Understanding health coverage: Health care glossary

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Affordable Care Act (ACA)
The comprehensive federal health care reform law enacted in March 2010. Also known as "Obamacare" or "health care reform."
The percentage of charges you pay when you receive a covered service. Your health plan coverage pays the rest. Coinsurance amounts vary depending on your plan and the service.
The fixed dollar amount you pay when you receive certain covered services or prescriptions. Your health plan coverage pays the rest. Copayments vary depending on your plan and the service.
The fixed amount you must pay in a plan (group) or policy (individual) year for certain health care services before your health plan coverage begins to pay.
A family member, such as a spouse, child, or partner, who is covered under a policyholder or subscriber's plan, depending on applicable law and the plan's terms and conditions.
Essential health benefits package
Benefits package including ten categories of health care services that must be covered by certain plans, starting in 2014.
Essential health benefits must include items and services within at least the following 10 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 and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Federal financial assistance (sometimes called "subsidy")
Financial help the federal government may provide to help some people pay for health coverage or care. The government will pay premium assistance and in some cases out-of-pocket expenses directly to the health plan. Qualification and the amount are determined by income and family size.
HSA-qualified deductible plan
HSA-qualified deductible plans allow you to pay for qualified medical expenses with tax-deductible dollars.
Health care reform
A general term for the major health policy changes put in place by the federal Affordable Care Act and any state laws passed to put it in place.
Health benefit exchange(s) (formerly Health Insurance Marketplace(s))
State- or federally run and regulated markets where you can shop, compare and buy health care coverage.
The exchange(s)
A common nickname for the health benefit exchange(s).
A government health coverage program for low-income persons.
Out-of-pocket expenses
The amounts you pay to providers for health care services you receive under the terms of your health care coverage, including copayments, coinsurance, and deductible payments, in contrast to the premium you pay each month for your health plan coverage.
Out-of-Pocket maximum
The maximum amount you will pay in a calendar year for most covered services.
Plan level
There are several standard levels of coverage known by their "metal" names: Bronze, Silver, Gold, and in some states, Platinum.
The amount you and/or your employer pay (usually each month) for health plan coverage.
Prescription drugs
Drugs and medications that by law require a prescription.
Summary of Benefits and Coverage
A plain-language summary of your benefits and coverage. In compliance with the ACA, every insurer must supply this document to members and prospective members during open enrollment and/or upon request, depending on the state. The SBC provides a brief summary of information such as the following:
  • Cost-sharing for some common medical services such as office visits or lab tests
  • Deductibles and out-of-pocket limits
  • Services not covered by the plan