Glossary of terms

See provider profile and accreditation terms

Health care coverage terms

Annual and lifetime limits

Health plan carriers are not allowed to place annual or lifetime dollar limits on the essential health benefits.

Appeals process

In 2010, new rules were established to ensure consumers in new plans have access to an effective internal and external appeals process to appeal decisions.

Essential Health Benefits

A core set of benefits that must be covered by all individual and small group plans.

Guaranteed issue

Within specific enrollment periods, all health plans must accept any individual that applies for coverage without regard to health status, use of services or pre-existing conditions.

Individual mandate

The vast majority of Americans are required to have health care coverage. Individuals who do not have a plan that qualifies as minimum essential coverage may have to pay a fee. People with very low incomes and others may be eligible for waivers.

Marketplace

The Marketplace is a Federal online resource to compare and purchase health care coverage plans for individuals and small group employers.

Maximum out-of-pocket costs

Out-of-pocket costs are your expenses for medical care. These costs aren't reimbursed by health plans and include deductibles, coinsurance and copayments for covered services plus all costs for services that aren't covered. The Affordable Care Act (ACA) requires that all plans adhere to out-of-pocket maximums on essential health benefits of $6,850 for self-only coverage and $13,700 for family coverage.

Medical loss ratio

The ACA includes a provision that requires plans in the individual and small group market to spend not less than 80 percent (80%) of premiums on medical services. Plans in the large group market must spend no less than 85 percent (85%) on medical services. Plans that don't meet these thresholds must provide rebates to policyholders.

Metal tier

Plans are primarily separated into four levels – Bronze, Silver, Gold or Platinum – based on the percentage the plan pays of the average overall cost of providing essential health benefits to members.

Minimum essential coverage

The type of coverage an individual needs to have to meet the individual responsibility requirement under the ACA. This includes individual market policies, job-based coverage, Medicare, Medicaid, Children's Health Insurance Program, TRICARE and certain other coverage.

Preventive services

Since 2010 preventive services have been covered with no copayments, coinsurance or deductibles. Beginning in 2012, additional preventive services for women were added without copayments, coinsurance or deductibles.

Provider term glossary

Look up important provider group terms and use of language.

Special enrollment period

A time outside of the open enrollment period during which an individual/family has the right to sign up for or change health coverage and receive guaranteed coverage. To be eligible, individual/family must have a qualifying life event.

Summary of benefits and coverage

Since 2012, health plan carriers have been required to provide consumers with a concise document outlining, in plain language, and simple and consistent information about health plan benefits and coverage.