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Plain Language Glossary of Health Care Enrollment Terms

August 2018

ACE TA Center

This quick reference glossary provides easy to understand, plain language explanations of health care enrollment terms and phrases for HIV providers.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Adjusted Gross Income: The amount you earn or receive before taxes are taken out, minus certain allowed tax deductions, such as some business and medical costs.


Affordable Care Act (ACA): The health care reform law passed in 2010 that makes health insurance available and more affordable to many people who did not have health insurance before. The Affordable Care Act is also known as ‘Obamacare.’


AIDS Drug Assistance Program (ADAP): The program that provides free HIV medications to low-income people. In many states, the program also helps pay for insurance for people living with HIV.


Advance Premium Tax Credit (APTC): The premium tax credit helps lower the cost of health insurance premiums for low-income people. Advance payments of the tax credit can be used right away to help lower the cost of premiums paid for health care coverage purchased through the Health Insurance Marketplace for a person or family. (See Premium, Premium Tax Credit)


Affordable: Low cost


Agent/Broker: A person who can help you apply for and enroll in a Qualified Health Plan (QHP) through the Marketplace. S/he can recommend which plan you should enroll in. S/he is licensed and regulated by the state and typically paid by a health insurance company for enrolling you in the company’s plans. Some agents/brokers may only be able to sell plans from specific companies. (See Qualified Health Plan)


Appeal: If you believe you were unfairly denied care or coverage by the Marketplace, Medicare, Medicaid or a health plan, you have the right to ask that the decision be reviewed for a possible change.


Assistance: Help


B

Benefits: The health care services or items covered under a health insurance plan. Covered benefits and excluded services are listed in the health insurance plan's coverage documents. In Medicaid and the Children’s Health Insurance Program (CHIP), covered benefits and excluded services are defined by state program rules.


C

Call Center: A phone number to call for help applying, enrolling and using health coverage. Help is often available in other languages.


Certified Application Counselor (CAC): A staff person trained to help you:

  • Look for health insurance options
  • Compare health insurance options
  • Complete application forms

CACs can provide information but cannot tell consumers which health plan to choose. Their services are free. (See Marketplace)


Consumer Assistance Program (CAP): The programs in some states that help with problems or questions about health insurance. They can help you learn about your rights and file a complaint or appeal with your health plan. (See Appeal)


Children’s Health Insurance Program (CHIP): The program that provides free or low-cost health insurance for children up to age 19. It covers U.S. citizens and eligible immigrants.


Coinsurance: People with health insurance may have to pay for part of their health care services. Coinsurance is a fixed percentage of a health care service that you are responsible for paying for after you’ve reached your deductible. (See Deductible). 

For example, if your plan has a coinsurance requirement of 20% and a health service costs $100, your health insurance would pay $80 and you would pay the remaining $20 if you had reached your deductible.

Coinsurance is different from co-payment. Co-payments are usually a flat fee paid at the time of service, and coinsurance is paid after the insurance company pays their percentage of the cost. (See Co-payment)


Co-payment/Co-pay: People with health insurance may have to pay for part of their health care services. One way is with a co-payment, which is a fixed amount you pay for some health care services. You usually pay a co-pay when you get the service. The amount may change for different types of care. For example, you might pay $15 when you go in for a doctor’s visit and $30 when you go to the emergency room.

Co-payment is different from coinsurance. Coinsurance is paid after the insurance company pays its percentage of the cost. Co-payments are usually a flat fee paid at the time of service. (See Coinsurance)


Comprehensive Coverage: A health insurance plan that covers the full range of care that you may need. This may include preventive services (like flu shots), physical exams, prescription drugs, and doctor or hospital care. 


Cost sharing: The amount of out-of-pocket costs that you must pay for services covered by a health plan or health insurance. Some examples include co-payments, deductibles, and coinsurance. (See Coinsurance, Co-payments, Deductible, Out-of-Pocket Costs).


Cost-sharing reduction (CSR): A discount from the federal government that lowers the amount individuals and families have to pay out-of-pocket for deductibles, coinsurance, and co-payments. CSRs are NOT used to pay premiums. If you qualify, your plan will automatically be discounted. (See Coinsurance, Co-payments, Deductible).


D

Deductible: People with health insurance may have to pay for a portion of their health care services. The deductible is the amount that you may have to pay for health care services before the health insurance plan begins to pay. For example, if your deductible is $500, your plan won’t pay anything until you’ve paid $500 for health care services covered by your health plan. After that, your health insurance plan will pay for services.

Some plans have lower deductibles and other costs that you must pay. (See Out-of-Pocket Costs, Coinsurance, Co-payments).


Deductions: Certain expenses that you are allowed to subtract from your income to reduce your taxes.


Demographics: Information about certain characteristics of a group of people, such as sexual orientation, gender identity, race, ethnicity, income level, and education.


Dependent: A person who relies on someone else—usually a family member—for financial support. A dependent is someone you include on your tax form, even if that person doesn’t live with you.

Under the Affordable Care Act, you may be able to get a premium tax credit to help cover the cost of insurance for yourself and the dependents who you list on your tax form. (See Premium Tax Credit).


Determination: A decision made by your insurance provider about your health insurance coverage. For example, your health insurance provider may decide not to pay for a service you received.


Disability: A physical or mental condition that greatly limits one or more major life activities. Major life activities include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.


Discrimination: Treating a person or group of people unfairly or differently from other people or groups of people (for example, race or sex discrimination).


E

Electronic Database(s): Organized information that is stored and accessed on a computer. For example, information about your income is stored in a computer by the Internal Revenue Service (IRS) from your tax return. This information can be accessed by approved individuals to check your income for your health insurance application.


Eligibility Renewal: Re-apply for insurance.


Eligible: Whether you meet the requirements to get a certain kind of insurance.


Eligible Immigration Status: Some immigrants are eligible for (allowed to get) Medicaid or buy health insurance through the Marketplace. The rules for who is eligible are different for Medicaid and the Marketplace. A family may have some members who are eligible and others who are not because of their immigration status.


Employed: Someone who has a paid job.


Employee: Someone who works for another person or organization and is paid for his/her work.


Employer: The person or organization that someone works for. Someone who works for a business that s/he owns is ‘self-employed.’ (See Self-Employed)


Enrollment/Enroll: Join, sign up for.


Essential Health Benefits (EHB): The 10 types of health services that must be covered by health insurance plans starting in 2014, including:

  1. Ambulatory patient services (care you get without be admitted into a hospital)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs (medication)
  7. Rehabilitative services and devices (help you regain skills lost to injury or illness, such as learning to walk after a stroke)
  8. Laboratory services (tests done for your injury or illness)
  9. Preventive and wellness services and chronic disease management (physicals, immunizations, screenings)

Pediatric services (children’s health services), including oral (mouth) and vision (eye) care. (See Preventive Services)


Exchange: See Marketplace


Expenses: Cost


F

Financial Assistance/Financial Help: Help paying for insurance costs. You may be able to get help paying for premiums or out-of-pocket costs. (See Premium, Premium Tax Credit, Out-of-Pocket Costs).


Formulary: A list of drugs your health insurance or plan covers. A formulary may include how much you pay for each drug.


G

Grievance: A complaint made to the health insurer or plan. For example, you may want to file a complaint if:

  • Your health plan is denying payment for a treatment you feel should be covered
  • If doctors, nurses, clinic staff, or someone else is rude or disrespectful to you
  • Any other problem you have with your health care

Gross Income: The total income including cash that you earn during a time period, usually a year, before taxes are taken out.


H

Healthcare.gov: See Marketplace


Health Disparities: The different levels of health and access to health services for one group of people compared to another. For example, some groups of people are more affected by HIV than other people.


Health Insurance: An agreement you make with a private insurance company to help pay for medical care, such as doctor’s visits and medicine. The insurance company pays a big part of your health care costs because you have been making regular payments (premiums) to the insurance company. Someone else, like ADAP, may make these payments for you. (See Premium) 


Household: The people who live with you, including but not limited to:

  • Spouse
  • Children
  • Unmarried partner (only if s/he needs health insurance)
  • Anyone who is a dependent on your tax return
  • Anyone under 21 who lives with you and you take care of.

I

Income: How much money you make or receive in a year.


Individual Mandate: If you can afford health insurance but choose not to buy it in certain states (including Massachusetts and New Jersey), you may have to pay a fee. (The fee is sometimes called the "penalty," "fine," or "individual responsibility payment). You may not have to meet this requirement if:

  • No affordable coverage is available to you
  • If you have a short gap in coverage during the year for less than three consecutive months
  • If you qualify for a minimum essential coverage exemption.

(See Minimum Essential Coverage)


In-Network: The doctors, clinics, health centers, and hospitals whose services are covered by a health insurance plan. It is important to get health services from doctors, clinics, health centers and hospitals that are in your health plan’s network, when possible, to keep your costs down. (See Out-of-Network)


In-Person Assister (IPA): A person who is trained to help you look for health insurance options through the Marketplace. S/he can help you understand what you are eligible for, compare health plans, and complete application forms. In-person assisters can provide information but cannot tell you which health plan to choose. Their help is free.


Interest Income: Money earned from investments, such as money saved in a bank account or stocks. You should include interest as part of your income if you are applying for help paying for health insurance.


L

Lesbian, Gay, Bisexual, and Transgender (LBGT): LGBT stands for lesbian, gay, bisexual, transgender. (See Transgender)


Life Changing Event: Changes in the number of people in your household or income that may affect your health insurance eligibility. Life changes include:

  • Income
  • Where you live
  • Disability status 
  • Marriage
  • Divorce
  • Pregnancy
  • Have,  adopt, or put a child up for adoption
  • Gain or lose a dependent
  • Any other events that change income or the number of people in your household

M

Managed Care Organization (MCO): Groups of doctors, clinics, hospitals, pharmacies, and other medical providers that work together to take care of patients' health care needs. Sometimes a managed care organization is called a ‘network’ or ‘health plan.’


Marketplace: The Marketplace is where individuals, families, and small businesses can:

  • Learn about health insurance options
  • Compare health insurance plans
  • Choose a plan
  • Enroll in insurance

You access the Marketplace through websites, call centers, and in-person assistance. The Marketplace has information on how people with low- to moderate-income can save money on health insurance. The Marketplace provides information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP).

The Marketplace is sometimes referred to as the Exchange. Healthcare.gov is the website for the national Marketplace. Your state may have its own Marketplace website with a different name.


Medicaid: The state-run health insurance program for:

  • Low-income families and children
  • Pregnant women
  • The elderly
  • People with disabilities
  • In some states, other low-income adults.

The federal government provides a portion of the funding for Medicaid and sets rules for the program. States can choose how they design their Medicaid program, so Medicaid varies by state. States may have their own name for this program.


Minimum Essential Coverage: Health coverage that is affordable and provides a minimum set of services.Generally includes health insurance plans available through the Health Insurance Marketplace, Medicare, Medicaid, CHIP, and certain other coverage.


Minimum Essential Coverage Exemption: A status that allows you to not have to make a payment for not having minimum essential coverage. You may be eligible for an exemption if you:

  • Lacked access to affordable coverage
  • Had a short coverage gap
  • Experienced certain hardships
  • Had income below your filing threshold
  • Were not lawfully present in the U.S.

Modified Adjusted Gross Income (MAGI): The amount of money you make or receive that is used to decide if you are eligible for a lower cost health plan. Generally, MAGI is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. (See Gross Income)


N

Navigator: A person or organization that is trained and able to help people, small businesses, and their employees look for health coverage options through the Marketplace. Navigators can help complete eligibility and enrollment forms. They are required to treat everyone equally, and their help is free.


Net Income: The amount of money you make or receive in a year, minus what you paid in taxes.


Network: See In-Network, Out-of-Network


Non-Preferred Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll generally pay more to see a non-preferred (or Out-of-Network) provider than to see a preferred (or In-Network) provider. (See In-Network, Out-of-Network)


O

Open Enrollment Period: The period of time when people who are eligible to enroll in a Qualified Health Plan can sign up for a plan in the Marketplace. For example, for coverage starting in 2015, the Open Enrollment Period was November 15, 2014–February 15, 2015. (See Qualified Health Plan)

People may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event). You can apply for Medicaid or CHIP at any time of the year.


Opt-In: To choose to take part in something. For example, a person may choose to take part in (opt-in) his or her company’s health insurance plan.


Out-of-Pocket Costs (OOP): People with health insurance may have to pay for part of their health care services. This is also referred to as cost sharing. You must pay for health care costs that aren't paid by the insurance plan “out of your own pocket.” Out-of-pocket costs include:

  • Deductibles
  • Coinsurance
  • Co-payments for covered services
  • All other costs for any services your insurance plan doesn’t cover

(See Cost sharing, Deductible, Coinsurance, Co-payment)


Out-of-Network: The doctors, clinics, health centers and hospitals whose services may cost more or not be covered at all by your health plan. (See In-Network Services)


Out-of-Pocket Limit: The most you will pay with your own money during a health insurance policy period (usually a year). After you reach this limit, your health insurance plan will pay 100% of the allowed costs for services covered by your health plan.

For example, if your plan’s out-of-pocket limit is $3,000, once you have paid $3,000 of your own money in deductibles, co-pays, and coinsurance (all added together), you won’t have to pay any more health insurance costs in the year.

However, your premium, costs for health services that your plan doesn’t cover, and certain other costs don’t count toward the out-of-pocket limit. Different health insurance plans count different things toward the out-of-pocket limit, so be sure you understand your plan’s rules.  
(See Premium, Deductible, Coinsurance, Out-of-Network)


Outreach: Finding ways to give information and bring people into services.


P

Pending: Waiting for something (often a decision or approval).


People Living with HIV (PLWH): People who have HIV (human immunodeficiency virus).


Plan: See Qualified Health Plan


Premium: The amount you pay for a health insurance plan. A premium may be paid every month, every three months, or every year. Part or all of your premium may be paid by your employer, ADAP, or someone else.


Premium Tax Credit (PTC): Helps low-income people afford health insurance. The tax credit helps to lower the cost of premiums paid for health care coverage purchased through the Health Insurance Marketplace for a person or family. Advance payments of the tax credit can be used right away to lower your monthly premium costs. (See Advance Premium Tax Credit, Premium)


Presumptive Eligibility: Short-term health coverage that begins right away so that you can get medical care while your insurance application is being processed.


Preventive Services: Routine health care that includes check-ups, tests, and counseling to prevent illnesses, disease, and other health problems.


Primary Care Doctor: Your main doctor. A general doctor who you go to for treatment of common illnesses and routine care like check-ups and shots. This doctor also helps you decide if you need to go to the hospital or get specialized treatment.

Primary care doctors include:

  • Family medicine (a doctor who treats people of all ages)
  • Pediatricians (a doctor who treats children)
  • Internist (a doctor who treats adults)
  • In some states, nurse practitioners and physician assistants

Private Health Insurance: Health coverage provided through a job or bought from a private health insurance company.


Q

Qualified Health Plan (QHP): A health insurance plan that is approved by the Marketplace. QHPs:

  • Provide essential health benefits
  • Follow limits on how much of their own money people pay for services covered by the health plan, such as limits on deductibles, co-payments, and out-of-pocket maximum amounts
  • Meet other requirements, such as being a licensed insurer

A qualified health plan must be approved by each Marketplace in which it is sold. (See Essential Health Benefits, Deductibles, Co-payments, Out-of-Pocket Limits, Marketplace)


Qualify: To meet the requirements to get insurance.


Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). (See Special Enrollment Period)


R

Renewal: Signing up to continue with your health plan each year.


Ryan White HIV/AIDS Program (RWHAP): The government program that helps low-income people with HIV to get HIV-related health care. The program fills gaps in HIV care not covered by other options.


S

Self-Employed: A person who works for her/himself and does not have a boss. For example, you own your own business or work as a freelancer.


Special Enrollment Period: The time outside the Open Enrollment Period when a person can sign up for job-based health coverage (health insurance paid in part or fully by the employer) or Marketplace health coverage.


Substance Use Disorder (SUD): Misuse, abuse, or addiction to alcohol or drugs.


T

Tax Credit: See Premium Tax Credit


Transgender: A person whose gender identity, gender expression, and/or behavior do not match his/her assigned sex at birth.


U

Unemployed: Someone who does not have a paid job.


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