A

Allowable Charge – The maximum amount a health plan will pay for a covered service. Also called “eligible expense” or “negotiated rate.”

Annual Enrollment Period (AEP) – The designated time each year when employees can enroll in, change, or drop their health insurance coverage.

Appeal – A formal request to your insurance company to reconsider a denial of coverage or payment for a service.

Authorization – Approval from your health insurance plan before receiving certain services or medications. Also called “prior authorization” or “pre-certification.”

B

Beneficiary – A person designated to receive benefits from a health insurance policy.

Benefit Period – The time frame during which benefits are available under a health plan, typically one calendar year.

Benefits Summary – A document outlining what services are covered under a health plan and at what cost-sharing level.

C

Claim – A request for payment submitted to your insurance company for services received from a healthcare provider.

COBRA (Consolidated Omnibus Budget Reconciliation Act) – Federal law allowing employees and their families to continue group health coverage temporarily after job loss or other qualifying events.

Coinsurance – Your share of costs for a covered service, calculated as a percentage (e.g., 20%) after you’ve paid your deductible.

Coordination of Benefits (COB) – The process of determining which insurance plan pays first when a person is covered by multiple health plans.

Copayment (Copay) – A fixed amount you pay for a covered service, usually at the time of service (e.g., $30 for a doctor visit).

Coverage – The healthcare services and treatments your insurance plan agrees to pay for.

Covered Services – Healthcare services and treatments that your insurance plan will pay for, either partially or fully.

D

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

Dependent – A spouse, child, or other family member covered under an employee’s health insurance plan.

Dependent Care FSA – A flexible spending account used to pay for eligible dependent care expenses with pre-tax dollars.

Durable Medical Equipment (DME) – Medical equipment ordered by a doctor for use in the home, such as wheelchairs, oxygen equipment, or hospital beds.

E

Effective Date – The date when your health insurance coverage begins.

Eligible Expenses – Healthcare costs that qualify for reimbursement or payment under your health plan.

Emergency Services – Healthcare services provided for a medical emergency, typically covered even if received out-of-network.

Enrollment Period – The timeframe during which eligible individuals can sign up for health insurance coverage.

EOB (Explanation of Benefits) – A statement from your insurance company explaining what was covered, what was paid, and what you owe after a claim is processed.

Exclusions – Services, treatments, or conditions not covered by your health insurance plan.

F

Flexible Spending Account (FSA) – A pre-tax account that lets employees set aside money for eligible healthcare or dependent care expenses.

Formulary – A list of prescription drugs covered by your health plan, often organized into tiers with different cost-sharing levels.

G

Grace Period – Additional time allowed to pay your premium before coverage is terminated.

Group Health Plan – Health insurance coverage offered by an employer or organization to its employees or members.

Guaranteed Issue – A requirement that health plans must offer coverage to all eligible individuals regardless of health status.

H

Health Maintenance Organization (HMO) – A type of health plan that requires members to use network providers and get referrals to see specialists.

Health Reimbursement Arrangement (HRA) – An employer-funded account that reimburses employees for qualified medical expenses.

Health Savings Account (HSA) – A tax-advantaged savings account paired with a high-deductible health plan, allowing you to save for medical expenses.

High-Deductible Health Plan (HDHP) – A health plan with a higher deductible and lower premiums, often paired with an HSA.

I

In-Network – Healthcare providers and facilities that have contracted with your insurance plan to provide services at negotiated rates.

Individual Coverage – Health insurance purchased by an individual rather than through an employer.

L

Lifetime Maximum – The total amount a health plan will pay over your lifetime (now prohibited for essential health benefits under the ACA).

Limitations – Restrictions on coverage, such as the number of visits or treatments allowed per year.

M

Maximum Out-of-Pocket (MOOP) – The most you’ll pay for covered services in a plan year. After reaching this limit, your insurance pays 100% of covered services.

Medically Necessary – Healthcare services or supplies needed to diagnose or treat an illness or condition, as determined by your insurance company.

Medicare – Federal health insurance program primarily for people 65 and older, and certain younger people with disabilities.

N

Network – The group of doctors, hospitals, and other healthcare providers contracted with your insurance plan.

Non-Covered Services – Healthcare services not paid for by your insurance plan.

O

Open Enrollment – The annual period when employees can enroll in or make changes to their health insurance coverage.

Out-of-Network – Healthcare providers and facilities that don’t have a contract with your insurance plan, typically resulting in higher out-of-pocket costs.

Out-of-Pocket Costs – Healthcare expenses you pay yourself, including deductibles, copayments, and coinsurance.

Out-of-Pocket Maximum – See Maximum Out-of-Pocket (MOOP).

P

Plan Year – The 12-month period during which your health benefits are active, often January 1 through December 31.

Point of Service (POS) Plan – A health plan combining features of HMO and PPO plans, offering some out-of-network coverage with referrals.

Pre-existing Condition – A health condition that existed before your insurance coverage began (discrimination based on pre-existing conditions is now prohibited under the ACA).

Preferred Provider Organization (PPO) – A health plan offering flexibility to see any provider, with lower costs for in-network care and no referral requirements.

Premium – The amount you or your employer pays monthly for your health insurance coverage.

Preventive Care – Healthcare services like screenings, check-ups, and immunizations designed to prevent illness, typically covered at 100% in-network.

Primary Care Physician (PCP) – Your main healthcare provider who coordinates your care and provides referrals to specialists (required in some plans).

Prior Authorization – Approval required from your insurance company before receiving certain services or medications.

Q

Qualifying Life Event (QLE) – A significant life change (marriage, birth, job loss) that allows you to enroll in or change health coverage outside open enrollment.

Qualified Medical Expenses – Healthcare costs eligible for reimbursement from HSAs, FSAs, or HRAs.

R

Referral – Written authorization from your primary care physician to see a specialist or receive certain services (required by some plans).

Rider – An amendment to a health insurance policy that adds or modifies coverage.

S

Special Enrollment Period (SEP) – A time outside the annual open enrollment when you can sign up for coverage due to a qualifying life event.

Specialist – A physician who focuses on a specific area of medicine or group of patients.

Summary of Benefits and Coverage (SBC) – A standardized document explaining what a health plan covers and what it costs.

Summary Plan Description (SPD) – A detailed document explaining your employer-sponsored health plan’s benefits, rights, and obligations.

T

Tier – A category in a health plan’s formulary that determines how much you pay for prescription drugs.

Third-Party Administrator (TPA) – A company that processes claims and handles administrative functions for self-insured health plans.

U

Urgent Care – Medical care for conditions requiring prompt attention but not constituting an emergency.

Utilization Review – The process insurance companies use to determine if services are medically necessary and appropriate.

W

Waiting Period – The time between when you become eligible for coverage and when your coverage actually begins.

Waiver – A form declining health insurance coverage, typically because you have coverage elsewhere.