A medical Well-Being Discount Plan provides members with discounts on medical services. It is not health insurance, and well-being discount plans do not make any payments to medical providers. Instead, members use their membership cards to redeem discounts at providers included in the program.

Woligo (WŌ-luh-go = Work-Life-Go) is here for the self-employed professionals, small business owners – people who are the boss of themselves and their businesses. Woligo is part of the Cameron Group along with INSURICA, First Fidelity Bank and many other companies that provide health, human resource, and financial security solutions to help our customers meet their goals.

Workers compensation is an insurance plan that employers are required to have to cover employees who get sick or injured on the job.

Still have questions?
We are here to help!

Woligo’s licensed agents are here to help answer your questions about health insurance.

yellow Woligo bookmark logo with W

Call now:

Do you have questions about health insurance and which plan is right for you?  Woligo’s team of experts can help you select the best coverage option for you.  Call us now (888) 633-5229 (option 1) to speak to a licensed agent today!

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