Navigating health insurance can feel like learning a new language, with all those complex terms and jargon. At SilverCross Group, we get it! That’s why we’ve created the Insurance ABC – a fun and easy-to-understand glossary of key health insurance terms. This guide will help you decode the most important concepts, so you can choose the right coverage with confidence. Let’s make health insurance simple and stress-free!
The ACA, also known as “Obamacare,” is a law designed to make health insurance more affordable and accessible. It provides subsidies, mandates essential health benefits, and protects people with pre-existing conditions.
Example:
Think of the ACA as a superhero law. If you don’t earn much, the ACA swoops in with tax credits to lower your insurance costs
The annual deductible is the amount you pay out-of-pocket for healthcare services each year before your health insurance starts covering costs.
Example:
Imagine your wallet has a $1,000 force field. You need to spend $1,000 on healthcare before your insurance steps in to cover the rest. Until then, you’re on the hook for medical bills.
Benefits are the healthcare services and items covered by your insurance plan, such as doctor visits, hospital stays, prescription drugs, and preventive care.
Example:
Benefits are like a buffet of healthcare goodies covered by your plan, from check-ups to surgeries.
A broker is a licensed professional who helps you find and purchase health insurance coverage that fits your needs.
Example:
Think of a broker as your personal health insurance shopper, finding the best deals for you. And the best broker? That’s SilverCross Group! Call us and let’s find your perfect plan today!
Co-insurance is your share of the costs of a healthcare service, usually a percentage (e.g., 20%) of the allowed amount for the service.
Example:
If your co-insurance is 20% and the service costs $100, you pay $20, and your insurance pays $80.
A co-payment is a fixed amount you pay for a covered healthcare service, typically when you receive the service (e.g., $25 for a doctor’s visit).
Example:
Think of a co-pay as the ticket price you pay at the door to see your healthcare provider. Just a small fee, and you’re in for quality care!
CSR is a discount that lowers the amount you have to pay for deductibles, co-payments, and co-insurance.
Example:
Think of a co-pay as the ticket price you pay at the door to see your healthcare provider. Just a small fee, and you’re in for quality care!
Comprehensive coverage refers to a health insurance plan that provides a wide range of healthcare services, including preventive, emergency, and long-term care.
Example:
Comprehensive coverage is like an all-inclusive vacation package – it covers almost everything you might need.
A dependent is a person covered under your health insurance plan, such as a spouse or child.
Example:
Dependents are your healthcare sidekicks, covered under your plan. Or Anyone that you claim as a tax dependant even if they are not going to be in the same health plan.
Essential health benefits are a set of 10 categories of services health insurance plans must cover under the ACA, including maternity care, mental health services, and prescription drugs.
Example:
These benefits are the must-haves of healthcare, ensuring comprehensive coverage.
An EPO is a type of health insurance plan that requires members to use a network of doctors and hospitals. There are no out-of-network benefits, except in emergencies.
Example:
An EPO is like a club where you can only use the services of its members unless it’s an emergency.
A formulary is a list of prescription drugs covered by your health insurance plan.
Example:
The formulary is like your insurance plan’s approved shopping list for medications.
A generic drug is a medication that has the same active ingredients as a brand-name drug but usually costs less.
Example:
Generic drugs are the no-frills versions of brand-name medications, offering the same benefits at a lower cost.
An HMO is a type of health insurance plan that requires members to get healthcare services from a network of providers and typically requires a referral from a primary care doctor to see a specialist.
Example:
An HMO is like a club with its own network of doctors and hospitals.
An HSA is a tax-advantaged account you can use to save money for medical expenses. Contributions are tax-deductible, and withdrawals for qualified expenses are tax-free.
Example:
An HSA is like a health-specific savings account that gives you tax breaks.
Hospitalization is the care you receive when admitted to a hospital for treatment.
Example:
Hospitalization covers your stay when you need more than a quick visit to the doctor.
An in-network provider is a doctor or healthcare facility that has a contract with your health insurance plan to provide services at a discounted rate.
Example:
In-network providers are the preferred partners of your insurance plan, offering lower costs.
An indemnity plan is a type of health insurance that allows you to choose any doctor or hospital, and the insurance company pays a set portion of your total charges.
Example:
Indemnity plans are like having a blank check for healthcare, giving you the freedom to choose.
A lifetime limit is a cap on the total benefits your insurance company will pay over your lifetime. The ACA has eliminated lifetime limits for essential health benefits.
Example:
Lifetime limits are like a ceiling on your insurance benefits, but the ACA has removed this ceiling for essential services.
Medicaid is a state and federal program that provides health coverage for low-income individuals and families.
Example:
Medicaid is like a safety net, offering health coverage to those who need financial assistance.
Medicare is a federal health insurance program for people aged 65 and older, and for some younger people with disabilities
Example:
Medicare is like a senior citizen’s health plan, kicking in at age 65.
Metal tiers categorize ACA health plans based on the percentage of healthcare costs they cover. Bronze plans cover 60%, Silver 70%, Gold 80%, and Platinum 90%.
Example:
Metal tiers are like medals in the insurance Olympics, each covering a different percentage of your costs.
A network is a group of doctors, hospitals, and other healthcare providers that have agreed to provide services to a health insurance plan’s members at discounted rates.
Example:
The network is like your insurance plan’s VIP list of preferred healthcare providers.
A non-preferred provider is a healthcare provider that is not part of your health insurance plan’s network, typically resulting in higher out-of-pocket costs.
Example:
Non-preferred providers are like out-of-network options that cost you more to see.
The out-of-pocket maximum is the most you have to pay for covered services in a plan year. After you reach this amount, your insurance pays 100% of covered services.
Example:
The out-of-pocket maximum is like a safety net – once you reach it, your insurance covers the rest.
The open enrollment period is the annual time when you can sign up for a health insurance plan, make changes to your existing plan, or cancel your plan.
Example:
Open enrollment is like the registration period for health insurance – don’t miss it!
An out-of-network provider is a healthcare provider that is not part of your health insurance plan’s network, typically resulting in higher out-of-pocket costs.
Example:
Out-of-network providers are like out-of-town guests – welcome, but they cost more.
A premium is the amount you pay for your health insurance plan, typically on a monthly basis.
Example:
Your premium is like a subscription fee you pay every month to keep your health coverage active. Yes, just like netflix but way more important.
Preventive care services are routine healthcare services that include screenings, check-ups, and counseling to prevent illnesses, disease, or other health problems.
Example:
Preventive care services are like regular maintenance checks for your body, helping you stay healthy and catch issues early.
A PCP (Primary Care Physician) is a healthcare provider who acts as the first point of contact for patients and provides continuous care.
Example:
Your PCP is like the quarterback of your healthcare team, coordinating your overall care.
A PPO is a type of health insurance plan that offers a network of healthcare providers but allows you to see out-of-network doctors at a higher cost. Referrals are not required to see specialists.
Example:
A PPO is like a flexible dining plan – you get the best deals at preferred restaurants but can still eat anywhere else for a bit more.
A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services.
Example:
A referral is like a hall pass from your doctor, giving you permission to see a specialist.
A special enrollment period is a time outside the open enrollment period during which you can sign up for health insurance if you have certain life events.
Example:
Special enrollment is like a backstage pass, letting you enroll in health insurance after life changes like getting married or having a baby.
A subsidy is financial assistance that helps you pay for health insurance, usually based on your income.
Example:
A subsidy is like a discount coupon from the government, making your health insurance more affordable.
Telehealth is the use of digital information and communication technologies to access healthcare services remotely.
Example:
Telehealth is like a virtual doctor’s visit from the comfort of your home.
Urgent care is medical care provided for illnesses or injuries that need immediate attention but are not severe enough for an emergency room visit.
Example:
Urgent care is like the middle ground between a regular doctor visit and the emergency room.
A waiting period is the time that must pass before some or all of your health coverage can begin.
Example:
A waiting period is like a countdown timer before your insurance benefits kick in. With ACA plans you have no waiting period. Check our plans today!
Wellness programs are health and fitness programs offered by employers or health plans to improve health and prevent disease.
Example:
Wellness programs are like health-boosting perks from your employer or insurance plan, encouraging a healthy lifestyle.
A yearly limit is a cap on the total benefits your insurance will pay in a year. The ACA has eliminated yearly limits for essential health benefits.
Example:
Yearly limits are like a spending cap, but the ACA has removed these caps for essential services.