Terms You Should Know

Health care is full of industry-speak. Without knowing the basics, it’s hard to understand how things work. Here are some key terms you should know as you navigate the world of health care.

Affordable Care Act (ACA)

The comprehensive federal health care reform law enacted in March 2010. Also known as “Obamacare” or “Health Care Reform.”

Coinsurance

The percentage of charges you pay when you receive a covered service. Your health plan coverage pays the rest. Coinsurance amounts vary depending on your plan and the service.

Copayment

The fixed dollar amount you pay when you receive certain covered services or prescriptions. Your health plan coverage pays the rest. Copayments vary depending on your plan and the service.

Cost share

The portion of charges for a service or prescription that the member is responsible for paying, such as a copayment, coinsurance, or deductible payment.

Deductible

The set amount you must pay in a plan (group) or policy (individual) year for certain health care services before your health plan coverage begins to pay.

Dependent

A spouse, child, or domestic partner who is covered under a policyholder or subscriber’s plan, depending on applicable law and the plan’s terms and conditions.

Essential health benefits

A set of health care service categories that must be covered by certain plans for individuals and employees of small businesses, starting in 2014. The Affordable Care Act requires these plans to offer a comprehensive package of items and services.

They must include items and services from within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Grandfathered plan

A health plan that has been in existence since on or before March 23, 2010, and that meets certain requirements. Grandfathered plans are exempt from some of the changes required under the Affordable Care Act.

Health care

The prevention, treatment, and management of diseases and injuries, as well as the preservation of mental and physical health, through services offered by trained and licensed professionals (like doctors, dentists, and psychologists).

Health care reform

A general term for the major health policy changes put in place by the federal Affordable Care Act and any state laws passed to put it in place.

Health insurance (also referred to as “coverage” or “plan”)

A contract that requires your health insurance issuer to pay some or all of your health care costs in exchange for a premium you pay.

Health Insurance Marketplace(s)
(formerly Health Insurance Exchange(s))

State- or federally run and regulated markets where you can shop, compare, and buy health care coverage. Link directly to your state’s Health Insurance Marketplace here.

State	URL
California	coveredca.com
Colorado	connectforhealthco.com
District of Columbia	dchealthlink.com
Georgia	healthcare.gov
Hawaii	hawaiihealthconnector.com
Maryland	marylandhealthconnection.gov
Oregon	coveroregon.com
Virginia	healthcare.gov
Washington	wahealthplanfinder.org

 Large employer

The definition of “large employer” is different for different purposes. In relation to the SHOP, an employer with 51 or more full-time equivalent employees can’t purchase coverage through the SHOP until 2016. In 2016, the SHOP becomes available to employers with 51 to 100 employees. States may allow all employers to purchase coverage in the SHOP in 2017. The ACA has a different definition for “large employer” in relation to the employer-shared responsibility mandate and potential tax penalties to be paid by the employer. In this case, a “large employer” has 50 or more full-time equivalent employees. The potential tax penalty is delayed until 2015.

The Marketplace

A common nickname for the Health Insurance Marketplaces, also called “Exchanges.”

Out-of-pocket expenses

The amounts you pay to providers for health care services you receive under the terms of your health care coverage, including copayments, coinsurance, and deductible payments, in contrast to the premium you pay each month for your health plan coverage. Also known as “cost share.”

Out-of-pocket maximum

The maximum amount of out-of-pocket expenses you will pay in a calendar year for essential health benefits.

Pre-existing condition

A medical condition that a person has before he or she applies for new health plan coverage.

Premium

The amount you and/or your employer pay (usually each month) for health plan coverage.

Preventive Care

Health services rendered to prevent diseases (or injuries) rather than curing them or treating their symptoms.

Provider

A physician, health care professional, or health care facility that is licensed, certified, or accredited to provide health care services and supplies as required by state law.

Small employer

The ACA defines “small employer” differently for different purposes. An employer is considered a “small employer” eligible to purchase coverage in the SHOP if the employer has 50 or fewer full-time equivalent employees. In 2016, an employer with 100 or fewer employees will be eligible to purchase coverage in the SHOP. Potential tax penalties for failure to provide coverage that meets the ACA standards does not apply to employers with 49 or fewer full-time equivalent employees.

Summary of Benefits and Coverage

A plain-language summary of your benefits and coverage. In compliance with the ACA, every insurer must supply this document and a uniform glossary of common health terms to members and prospective members during open enrollment or upon request.

The SBC provides a brief summary of information such as the following:

• Cost sharing for some common medical services such as office visits or lab tests
• Deductibles and out-of-pocket limits
• Services not covered by the plan

Kaiser Permanente members, you can request copies or more information
from your region:

California
Call Member Services:

• 1-800-464-4000 English
• 1-800-777-1370 TTY for the hearing/speech impaired

Colorado
Call Member Services:

• Denver/Boulder: 303-338-3800
• Northern Colorado: 1-800-632-9700
• Southern Colorado: 1-888-681-7878
• TTY users may call 303-338-3820 or 1-800-521-4874

Georgia
Call Member Services:

• 404-261-2590 or
• 1-888-865-5813

Hawaii
Call our Customer Service Center:

• 808-432-5955 (Oahu)
• 1-800-966-5955 (Neighbor Islands)

Maryland, Virginia, Washington, D.C.
Call our Member Services Contact Center:

• 1-855-249-5018
• 301-879-6380 TTY for the hearing/speech impaired

Oregon and Washington
Call Membership Services:

• 503-813-2000 or
• 1-800-813-2000

 

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