GLOSSARY

Understanding Your Coverage: A Guide to Insurance Terms

Navigating the world of insurance can feel like learning a second language. Whether you are transitioning to Medicare, selecting a plan through the Affordable Care Act, or looking for supplemental protection for your family, understanding the terminology is the first step toward making a confident decision. We’ve compiled this comprehensive glossary to help demystify the most common terms across our health, life, and supplemental products.

Affordable Care Act (ACA) & Marketplace Terms

• Advanced Premium Tax Credit (APTC): A federal subsidy available to individuals and families who purchase health insurance through the Marketplace to help lower monthly premium costs.

• Affordable Care Act (ACA): The comprehensive healthcare reform law (passed in 2010) that increased health insurance coverage for the uninsured and implemented reforms to the health insurance market.

• Essential Health Benefits (EHB): A set of 10 categories of services health insurance plans must cover, including emergency services, maternity care, and mental health.

• Subsidized Coverage: Health insurance with reduced premiums or lower out-of-pocket costs provided by the government based on income.

• Summary of Benefits and Coverage (SBC): An easy-to-read document that lets you compare different health plans by showing costs and coverage details.

Core Insurance & Clinical Concepts

• Ambulance Services: Medically necessary transportation by ground or air for patients whose condition does not allow for standard transportation.

• Benefits: The healthcare items and services covered under a health insurance plan.

• Benefit Year: A consecutive 12-month period during which your health insurance benefits are calculated. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31, even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.

• Claim: A formal request for payment sent to an insurance company for services received.

• Clinical Research: Medical studies involving human participants to evaluate the safety and effectiveness of medications or treatments.

• COBRA: A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, 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.

• Coinsurance: Your share of the costs of a covered service, calculated as a percent (e.g., 20%) of the allowed amount.

• Copayment (Copay): A fixed dollar amount (e.g., $20) you pay for a specific service.

• Deductible: The amount you must pay out-of-pocket for covered services before your insurance company begins to pay.

• Dependent Coverage: Health insurance coverage extended to the children or spouse of the primary policyholder.

• Diagnostic Testing: Tests ordered to investigate specific symptoms or monitor a condition (e.g., X-rays or blood work).

• Durable Medical Equipment (DME): Equipment that provides therapeutic benefits to a patient in the home (e.g., wheelchairs, oxygen tanks).

• Excluded Services: Health care services that your health insurance or plan doesn’t pay for or cover.

• Health Care Provider: A person or facility (doctor, nurse, hospital) licensed to provide health care services.

• In-Network Provider: A provider who has a contract with your insurer to provide services at a discounted rate.

• Inpatient Care: Health care that you get when you’re formally admitted as an inpatient to a healthcare facility, like a hospital or skilled nursing facility.

• Maternity and Newborn Coverage: Care provided to women during pregnancy and childbirth, and care for the infant after birth.

• Medically Necessary Services: Services or supplies needed to prevent, diagnose, or treat an illness, injury, or condition that meet accepted standards of medicine.

• Mental Health Services: Inpatient and outpatient care for mental health conditions and substance use disorders.

• Network: The facilities, providers, and suppliers your insurer has contracted with.

• Out-of-Network Provider: A provider who does not have a contract with your plan. Costs are typically higher here.

• Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance (includes deductibles, coinsurance, and copays).

• Out-of-Pocket Maximum: The most you have to pay for covered services in a plan year.

• Pre-existing Condition: A health problem you had before the date that new health coverage starts.

• Pre-natal Appointments: Routine healthcare visits for pregnant women to monitor health before birth.

• Premium: The fixed amount you pay (usually monthly) to keep your insurance active.

• Preventive Services: Routine healthcare, such as screenings and check-ups, to prevent illnesses or detect them early.

• Primary Care Physician (PCP): Your first point of contact for healthcare who coordinates your overall care.

• Private Health Insurance: Health insurance that is marketed by the private health insurance industry rather than government-run programs.

• Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services.

• Specialist: A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

• Well-Child Visits: Routine pediatric visits to track a child's growth and development.

• X-ray: A type of diagnostic testing that uses high-energy radiation to take pictures of the inside of the body.

Financial & Administrative Terms

• Effective Date: The date on which an insurance policy becomes active.

• Enrollment: The process of signing up for a health insurance plan.

• Flexible Spending Account (FSA): An employer-sponsored account that lets you pay for many out-of-pocket medical expenses with tax-free dollars.

• Health Insurance Agent: A professional licensed by the state to help you find and enroll in health insurance.

• Health Savings Account (HSA): A tax-advantaged savings account available to people who have a high-deductible health plan (HDHP).

• HIPAA: The Health Insurance Portability and Accountability Act, a federal law that protects sensitive patient health information from being disclosed without consent.

• Lapse: The termination of an insurance policy due to non-payment of premiums.

• Medical Underwriting: The process an insurer uses to decide your eligibility or premium based on your health history.

• Open Enrollment Period: The yearly period when people can enroll in a health insurance plan.

• Special Enrollment Period (SEP): A time outside the yearly Open Enrollment Period when you can sign up for health insurance if you have a Qualifying Life Event.

• Waiting Period: The time that must pass before some or all of your coverage begins.

Life Insurance Terms

• Beneficiary: The person named in a policy to receive the death benefit.

• Cash Value: The equity amount in a permanent life insurance policy.

• Death Benefit: The amount paid to beneficiaries when the insured passes away.

• Term Life Insurance: Coverage for a specific period (the "term").

• Universal Life Insurance: Permanent life insurance with flexible premiums and death benefits.

• Whole Life Insurance: Permanent life insurance with guaranteed cash value growth.

Medicare Terms

• Annual Election Period (AEP): The yearly window (Oct 15 – Dec 7) to change Medicare Advantage or Part D plans.

• Donut Hole (Coverage Gap): A limit on what a Part D plan will cover for drugs before you reach catastrophic coverage.

• Extra Help: A Medicare program to help people with limited income and resources pay Medicare Part D premiums, deductibles, and coinsurance.

• Formulary: A list of prescription drugs covered by a plan.

• Initial Coverage Election Period (ICEP): The first time you can enroll in a Medicare Advantage plan when you are new to Medicare.

• Low Income Subsidy (LIS): Another name for the "Extra Help" program for Part D costs.

• Medicare Advantage (Part C): Private "all-in-one" alternatives to Original Medicare.

• Medicare Part A: Hospital insurance.

• Medicare Part B: Medical insurance (doctor visits/outpatient care).

• Medicare Part D: Prescription drug coverage.

• Medicare Supplement (Medigap): Private insurance that pays costs Original Medicare doesn't (e.g., Plan G, N, F).

• Optional Supplemental Benefits: Extra benefits, like dental or vision, that a Medicare Advantage plan may offer for an additional premium.

• Retireflo: A questionnaire utilized prior to our meeting to get to know you better, which collects your doctor, prescription, and prior Medicare information.

• Tiers: The levels into which a drug formulary is divided; drugs in lower tiers generally cost less than those in higher tiers.

Supplemental & Ancillary Terms

• Accident Insurance: Provides a cash benefit for covered accidental injuries.

• Cancer Insurance: A policy that pays benefits upon a cancer diagnosis or treatment.

• Home Health Care: Health care services given in your home for an injury or illness.

• Hospice Services: Care for people with terminal illness, focusing on comfort and quality of life.

• Hospital Indemnity Plan: Pays a fixed daily cash benefit while you are hospitalized.

• Long-Term Care: A range of services and support for your personal care needs over a long period.

• Short-Term Health Insurance: Temporary coverage to bridge gaps in insurance.

• Skilled Nursing Facility Care: Skilled nursing and rehabilitation services provided to inpatients in a licensed facility.

• Travel Health Insurance: Medical coverage for emergencies while traveling abroad.

• Vision Coverage: A type of plan designed to reduce costs for routine eye exams and eyewear.