Glossary

Click one of the letters above to advance the page to terms beginning with that letter.

A

Actuarial Value
A health plan’s actuarial value is the percentage of total average costs for benefits that a plan covers. Starting in 2014, all health plans have an actuarial value assigned to them: bronze, silver, gold or platinum. As the metal category increases in value, so does the percent of medical expenses that a health plan will cover. This means the platinum-level plans will cover the highest percentage of health care expenses. These expenses are usually incurred at the time of health care services – when you visit the doctor or the emergency room, for example. The health plans that cover the greatest percentage of health care expenses also usually have higher premium payments.
Affordable Care Act
Enacted in March 2010, the federal Patient Protection and Affordable Care Act, commonly referred to as “Obamacare,” provides the framework, policies, regulations and guidelines for implementation of comprehensive health care reform by states. The Affordable Care Act expands access to high-quality affordable insurance and health care.
Allowed Amount
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Annual Household Income
The total amount of income for a family in a calendar year.
Annual Limit or Annual Maximum
A cap on the benefits your insurance company will pay in a year. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated healthcare costs for the rest of the year. Note: In 2014, under the Affordable Care Act, annual limits are no longer applicable for most benefits.
Appeal
A request for your health insurer or plan to revisit a claim decision or a grievance.
Attestation
To officially affirm that information provided is correct, true or genuine. To certify by signature, oath or any official capacity.

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B

Balance Billing
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Benefits (also called Covered Services)
Products and services covered under your insurance plan. Covered benefits and excluded services are defined in the health plan's explanation of coverage or state program rules.

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C

Certified Insurance Agents
Certified Insurance Agents are registered, trained and certified by Covered California. Certified Agents are individuals that are responsible for facilitating the enrollment process, providing expert advice regarding insurance plans, and providing assistance to consumers regarding health plan selection for the Covered California marketplace.
Claim
A formal request to an insurance company asking for a payment based on the terms of the insurance policy.
Coinsurance
"Your share of the costs of a covered health care service calculated as a percent (for example, 20%) of the allowed amount for the service. You are responsible for paying the co-insurance plus any deductibles you owe. For example, if your health plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. (See also in-network co-insurance)"
Complications of Pregnancy
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section are not complications of pregnancy.
Continuum of Coverage
Eligibility for insurance affordability programs falls along a continuum based on income, age and other eligibility factors. Income is measured as a percent of the Federal Poverty Level (FPL).
Copayment (also called copay)
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service’s allowed amount.
Cost Sharing
Any expenditure required by or on behalf of a participant with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for non-network doctors and hospitals, and spending for non-covered services.
Cost Sharing Reductions
After payment of premium and plan enrollment, cost-sharing reductions help people with their out-of-pocket costs like deductibles, coinsurance and copayments.
Covered California
Covered California is the state's health insurance exchange marketplace that connects Californians to affordable, quality health coverage for themselves, their dependents and/or small business.

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D

Deductible
"The amount you owe for health care services before your health insurance or plan benefits are covered. For example, if your deductible is $1000, your plan will not pay for covered health care services subject to the deductible until you’ve met your $1000 deductible. The deductible may not apply to all services."
Dependents
Spouses, children, or partners of the main participant or policy holder.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Examples of DME may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

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E

Emergency Medical Condition
An illness, injury, symptom or condition so serious that a reasonable person seeks immediate care to avoid severe harm.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency Room Care
Emergency services you receive in an emergency room.
Emergency Services
The evaluation and treatment of an emergency medical condition to keep the condition from getting worse.
Enrollment Period
An enrollment period or “open enrollment” is a period of time when participants may select or make changes to a health plan and enroll. Open enrollment usually happens once a year. Some exceptions (see “Special Enrollment”) can be made when certain qualifying events occur, such as a marriage, divorce, or birth of a child.
Essential Community
Providers (doctors and hospitals) that serve predominantly low-income, medically under-served.
Essential Health Benefits
Health care service categories that must be covered by certain plans starting in 2014. These service categories include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, behavioral health treatment, prescription drugs, rehabilitative and habilitation services and devices, laboratory services, preventive and wellness services, chronic disease management, and pediatric services, including dental and vision care. Insurance policies, including Medicaid state plans, must cover these benefits in order to be certified and offered in the marketplace,
Evidence of Coverage (EOC)
Participants will receive an Evidence of Coverage (EOC) after they enroll in their health plan. The EOC is part of the contract between the health insurance company and the participant. This legal document should be kept in a safe place.
Excluded Services
Health care services that your health insurance plan does not pay for or cover.
Exclusive Provider Organization (EPO)
An EPO health plan is similar to a Health Maintenance Organization (see HMO). Like an HMO, participants have access to the health plan’s provider network. Unlike an HMO, the health plan may cover services participants get from out-of-network doctors and hospitals, although coverage for those services is typically less than it would be for in-network services. Unlike an HMO, the participant does not generally need a referral from a partcipating care provider to receive care from an in-network specialist.
Explanation of Benefits (EOB)
After participants receive care from a doctor, hospital or other provider, the health insurance company will send them an Explanation of Benefits (EOB). The EOB describes the payment between the health insurance company and the doctor, hospital or other provider for the services rendered. It is not a bill.

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F

False Claims Act
The Federal False Claims Act (32 USC 3729) and California Government Code 12650 prohibit knowingly and willfully executing or attempting to execute a scheme or artifice to defraud any healthcare benefit program. To obtain (by means of false and fraudulent pretenses, representations or promises) any of the money or property owned by or under the custody or control of any health benefit program in connection with the delivery of or payment for healthcare benefits, items or services.
Federal Poverty Level
A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. In 2012, the federal poverty level for an individual was $11,170 per year and $23,050 for a family of four. To see a chart with more information on federal poverty levels, please visit http://www.familiesusa.org/resources/tools-for- advocates/guides/federal-poverty-guidelines.html
Federal Tax Information (FTI)
Federal Tax Information (FTI) is a subset of Personally Identifable Information (see PII). Safeguards established by the Internal Revenue Service (IRS) protect against unauthorized access and use of federal tax returns and information that the IRS uses to determine a person’s tax liability or potential tax liability.
Full-Time Eligible Employee
Any permanent employee who works on a full-time basis with a normal work week of 30 hours per week on average over the course of a month.

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G

Geographic Service Area
A defined geographic area that a health insurance plan proposes to serve and is approved by the applicable State Health Insurance Regulator to serve.
Grievance
A complaint that you communicate to your health insurer or plan.
Guaranteed Issue
A requirement that health plans must permit you to enroll in their health plan regardless of health status, age, gender, or other factors that might predict the use of health services.
Guaranteed Renewal
A requirement that your health plan must offer to renew your policy as long as you continue to pay premiums.

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H

Habilitative Services
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Health Insurance
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The Privacy Rule standards address the use and disclosure of individuals’ health information and standards for individuals' privacy rights to understand and control how their health information is used.
Health Maintenance Organization (HMO)
An HMO is a health plan that connects members with a primary care physician (PCP) or a team of physicians who work for or contract with the HMO. The PCP (or care team) coordinates the member’s care.
Home Health Care
Health care services a person receives at home.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation can be considered outpatient care (see Hospital Outpatient Care).

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I

In-network Co-insurance
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 co-insurance usually costs you less than out-of-network co-insurance.
In-network Co-payment
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 co-payments usually are less than out-of-network co-payments.
Information Practices Act of 1977
The Information Practices Act of 1977 is a California law that regulates the collection and use of personal information by state government agencies. The law also details the rights of the individual pertaining to personal information and includes the following: privacy, protected information, collecting information, disclosure and individual rights.
Insured (also called Member or Participant)
The policyholder of the purchased insurance and the person who receives benefits under the health plan.

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L

Lifetime Limit
As of 2014, the Affordable Care Act has banned all lifetime limits. Previously, this limit put a cap on the total lifetime benefits you would get from your insurance company or health plan―for example, a $1 million lifetime cap on benefits or a limit on specific benefits (like a $200,000 lifetime cap on organ transplants), or a combination of the two. After a lifetime limit is reached, the insurance plan no longer pays for covered services.

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M

Managed Care
In the United States, the majority of health plans offered through both private and public health insurance companies are considered managed care plans. With managed care plans, members access care through a doctor or hospital affiliated with a provider network.
Marketplace (Health Insurance)
Starting in 2014, eligible individuals and small businesses are able to purchase affordable health insurance directly from their state's health insurance marketplace or "exchange." The marketplace facilitates convenient online access to Qualified Health Plans and provides financial subsidies to those that qualify for assistance.
Medi-Cal
California's Medicaid health care program. This program provides free medical services for children and adults with limited income and resources. Your local County Welfare/Social Services Department manages Medi-Cal eligibility determinations.
Medically Necessary
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Member (also called Insured or Participant)
The policyholder of the purchased insurance and the person who receives benefits under the health plan.
Metal Levels
The Health Insurance Marketplaces (see Marketplace) offer four major levels of coverage: Bronze, Silver, Gold, and Platinum. Each type of plan must cover essential health benefits, but they differ in the share of health care costs that they cover on average. On average, a Bronze plan will cover 60 percent of covered benefits, a Silver plan 70 percent, a Gold plan 80 percent and a Platinum plan 90 percent. Participants pay for the remaining cost of their medical expenses with their own funds through deductibles, co-insurance and co-payments. The “higher” a metal level, the more expensive the premium (i.e., the cost of enrolling in the plan).
Minimum Essential Coverage
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.

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N

Network
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Nonpreferred Provider, or Nonparticipating Provider
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 where you must pay extra to see some providers.

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O

Open Enrollment
An enrollment period or “open enrollment” is a period of time when participants may select or make changes to a health plan and enroll. Open enrollment usually happens once a year. Some exceptions (see “Special Enrollment”) can be made when certain qualifying events occur, such as a marriage, divorce, or birth of a child.
Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
Out-of-Pocket Costs
Out-of-pocket cost is the amount the participant pays for the health services they use, which are not paid by their health plan. This is also called cost-sharing and usually includes coinsurance and co-payments, or similar charges, and deductibles.
Out-of-Pocket Limit
"The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans do not count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit."

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P

Personally Identifiable Information (PII)
Personally Identifiable Information (PII) is any data that could potentially identify a person. Examples include, but are not limited to: name, birthplace, e-mail, credit card numbers, residence, name of schools attended, Social Security numbers, biometric records, driver’s license numbers, digital screen names, age, grades, salary, job titles, date-of-birth, mother’s maiden name, etc.
Physician Services
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Plan
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Policy
The contract (agreement) between the person buying health insurance and the company providing it, describing specific health care services that will be covered, any coverage limitations and any out-of- pocket costs (copays, deductibles and/or coinsurance) that might be required.
Pre-existing Medical Condition
Any illness or condition a patient has prior to obtaining health insurance.
Preauthorization (also called Preapproval)
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services and procedures before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Provider (also called Participating Provider)
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network where you must pay extra to see some participating providers.
Preferred Provider Organization (PPO)
A PPO is a health plan that creates a network of preferred (or participating) providers by contracting with doctors and hospitals. Participants choose their providers and where they get covered services. Participants pay less when they use a network provider but always have the option to see an out-of-network provider at substantially higher cost.
Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Premium Assistance
One of the largest subsidy programs for health insurance to help consumers pay health insurance premiums.
Premium Development
The premium is the amount paid to the health insurance company for coverage. Under the ACA and California law, health insurance companies are only permitted to vary premiums for particular plans based on the following factors: age, geographic pricing regions, and family composition.
Prescription Drug
Drugs and medications that by law require a prescription.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Preventive Services
Routine healthcare that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems.
Primary Care Physician (PCP)
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Privacy Rule
"The Privacy Rule became effective on April 14, 2001, and covers: ·         The use and disclosure of a person’s individually identifiable health information by organizations subject to the Privacy Rule (covered entities) ·         The ability for individuals to understand and have more control over their health information and how it is used A major goal of the Privacy Rule is to make sure an individual’s health information is protected. The Privacy Rule works to strike a balance between the important uses of information and the protection of privacy. The Privacy Rule covers al Protected Health Information (PHI), whether written, oral, or electronic (see also HIPAA)"
Protected Health Information (PHI)
"Information is considered Protected Health Information (PHI) if it: ·         Contains information about a past, present, or future physical or mental health or condition, provision of health care, or past, present or future payment for health care ·         Was created/received by a doctor, hospital, or any other health care provider, a health insurance company, an employer or health care clearinghouse (e.g. a 3rd party medical biller) ·         Is individually identifiable ·         Includes documents in ANY medium―written, oral, or electronic Examples of PHI include: medical records, conversations about patient care or treatment, any health information about an individual that resides within a computer system, billing information about a patient."
Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

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Q

Qualified Health Plan
An insurance product that is certified by a marketplace, provides Essential Health Benefits, follows established limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts) and meets other requirements. A Qualified Health Plan will have a certification by each marketplace in which it is sold.

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R

Reconstructive Surgery
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Rehabilitation Services
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

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S

Security Rule
Today, new technologies have enabled doctors and hospitals to use paper processes less and rely more on the use of electronic information systems. As such, the Security Rule protects an individual’s electronic protected health information, or e-PHI. A major goal of the Security Rule is to allow covered entities to use new, more-efficient technologies to help improve the quality of consumer care and still protect the privacy of an individual’s health information.
Share of Cost (SOC)
The dollar amount participants must pay, or agree to pay, toward medical expenses before they qualify for Medi-Cal benefits. This amount depends on the participant's individual or household monthly income.
Skilled Nursing Care
Services from licensed nurses, skilled care technicians and therapists in your own home or in a nursing home.
Small Business Health Options Program (SHOP)
The Small Business Health Options Program (SHOP) is the exchange health insurance marketplace, either state or federal, for employers with 1 - 50 eligible employees.
Special Enrollment
The opportunity for people who experience a life-changing event, such as the loss of a job, marriage, divorce, or birth of a child, to sign up immediately in an employer’s health plan, even if it is outside of the plan’s specified enrollment period.
Specialist
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Summary of Benefits (SOB)
The Summary of Benefits (SOB) is a document designed to help consumers better understand their coverage. It provides a description of the coverage including any amounts the member has to pay for the services they use, such as deductibles, coinsurance and copayments. It also contains information about any exceptions, reductions or limitations under the coverage.

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T

Tax Credit
Tax credits are available through the SHOP Marketplace to eligible small businesses with no more than 25 full-time equivalent employees to help offset the cost of providing coverage.

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U

UCR (Usual, Customary and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent Care
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

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W

Wellness Programs
A program intended to improve and promote health and fitness that is usually offered through the work place, although insurance plans can offer them directly to their participants. The program allows your employer or plan to offer premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.

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