Learn words commonly used throughout the Health Insurance World.
Click on one of the words below to see the answer:
A SUBSIDY is an opportunity to finance a health plan in accordance with the Affordable Care Act for a person/family meeting these certain conditions:
- Adequate family income
- Regulated Immigration Status
- Joint income tax return if married
No insurance offer through the spouse’s workplace (there are some exceptions)
The level of support will depend on the level of family income relative to the Federal Poverty Level. To receive funding, your income should be between 138% and 400% of the pervert level, and you must meet the above conditions.
The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).
Makes affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL).
MEDICARE is a social secirty program administered by the federal government since 1966.
It guarantees access to health insurance for people over the age of 65 who have worked in the US for at least 40 quarters and paid their taxes for Medicare when settling income taxes, and for younger people who have been on a disability pension for at least 24 months, ie. Disability Relief
For more information on Medicare, please click below.
Automatically awarded when you receive Medicare (worked 40 quarters and payed taxes), partially covers hospital costs (at no cost for most people)
Awarded to people who do not have insurance at work or have resigned from work. It covers 80% of medical costs after paying the annual deductible and has a fixed monthly fee (for 2023 at least $164.90)
Part C consists of Medicare Advantage Plans (MAPD)
Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare.
Same of the Medicare Advantage Plans include drug coverage (Part D).
These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services.
Prescription Drug Plans
Necessary plan that allows you to obtain preferred price for prescription drugs. The price depends on the plan and what insurance company you choose.
A deductible is the amount of money you pay for covered health care serviced before your insurance plan starts to pay. With a $2,000 deductible for example, you pay the first $2,000 of covered services yourself.
After you pay your deductible, depending on your plan you might pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Many plans pay for certain services, like a checkup or disease management programs before you’ve met your deductible. This depends on the details of your plan
All marketplace health plans pay the full cost of certain preventative benefits even before you’ve met your deductible
IMPORTANT: please remember we are talking about using the services of a doctor, hospital, etc. WITHIN the network of a given plan!
After you pay your deductible, you may still be responsible for some of the medical costs. Typically in the range of 10%-50% (so called Co-Insurance), until you reach the policy Limit (Maximum Out of Pocket).
Let’s say, for example, that a plan has a $10,000 Maximum out of Pocket, a deductible of $5,000, and Co-Insurance of 80%. This means that after your deductible, you still have to spend $5,000 out of pocket, equal to 20% of each bill, until the sum of your annual expenses for medical costs reaches $10,000. After this amount, the insurance company covers 100% of the treatment costs.
IMPORTANT: please remember that we are talking about using the services of a doctor, hospital, etc. within the network of a given plan!
Submission of a request for payment to the insurance company in connection with the rules contained in the policy/contract
A group of doctors, clinics, hospitals, or medical facilities with established contracts with an insurance company.
You want to stay In network, as this impacts how much you pay for care.
Your Primacy Doctor, often called the family doctor.
Required when using HMO plans, as your PCP has to get you referrals to see a specialist.
Monthly amount that you have to pay for your insurance policy.
A pre-established fee for using specific services.
- Doctor Visits
- Emergency Room
The level of support will depend on the level of family income relative to the Federal Poverty Level.
Reducing the level of responsibility for treatment costs
Eligible individuals may also qualify for Cost Sharing as long as their income is less than 250% of the Federal Poverty Level.
Cost Sharing consists in reducing or eliminating the deductible and reaching the Max Out of Pocket Level. This reduction is possible only at the level of silver plans.
The maximum amount for what we are insured for.
A Beneficent: The person or organization authorized by you to receive the benefits set out in the policy.
A doctor who specializes in a specific field of medicine
In HMO plans, a referral from your PCP is required to go see a specialist.
In PPO plans, we can go directly to a specialist within the network of a given insurance plan.
Medical care for an adult or child resulting from a sudden, serious illness, or accident. Most commonly associated with ERs located at hospitals.
Health Care related to the diagnosis and coordination of life-threatening conditions or the protection of major organs in the body.
A type of clinic focused on outpatient care in a location not related to the hospital. Focused on taking care of diseases and accidents that do not necessarily require an ER visit.