Glossary of health insurance terms
When your health plan processes a claim, it's called adjudication. After they adjudicate (or process) your claim, they will decide whether to pay it.
This is important if you have a family plan. This is a health plan that covers you, as well as other dependents. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An aggregate deductible means the family has to meet the deductible before your plan helps pay for care for any of you. Plans may vary, but the costs you pay for covered care and services usually go toward meeting this deductible. Cigna calls this a "family deductible."
An allowable charge is what an in-network health care provider bills for a service. This is usually less than they would charge if you didn't have your health plan.
An allowable expense is what an in-network health care provider bills for a service. This is usually less than they would charge if you didn't have your health plan. Cigna calls it an "allowable charge."
The allowed amount, is the most a health plan will pay a health care provider for care. If you see an out-of-network provider who charges more than that amount, you may have to pay the rest. But, with in-network providers, you pay your share based only on the allowed amount.
The amount you owe is the amount you pay to a health care provider. It is the amount your insurance carrier doesn't pay.
Your annual deductible is the amount of money you need to pay for care before your health plan begins to help pay for care. An individual deductible is for you alone. A family deductible is for all the members of your family who are covered by your health plan.
This is important if you have a family plan. This is a health plan that covers you, as well as other dependents. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An annual deductible combined means the family has to meet the deductible before your plan covers care for any of you. Plans may vary, but usually the cost you pay for covered care and services goes toward meeting this deductible. Cigna calls this a "family deductible."
Your health plan may define a total amount it will pay for services in a plan year. This is the annual limit. For example, it may only pay a certain amount on prescription drugs. After you reach your annual limit, you pay for prescriptions on your own. Cigna calls this the "benefits maximum."
An annual out-of-pocket maximum is the most you’ll pay for covered health care costs during one plan year. If you meet the out-of-pocket maximum, your health plan will pay for all your covered health care costs for the rest of the year.
Your annual plan premium is the total you pay over a year in health insurance premium payments. You typically pay your premium every month.
If your health plan denies a claim, you can appeal it. When you appeal, you ask your health insurance carrier to review or change their decision.
The appeals process is how you appeal a health plan's decision. For example, if your health plan denies a claim, you can appeal it. When you appeal, you ask your health insurance carrier to review or change their decision.
If your health plan pays less than an out-of-network health care provider charges, the provider may charge you (the patient) for the rest. That's called balance billing.
Your health plan may define a total amount it will pay for services in a plan year. This is the benefit maximum. For example, it may only pay a certain amount on prescription drugs. In this example, after you reach your benefit maximum, you would pay for prescriptions on your own.
Benefits exclusion refers to those products or services that your health plan does not cover. These exclusions are stated in your plan documents.
A claim is a payment request to your health plan. When you get care from a in-network doctor or other provider, they send a claim to your health insurance carrier, and ask to be paid for services. This payment is based on the services covered under your health plan.
After you submit a claim to your health plan, the claim status tells you where in the process the claim is. The claim status could be "pending" if the health plan is still gathering information. Or it could be "paid" or "denied."
When your health insurance carrier gets a claim asking them to pay for your care, they review it. They make sure the information is correct and that your plan pays for covered services.
When you pay coinsurance, you pay a percentage of your covered health care cost. For example, you may pay 20% of your costs. Your health planpays the rest. Your coinsurance usually starts when you meet your deductible (depending on your plan). This is different from a copay.
A copay, or copayment, is the amount you pay at a doctor's appointment, usually at the time of the visit/service. It is a set amount, such as $15 or $30.
Cost sharing is a payment you make for health care or medication. Your copay, coinsurance, and your deductible are all types of cost sharing.
A cost sharing reduction (CSR) is a discount on out-of-pocket expenses. It means you pay less for your portion of your copay, coinsurance, or your deductible. You may qualify if you buy your own health coverage on a public exchange and have a certain household size and income limit. CSRs may only be used for Silver Qualified Health Plans.
Date claim received is when your health plan gets the information for a claim. Then they can begin processing it. Your provider typically needs to submit the claim within 3 or 6 months of the date of your care.
The date you saw a doctor or other health care provider is the date of service. Knowing your date of service will help if you have questions about a bill or claim.
When you see a doctor or other health care provider, they submit a claim to your health plan. The claim is then processed. The date processed is the date the claim is either accepted (will be paid) or denied (will not be paid).
Your deductible is the amount of money you need to pay for care before your health plan begins to help pay for care. An individual deductible is for you alone. A family deductible is for all the members of your family who are covered by your health plan.
When your health plan does not pay for a health care service, your claim is denied. This may happen for many reasons. For example, maybe you saw an out-of-network doctor and have a plan that provides no out-of-network coverage.
This is important if you have a family plan. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An embedded deductible means your health plan will begin covering you as soon as you meet your deductible, even if the family deductible has not been met.
If your health plan does not cover a service, you can file an appeal. At that point, the decision may go to external review. In an external review a third-party will review the claim and appeal. The third-party is someone not connected to you or your health plan. Both you and your health plan must accept the third-party decision.
Extra savings is a discount on out-of-pocket expenses. It means you pay less for your portion of your copay, coinsurance, or your deductible . You may qualify if you buy your own health coverage on a public exchange and have a certain household size income limit. Extra savings may only be used for Silver Qualified Health Plans.
This is important if you have a family plan. This is a health plan that covers you, as well as other dependents. Your deductible is what you need to pay for care before your health plan starts to help pay for care. A family deductible means the family has to meet the deductible before your plan helps pay for care for any of you. The costs you pay for covered care and services goes toward meeting this deductible.
This is important if you have a family plan. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An individual deductible means your health plan will begin covering you as soon as you meet your deductible, even if the family deductible has not been met.
Your lifetime limit is the most your health plan will ever pay in benefits. It lasts as long as you have a plan with that health insurance carrier.
Your lifetime maximum is the most your health plan will ever pay in benefits. It lasts as long as you have a plan with that health insurance carrier.
Your health plan may define a total amount it will pay for services in a plan year. This is the maximum amount. For example, it may only pay a certain amount on prescription drugs. After you reach your benefit maximum, you pay for prescriptions on your own. Cigna calls this the "benefits maximum."
Your health plan may define a total amount it will pay for services in a plan year. This is the maximum benefit amount. For example, it may only pay a certain amount on prescription drugs. After you reach your benefit maximum, you pay for prescriptions on your own. Cigna calls this the "benefits maximum."
Your health plan may define a total amount it will pay for services in a plan year. This is the maximum plan benefit coverage. For example, it may only pay a certain amount on prescription drugs. After you reach your benefit maximum, you pay for prescriptions on your own. Cigna calls this the "benefits maximum."
The maximum reimbursable charge is the most a health plan will pay an out-of-network provider. It may be less than the provider usually charges. The provider may charge you for the rest.
Your member liability is the amount you pay to a health care provider. It is the amount your health plan doesn't pay. It does not include your copay. Cigna calls this the "amount you owe."
Your member responsible amount (mbr resp amt) is the amount you pay to a health care provider. It is the amount your health plan doesn't pay. It does not include your copay. Cigna calls this the "amount you owe."
Your out-of-pocket costs are anything that you pay for. For example, copays, coinsurance, and your deductible are out-of-pocket costs. You pay them. Your health plan does not.
An out-of-pocket maximum is the most you’ll pay for covered health care costs during one plan year. If you meet the out-of-pocket maximum, your health plan will pay for your covered health care costs for the rest of the year.
Your patient liability is the amount you pay to a health care provider. It is the amount your health plan doesn't pay. It does not include your copay. Cigna calls this the "amount you owe."
A pended claim is a claim that requires you to provide more information before your health plan can process it.
Your health plan may define a total amount it will pay for services in a plan year. This is the plan maximum. For example, it may only pay a certain amount on prescription drugs, so after you reach your plan maximum, you pay for prescriptions on your own. Cigna sometimes calls this the "benefits maximum."
Your plan premium is the amount you pay to your health insurance carrier in order to have a health plan. Premiums are often paid monthly.
Your premium is the amount you pay to your insurance carrier in order to have a plan. Premiums are often paid monthly.
The recognized charge is the most a health plan will pay a health care provider for care. If your provider charges more than that amount, you may have to pay the rest. Cigna calls this the "allowed amount."
Disability Insurance[edit | edit source]
This is important if you have disability benefits. The benefit duration is the longest amount of time your plan will pay benefits.
Some disabiity plans include or give the option to add a Cost of Living Adjustment (COLA). If you do, your monthly disability income benefits may change every month. The change is based on the national cost of living.
This is important if you have disability benefits. The coverage duration is the longest amount of time your plan will pay benefits.
This is important if you have disability insurance. The date a claim is incurred is the date of the injury.
If you have disability insurance and get injured at work, you may be asked for the date last worked. This is the last day you worked before your injury.
If you have disability insurance and need to submit claims, you will be asked for the date of claim. This is the date that you were injured to the point of disability. If you were injured at work, it might be the same as date last worked.
If you have disability insurance and need to submit claims, you will be asked for the date of disability. This is the date that you were injured to the point of disability. If you were injured at work, it might be the same as date last worked.
If you have disability insurance and need to submit claims, you will be asked for the disability begin date. This is the date that you were injured to the point of disability. If you were injured at work, it might be the same as date last worked.
A disability benefit is a type of benefit your health plan can offer. It helps pay part of your salary if you are sick or injured and can't work. It may be part of your medical plan. Or you may buy disability insurance in addition to your medical plan.
Disability insurance is a type of supplemental insurance. You can buy it in addition to your health plan. It will pay some, or all of your salary if you are injured and can't work.
If you have disability insurance, you will need to know your earnings definition. It is the same as your base pay. That means your salary or hourly wage. It does not include bonuses or commissions.
This is important if you have disability insurance. The elimination period starts the day you become ill or injured. It ends the date your benefits begin. The length of it depends on your plan, but it's usually less than 30 days.
If you have disability insurance and need to submit claims, you will be asked for the incurred date. This is the date that you were injured to the point of disability. If you were injured at work, it might be the same as date last worked.
Long-term Disability (LTD) is a type of supplemental insurance. You can buy it in addition to your health plan. It pays a part of your salary when you can't work due to long-term illness or injury.
This is important if you have disability benefits. The maximum benefit period is the longest amount of time your plan will pay benefits.
This is important if you have disability benefits. The maximum coverage period is the longest amount of time your plan will pay benefits.
This is important if you have disability insurance. If you have an illness or disability, you may get a premium waiver. With the waiver, you do not have to pay your premium. But you keep your insurance.
This is important if you have disability insurance. The qualifying period starts the day you become ill or injured. It ends the date your benefits begin. The length of it depends on your plan. It's usually less than 30 days.
If you have disability insurance your plan may have a recurrent disability provision. The provision helps you if you come back to work but have to leave again for the same disability. If that happens, your disability payments will continue without any break.
Residual coverage is a health care benefit. It pays part of your salary when you can't work full time due to injury or illness. For example, someone might get residual coverage if they had a serious medical condition, like multiple sclerosis, and could only work part time.
A Return-to-Work (RTW) incentive is part of a disability plan. It encourages people to go back to work part time. It's important if your disability benefits and your new pay are less than your pay before you were injured or became ill. It covers some of your pay if you go back to work part time.
If you have a disability plan and you die, you can leave the money in the plan to someone else. This is their survivor benefit.
This is important if you have disability insurance. If you have an illness or disability, you may get a waiver of premium. With the waiver, you do not have to pay your premium. But you keep your insurance.
Health Insurance Basics[edit | edit source]
Your activation date is the date your health plan starts. For example, you might buy your health plan on July 15th. But, your activation date might be September 1st. Cigna calls this your "coverage start date."
The Affordable Care Act (ACA) is a law which created rules and guidelines for health care coverage. It was signed by President Obama in 2010. The ACA changed how many people buy and pay for health insurance. For example, it requires many employers to offer certain health benefits.
Authorization means that you need to get approval from your health insurance carrier before getting care. The care may be a treatment, prescription, or other service. If you don't get approval first, then your care may not be covered by your health plan. Cigna calls this "precertification" or "prior authorization."
A beneficiary is anyone who is covered by the health plan. This could be the person who signed up for the plan, or it could be a dependent. For life insurance plans, this is the person who will receive payment if the person who bought the plan dies.
The benefit period is how long your health plan covers you. It is typically the same as your plan year. After that, you need to re-enroll.
A benefit is a service your health plan covers. For example, you might have prescription drug benefits. That means your health plan covers part or all of the cost of certain medications.
Your benefits summary is a type of plan summary. It highlights what care and services your health plan will cover.
Your certificate of coverage is a type of plan document. It explains what care and services your health plan will cover.
Certification means that you need to get approval from your health insurance carrier before getting care. The care may be a treatment, prescription, or other service. If you don't then your care may not be covered by your health plan. Cigna calls this "precertification" or "prior authorization."
Your contract explains the benefits you get as a member. That means the things your health plan will pay for. It also explains what is not covered by your plan, in the limitations and exclusions.
The contract holder is the person who signed up for the health plan. Cigna calls this the "subscriber."
Your contract year is the 365 day period that your health plan covers you. After your coverage year is over you need to renew your plan or choose a new one. Cigna calls this your "plan year."
Coverage is the benefits your health plan provides you and any covered dependents. It includes the services and expenses your plan helps pay for.
A coverage plan is a way to refer to the health insurance benefits you have. You may get a health plan through your employer or on your own through a health exchange. Your plan will cover certain health care services. For example, doctors visits and hospitalizations. Cigna calls this your "health plan."
Your coverage start date is the date your health plan starts. For example, you might buy your health plan on July 15th. But, your coverage start date might be September 1st.
Your coverage year is the 365 day period that your health plan covers you. After your coverage year is over you need to renew your plan or choose a new one. Cigna calls this your "plan year."
A covered benefit is a service your health plan helps pay for. For example, you might have prescription drug benefits. That means your health plan pays for part or all of the cost of your covered medications.
A covered expense is a service your health plan helps pay for. For example, you might have prescription drugs as a covered expense. That means your health plan pays for part or all of the cost of your covered medications.
A covered person is anyone who is covered by the health plan. This could be the person who signed up for the plan, or it could be a dependent.
A covered service is a service your health plan helps pay for. For example, you might have prescription drugs as a covered service. That means your health plan pays for part or all of the cost of your covered medications.
A customer is anyone who is covered by the health plan. This could be the person who signed up for the plan, or it could be a dependent.
Your customer ID number is assigned only to you. It is usually shown on your plan ID card. Your health care provider uses this number to be sure they are looking at your health information, even if you have a common name.
A dependent is usually someone related to you who can be covered by your health plan. It may be a spouse, partner, children, or adopted children. They can usually be covered under your health plan because of their relationship to you. If you are on someone else's health plan, you are their dependent.
Your effective date is the date your health plan starts. For example, you might buy your health plan on July 15th. But, your effective date might be September 1st. Cigna calls this your "coverage start date."
If you are eligible for coverage it means you meet the requirements to enroll in a certain health plan. Some plans have rules about eligibility. For example, you might need to be employed full time to enroll in your employer's group health plan. Or you might need to live in a certain area.
An eligible dependent is usually someone related to you who can be covered by your health plan. They may be a spouse, partner, children, or adopted children. You usually have the option to add them to your health plan.
Enrollment means signing up for a health plan. If you are the person enrolling, you are called the enrollee.
The enrollee is the person who signed up for the plan. Cigna calls this the "subscriber."
Evidence of Coverage (EOC) is a type of plan document. It lists your coverage under your plan. It also explains your rights under your plan.
The Exchange is another term for the Health Insurance Marketplace. It is an online place to buy health insurance. You can also use it to learn about health care plans. It also offers programs to help people with low to medium incomes pay for coverage.
Exclusions and limitations are things your health plan does not cover. An exclusion is a condition or situation that is not covered. A limitation can mean your coverage won't apply at certain times. Or it can mean your coverage goes to a set amount and then ends.
When you see a doctor or other health care provider you will receive an Explanation of Benefits (EOB). This document shows what the doctor charged, what your health plan paid, and what you owe. It is not a bill, and you do not need to respond to it. If you owe something, your doctor will send you a bill. Your EOB is just for your information.
A health benefit plan is a way to refer to the health insurance benefits you have. You may get a health plan through your employer or on your own through a health exchange. Your plan will include coverage for certain health care services. For example, doctors visits and hospitalizations. Cigna calls this your "health plan."
Health care is a broad term. It means any kind of care, check-up, appointment, hospital visit, or other treatment. You can use the phrase "health care" to mean any care you or your insurance pays for.
The Health Care Marketplace is an online place to buy health plans, if you don't get health insurance through an employer. You can also use the marketplace to learn about available health plans. It also offers programs to help people with low to medium incomes pay for coverage.
A health care provider (or professional) is someone who diagnoses or cares for you. Doctors, nurses, and therapists are all types of providers.
Health care services is a broad term. It means any kind of care, check-up, appointment, hospital visit, or other treatment. You can use the phrase "health care services" to mean any health care you or your insurance pays for.
Health coverage helps you pay for expenses related to your health.
Health insurance helps you pay for expenses related to your health.
A health insurance carrier is a company that offers health plans. You pay a monthly premium to the company. And they help pay for your health care expenses. Cigna, for example, is a health insurance carrier.
The Health Insurance Marketplace is an online place to buy health insurance. You can also use it to learn about health care plans. It also offers programs to help people with low to medium incomes pay for coverage.
A health plan is a way to refer to the health insurance benefits you have. You may get a health plan through your employer or on your own through a health exchange. Your plan will help you pay for certain health care services. For example, doctors visits and hospitalizations.
When you enroll in a health plan, you will get an identification (ID) card. Health care providers use the information on your ID card to make sure your health plan will help pay for their services. It usually also shows how much you pay and your plan pay for certain care and services.
Most health plans have a group, or network, of doctors, hospitals, labs, and other health care providers that they contract with to provide services at a discounted rate. You typically pay less when you see in-network providers.
The Individual Insurance Marketplace is an online place to buy health plans. You can also use it to learn about health plans. It also offers programs to help people with low to medium incomes pay for coverage.
An individual plan is a health plan you buy on your own through the Health Insurance Marketplace. It can cover you and any eligible dependents.
Inpatient care requires you to stay overnight. This can be for any kind of health care service. For example, an inpatient surgery means you need to spend at least one night in the hospital. If you have outpatient surgery, you would go home the same day.
When you enroll in a health plan, you will get an insurance card. Health care providers use the information on your insurance card to make sure your health plan will help pay for their services. It usually also shows how much you pay and your plan pay for certain care and services. Cigna calls this your "ID card."
If you are insured, it means you are enrolled in a health insurance plan.
An insurer is a company that offers health plans. Cigna, for example, is an insurer. Cigna calls these companies "health insurance carriers."
A member is anyone who is covered by the health plan. This could be the person who signed up for the plan, or it could be a dependent.
Your member handbook explains the benefits you get as a member. That means the things your health plan will pay for. It also explains what is not covered by your plan, in the limitations and exclusions.
Your member ID number is assigned only to you. It is usually shown on your plan ID card. Your health care provider uses this number to be sure they are looking at your health information, even if you have a common name.
A network is a group of health care providers that have contracts with a health insurance company or other health plan carrier. It includes doctors, hospitals, labs, and others. A doctor may be in-network for one health plan but not another. So always check that your doctors are in your network before choosing a plan.
Obamacare is another name for the Patient Protection and Affordable Care Act (PPACA). It is a law which created rules and guidelines for health care coverage. It was signed by President Obama in 2010. The PPACA changed how people buy and pay for health insurance. For example, it requires employers to offer certain health benefits.
Many health plan provider networks cover a specific set of towns, counties, or states. However, a health plan may also help pay for some health care providers outside of that area. These are "Out-of-Area (OOA) benefits."
The Patient Protection and Affordable Care Act (PPACA) is a law which created rules and guidelines for health care coverage. It was signed by President Obama in 2010. The PPACA changed how people buy and pay for health insurance. For example, it requires employers to offer certain health benefits.
A payer is a company that offers health plans. You pay a monthly premium to the company. And they help pay for your health care expenses. Cigna, for example, is a payer. Cigna calls these companies "health insurance carriers."
Your plan explains the benefits you get as a member. That means the things your health plan will pay for. It also explains what is not covered by your plan, in the limitations and exclusions.
Your plan certificate is a type of plan document. It explains what care and services your health plan will cover.
Your plan documents are all the details that your health insurance carrier gives you. They explain your health plan. For example, your certificate of coverage is a plan document. So is your summary of benefits.
Plan exclusions and limitations are things your health plan does not cover. An exclusion is a condition or situation that is not covered. A limitation can mean your coverage won't apply at certain times. Or it can mean your coverage goes to a set amount and then ends.
Plan features are an overview of a health plan. It outlines what services are covered and what costs you and your health plan share.
Your plan summary is a type of plan document. It explains some of the care and services your health plan will cover. Cigna sometimes calls this a "Summary of Benefits and Coverage."
Your plan year is the 365 day period that your health plan covers you. After your coverage year is over you need to renew your coverage or choose a new plan.
Your policy explains the benefits you get as a member of a health plan. These are the things your health plan will pay for. It also explains what is not covered by your plan, in the limitations and exclusions.
Preauthorization means that you need to get approval from your health insurance carrier before getting care. The care may be a treatment, prescription, or other service. If you don't then your care may not be covered by your health plan. Cigna calls this "precertification" or "prior authorization."
Precertification means that you need to get approval from your health insurance carrier before getting care. The care may be a treatment, prescription, or other service. If you don't then your care may not be covered by your health plan. Cigna calls this "prior authorization."
A Primary Care Provider (PCP) is the health care provider you see for routine care. It may be your family practitioner or pediatrician. Your PCP can refer you to specialists. Some types of health plans require you to choose a PCP. Depending on your plan, to receive coverage, you may need a referral from your PCP before seeing a specialist.
Prior authorization means that you need to get approval from your health insurance carrier before getting care. The care may be a treatment, prescription, or other service. If you don't then your care may not be covered by your health plan. Cigna calls this "precertification."
A provider is someone who diagnoses or cares for you. Doctors, nurses, therapists, hospitals, and labs are all types of providers.
A referral is a recommendation to go see another health care provider. It usually comes from your Primary Care Provider (PCP). Your PCP sends the referral to your health insurance carrier. Some health plans require you to get a referral before you see a specialist. If you do not get the referral, the health plan may not pay for your care.
Your schedule of benefits (SOB) is a type of plan document. It explains what care and services your health plan will cover. Cigna calls this a "Summary of Benefits and Coverage," or "Summary Plan Description."
Your start date is the date your health plan starts. For example, you might buy your health plan on July 15th. But, your start date might be September 1st. Cigna calls this your "coverage start date."
Uncovered services are things your health plan does not cover. They may be exclusions, or limitations. An exclusion is a condition or situation that is not covered. A limitation can mean your coverage won't apply at certain times. Or it can mean your coverage goes to a set amount and then ends.
Health Insurance Marketplace[edit | edit source]
A health insurance agent helps people choose a health plan. They help businesses choose plans, too.
A health insurance broker helps people choose a health plan. They help businesses choose plans, too.
In the Health Insurance Marketplace, there are four levels of plans. Bronze plans typically have the lowest monthly premium, but the highest costs when you get care. They usually cover about 60% of your health care costs.
In the Health Insurance Marketplace, there are four levels of plans. Gold plans typically have a higher monthly premium and lower costs when you need care. They usually cover about 80% of your health care costs.
Open Enrollment is a time when you can buy or change your health plan. It happens at different times during the year. If you buy your health plan through the Health Insurance Marketplace, Open Enrollment is in the fall. If you get your health plan through your job, Open Enrollment can be any time of year, depending on when your company first enrolled.
In the Health Insurance Marketplace, health plans are broken into plan levels. There are four levels: platinum, gold, silver, and bronze. Platinum plans typically have the highest monthly premium, and the lowest cost when you need care. Bronze usually have the lowest monthly premium with the highest cost when you need care.
In the Health Insurance Marketplace, there are four levels of plans. Platinum health plans usually have the highest monthly premium and the lowest cost when you need care. They typically cover about 90% of your health care costs.
A Qualifying Life Event (QLE) is something that happened in your life that lets you change your health plan. It includes things like getting married, divorced, or starting or leaving a job. If you have a QLE, you can enroll in a health plan during the Special Enrollment Period, or SEP. This is different from the Open Enrollment Period.
Every health plan shown on the Health Insurance Marketplace has a quality rating, which is based on scores for 3 elements: member experience, medical care, and plan administration. The rating goes from 1 to 5 stars. This is important if you buy your own health plan and don't get one through an employer.
In the Health Insurance Marketplace, there are four levels of plans. Silver health plans typically have a lower monthly premium, but a higher cost when you need care. They usually cover about 70% of your health care costs.
There are specific times of year when you can enroll in health insurance. The first time is the annual Open Enrollment. The other time is called a Special Enrollment Period (SEP). A Special Enrollment Period is when you have a qualifying life event outside of the yearly Open Enrollment Period. If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.
Every health plan shown on the Health Insurance Marketplace has a star rating which is based on scores for 3 elements: member experience, medical care, and plan administration. The rating goes from 1 to 5 stars. This is important if you buy your own health plan and don't get one through an employer.
The subscriber is the person who signed up for the plan. Cigna sometimes calls this the "primary customer."
When you enroll in a health plan, you will get a subscriber card. Health care providers use the information on your subscriber card to make sure your health plan will help pay for their services. It usually also shows how much you pay and your plan pay for certain care and services. Cigna calls this your "ID card."
Your summary of benefits and coverage (SBC) is a type of plan document. It provides a summary of the care and services your health plan will cover.
Your summary plan description (SPD) is a type of plan document. For most health plans provided through an employer, the plan administrator is required to provide plan participants with an SPD. It summarizes the plan and how it operates, including the care and services the health plan will and will not cover.
Insurance Plans[edit | edit source]
Accidental death and dismemberment (AD&D) is a type of supplemental insurance. It pays you or your beneficiaries if you have a serious injury or die. For example, a serious injury might mean you lose your sight or hearing. Or it could mean you lose a limb.
Accidental injury insurance is a type of supplemental insurance. If you suffer injuries in a covered accident, it pays you a fixed benefit. It can help pay for both medical and personal expenses.
Administrative Services Only (ASO) is usually a contract between an employer and third-party adminstrator or carrier. The third-party administrator or health plan carrier does the administrative work, such as processing claims. The employer is responsible for paying all covered claims.
Cancer insurance is a type of supplemental insurance. You can buy it in addition to your health plan. It helps give you more coverage if you are diagnosed with a type of cancer covered by the plan.
Catastrophic health insurance is a type of qualified health plan. It only provides coverage for emergencies and preventive care. It usually comes with lower monthly premiums. It also has higher out-of-pocket costs for deductibles, copays, and coinsurance. You may be eligible if you are under 30 years old, or you qualify due to financial hardship.
A consumer-driven health plan (CDHP) is a type of health plan. These plans come with either a Health Reimbursement Account (HRA) or Health Savings Account (HSA). Your account can help pay for care. You can get reimbursed or paid back out of your account when you pay for covered expenses.
A contributory plan is a kind of group life insurance plan. In a contributory plan, both employees and employer pay part of the premium. They also share other costs.
Critical illness insurance is a type of supplemental insurance. You can buy it in addition to your health plan. It pays you a lump sum benefit if you are diagnosed with certain serious illnesses. For example, it may cover things like heart attack or stroke.
A Dental Health Maintenance Organization (DHMO) plan is a type of dental plan where you usually choose a primary care dentist in the plan’s network. They give you routine dental care and refer you, as necessary, to a specialist.
A Dental PPO plan is a type of dental plan where you can see any dentist. It helps you save money by providing discounts when care is received from the network of preferred dental providers.
If you have a Dependent Care Reimbursement Account, you can pay for eligible services for your dependents with pre-tax dollars. For example, you can pay for child care with a Dependent Care Reimbursement Account. Cigna calls this a "Dependent Care Flexible Spending Account (Dependent Care FSA)."
A Direct Access Plan (DAP) is a type of health plan. If you have this kind of plan you can see specialists without a referral. Cigna calls this an "Open Access Plan (OAP)."
Excepted benefits are plans that are separate from a health plan. You can buy them in addition to your health plan. For example, you can get supplemental dental, vision, or life insurance. You can also get supplemental coverage for critical care or hospital care. Cigna calls this "supplemental insurance," or "voluntary benefits."
An Exclusive Provider Organization (EPO) is a certain type of health plan. You can visit specialists without a referral but receive coverage through the plan's network. You don't need a Primary Care Provider (PCP). You generally will not be covered for out-of-network care, except in an emergency.
A flexible benefits plan is a type of group health plan. If your employer offers a flexible benefits plan, you will be able to build your own health plan. You will choose the types of coverage you want from a list of options.
A flexible coverage plan is a type of group health plan. If your employer offers a flexible benefits plan, you will be able to build your own health plan. You will choose the types of coverage you want from a list of options.
A fully insured plan is a type of group health plan. The employer or group contracts with a health insurance carrier to provide coverage to its employees and their dependents. The health insurance carrier then pays the covered claims.
Fully insured employers is a type of group health plan. The employer or group contracts with a health insurance carrier to provide coverage to its employees and their dependents. The health insurance carrier then pays the covered claims.
A fully insured job-based plan is a type of group health plan. The employer or group contracts with a health insurance carrier to provide coverage to its employees and their dependents. The health insurance carrier then pays the covered claims.
Group coverage is a type of health plan. It is one an employer offers to a company's employees. If you get your insurance through your job, you have group coverage. There are group health plans, disability plans, life insurance, and many other kinds.
Group health coverage is a type of health plan. It is one an employer offers to a company's employees. If you get your insurance through your job, you have group health coverage. There are group health plans, disability plans, life insurance, and many other kinds.
Group health insurance is a type of health plan. It is one an employer buys for a company's employees. If you get your insurance through your job, you have group health insurance. There are group health plans, disability plans, life insurance, and many other kinds.
A group health plan is a type of health plan. It is one an employer offers to a company's employees. If you get your health care coverage through your job, you have a group health plan. There are group health plans, disability plans, life insurance, and many other kinds.
Group insurance is a type of benefits plan. It is one an employer offers to a company's employees. If you get your insurance through your job, you probably have group insurance. There are group health plans, disability plans, life insurance, and many other kinds.
Group Universal Life (GUL) is a type of life insurance plan. It lets you open a cash accumulation fund, or CAF to help you save money.
A Health Maintenance Organization (HMO) plan is a type of health plan. With an HMO plan you usually need to choose an in-network Primary Care Provider (PCP). You also get coverage for eligible services from in-network hospitals and other providers.
Heart Attack and Stroke Insurance is a type of supplemental insurance. You can buy it in addition to your health plan. If you have this plan, it provides a lump sum benefit if you have a covered heart condition, a heart attack, or a stroke.
A High Deductible Health Plan (HDHP) is a health plan that comes with a higher deductible than some other plans may have. HDHPs can also have a Health Reimbursement Account (HRA) or Health Savings Account (HSA) to help you pay for covered expenses.
Hospital care (indemnity) insurance is a type of supplemental insurance. You can buy it in addition to your health plan. If you have hospital care (indemnity) insurance, it pays fixed benefits for costs associated with a hospital stay. It helps cover out-of-pocket expenses not covered by your health plan.
Hospital indemnity insurance is a type of supplemental insurance. You can buy it in addition to your health plan. If you have hospital indemnity insurance, it pays fixed benefits for costs associated with a hospital stay. It helps cover out-of-pocket expenses not covered by your health plan.
An indemnity plan is a type of health plan. With this plan you can choose any licensed health care provider you want, and you won't need referrals. However, you will probably have a deductible and copay or coinsurance.
Life insurance is a type of supplemental insurance. You can buy it in addition to your health plan. It provides a lump-sum payment, known as a death benefit, to your beneficiaries when you die.
A limited medical plan is a type of health plan. It provides a small number of benefits to part-time and low-wage workers.
Long-term Care Insurance is a type of supplemental insurance. You can buy it in addition to your health plan. It covers more services than most plan types. For example, it helps pay for home health care if you need help bathing, dressing, and eating. It can also help pay for assisted living facilities and nursing homes.
An MA-PD plan is a type of Medicare Advantage plan. It offers Medicare Part A, Part B, and Part D (prescription) benefits in one plan.
Managed care is a term for using care coordination to help lower health costs. A managed care organization offers health plans like HMOs, PPOs, POSs, and PFFSs.
A Medicare Advantage Plan is a type of Medicare plan offered by a private company which contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Also called Part C, Medicare Advantage Plans can be HMOs, PPOs, Private Fee-for-Service Plans, or Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not directly paid for under the Original Medicare Plan.
Medicare Part A pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B helps pay for doctors' services, outpatient hospital care, and other medical services that aren't covered by Part A.
Medicare Part C, also called Medicare Advantage Plans, is a type of Medicare plan offered by a private company which contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans (Part C) can be HMOs, PPOs, Private Fee-for-Service Plans, or Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not directly paid for under Original Medicare.
Medicare Part D is the official name of Medicare's prescription drug program. Part D plans are offered by Medicare-approved insurance companies. These plans provide prescription coverage to people who are eligible for Medicare.
Medicare Supplement Insurance is sold by private insurance companies to fill "gaps" in Original Medicare coverage. These policies only work with Original Medicare, not with Medicare Advantage.
Medigap plans are sold by private insurance companies to fill "gaps" in Original Medicare coverage. These policies only work with Original Medicare, not with Medicare Advantage.
A mini-med plan is a type of health plan. It provides a small number of benefits to part-time and low-wage workers.
A non-contributory plan is a kind of group life insurance plan. It means your employer pays all of the premium.
An Open Access Plan (OAP) is a type of health plan. If you have this kind of plan you can see specialists without a referral.
A Point of Service (POS) plan is a type of health plan. It provides coverage for both in-network and out-of-network health care providers.
A Preferred Provider Organization (PPO) plan is a type of health plan. A PPO offers a network of preferred providers. Out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. You are not required to choose a Primary Care Provider (PCP) with a PPO plan. You can see specialists without getting a referral. And you may use out-of-network services, but typically at a higher cost.
A prepaid dental plan is a type of dental plan. If you have this plan you usually choose a primary care dentist in the plan’s network. They give you routine dental care and refer you, as necessary, to a specialist.
A Section 125 plan is a type of group health plan. If you have a Section 125 plan, you can pay for premiums and plan contributions with pre-tax dollars.
A self-funded plan is a type of group health plan. The health insurance carrier or third-party administrator does the administrative work, such as processing claims. The plan sponsor, such as an employer, is responsible for funding all covered claims. Cigna also calls this "Administrative Services Only (ASO)" or "self-insured."
A self-insured plan is a type of group health plan. The health insurance carrier or third-party administrator does the administrative work, such as processing claims. The plan sponsor, such as an employer, is responsible for funding all covered claims. Cigna also calls this "Administrative Services Only (ASO)."
Short-term disability insurance is a type of supplemental plan. You can buy it in addition to your health plan. Short-term disability plans pay benefits if you can't work for a certain period time due to a covered illness or injury.
Short-term health insurance is a type of insurance. You can only get it for a limited amount of time. For example, if you are between jobs you can get short-term health insurance to help cover you while you're unemployed.
Small business health insurance is a type of insurance. In most states, it is for companies that have 50 or less employees.
A small employer plan is a type of insurance. In most states, it is for companies that have 50 or less employees.
A small group plan is a type of insurance. In most states, it is for companies that have 50 or less employees.
A Special Needs Plan (SNP) is a special type of Medicare Advantage plan (Part C). It provides more focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.
A Staff Model Health Maintenance Organization (HMO) plan is a type of health plan. If you have a staff model HMO plan, the doctors in your plan's network work for the Health Maintenance Organization.
A stand-alone dental plan is a type of supplemental insurance. You can buy it in addition to your health plan. You may choose to buy it if your health plan doesn't include coverage for dental treatment.
Supplemental insurance is a plan that is separate from a health plan. You can buy it in addition to your health plan. For example, you can get dental, vision, or life insurance. You can also get coverage for cancer, accidental injury, or hospital care.
Term Life Insurance is a type of life insurance. It covers you for a specific period of time, or term. If you die during the term, your beneficiary will receive a payment for a covered claim.
A traditional plan is a type of health plan. With this plan you can get coverage for any licensed health care provider, and you won't need referrals. However, you will probably have a deductible. Cigna calls this an "indemnity plan."
TRICARE is a federal health care program. It is for active-duty and retired military. It is also for their families.
TRICARE For Life (TFL) is an expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.
Vision coverage is a type of supplemental insurance. You can buy it in addition to your health plan. If you have vision coverage it can help you pay for routine care from an eye doctor. This is usually an optometrist or ophthalmologist. They will check your vision and check for diseases. They can also give you prescriptions for glasses or contacts, if you need them. Depending on your coverage, your vision plan may help pay for glasses, contacts, or other materials or supplies.
Voluntary benefits are plans that are separate from a health plan. You can buy them in addition to your health plan. For example, you can get dental, vision, or life insurance. You can also get coverage for cancer, accidental injury, or hospital care.
Whole life insurance is a type of life insurance policy. It will remain active for your entire lifetime (as long as you pay your premiums) or until the maturity date. If you reach the maturity date, you will be paid a cash lump sum. This is different from a term life policy.
Medicare[edit | edit source]
An Accountable Care Organization (ACO) is a group of doctors who work together to manage patient care. They have 3 goals: Improve quality, reduce costs, and improve the patient experience.
This is important if you have Medicare Advantage. An advance coverage decision is a notice from your health plan. It lets you know whether or not the plan will cover a particular service.
This is important if you have Medicare Advantage. An advance coverage determination is a notice from your health plan. It lets you know whether or not the plan will cover a particular service.
This is important if you have a Medicare plan. The annual election period (AEP) is when you can make changes to your plan. It runs from October 15 to December 7 every year. During this time you can only make changes. If you need to enroll for the first time, you can do that in the initial election period.
Catastrophic coverage is a part of Medicare Part D. Catastrophic coverage makes sure you won't pay more than $5000 out-of-pocket. After that, you will pay very little on each drug for the rest of the year.
For Medicare Prescription Drug Coverage, the Coverage Gap occurs between the Initial Coverage limit and the Catastrophic Coverage level. You will have to pay a higher portion of costs while in the coverage gap until you reach the Catastrophic Level. Plans may offer additional gap coverage.
Initial coverage is the first level of coverage in a Medicare Prescription Drug (Medicare Part D) plan. In this level you typically pay only a portion of the cost (might be a copay or coinsurance) to fill your prescriptions until you reach a next certain level where the Coverage Gap begins. With some plans there may be a deductible before the initial coverage begins.
This is important if you are eligible for Medicare. You can join Medicare during your initial coverage enrollment period. It starts three months before your 65th birthday. It ends three months after you turn 65. For disability benefits, the period is different. It starts three months before the 25th month of your benefits. It also lasts seven months. If you miss this period, you can still enroll during the general enrollment period.
This is important if you are eligible for Medicare. You can join Medicare during your initial enrollment period. It starts three months before your 65th birthday. It ends three months after you turn 65. For disability benefits, the period is different. It starts three months before the 25th month of your benefits. It also lasts seven months. If you miss this period, you can still enroll during the general enrollment period.
Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
The Medicare annual enrollment period is the time during the year that you can make changes to your Medicare plan. It runs from October 15 to December 7. You can only make changes to an existing plan. This is not for enrollment.
You are a Medicare beneficiary if you have a Medicare plan. That usually means you have Part A and Part B.
The Medicare Supplement open enrollment period is when you can sign up for Medigap. It starts after you turn 60 and enroll in a Medicare Part Bplan. You will have six months to enroll in Medigap. This is the open enrollment period.
In Original Medicare, the Medicare-approved amount is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
Your Prescription Drug Coverage is an insurance benefit. It is how your health plan helps pay for your covered prescription medications.
Your Prescription Drug Plan (PDP) is an insurance benefit. It is how your health plan helps pay for your covered prescription medications.
Respite care is temporary care. It's for someone who needs ongoing help. For example, if you are caring for a parent in your home, respite care would take care of them in a nursing home for a short period of time.
This is important if you have Medicare. The Special Election Period is anytime other than open enrollment. If you have a qualifying reason, you can make changes to your Medicare Advantage plan or to your Medicare Part D prescription drug coverage during the special election period.
If you have Medicare, your True Out-of-Pocket Costs (TrOOP) are all the payments you make for Part D drugs. Once you reach the limit of your TrOOP, your catastrophic coverage begins.
Pharmacy[edit | edit source]
A brand name drug is a medication. It's made by a company that patented the name. It often costs more than generic forms of the same drug.
Many medications have both brand name and generic drug options. If a doctor writes "dispense as written" on your prescription, it means that you need that brand and not a generic version.
A drug formulary is a list of the prescription drugs that your health plan helps pay for. Different plans have different formularies.
Within a health plan, prescription drugs are divided into levels. Each level has a different copay. Most health plans have either three or four levels, which may determine how much you pay out-of-pocket, such as a copay or coinsurance.
A drug list is a list of the prescription drugs that your health plan helps pay for. Different plans have different drug lists.
Within a health plan, prescription drugs are divided into drug tiers. Most health plans have either three or four drug tiers, which may determine how much you pay out-of-pocket, such as a copay or coinsurance.
A formulary is a list of the prescription drugs that your health plan helps pay for. Different plans have different formularies.
Prescription drugs are available as brand name drugs or generic drugs. Most drugs have a brand name version and a generic version. Both versions have the same active ingredients. The difference is that you may not know the generic name. The generic is often cheaper than the brand-name version.
Prescription drugs are available as brand name drugs or generic prescription drugs. Most drugs have a brand-name version and a generic version. Both versions have the same active ingredients. The difference is that you may not know the generic name. The generic is often cheaper than the brand-name version.
Most health plans have a group of pharmacies that have contracts with them. These are in-network pharmacies. You typically pay less for your prescription drugs when you use in-network pharmacies.
A legend drug is a type of medication that you can only get with a doctor's permission. There are two kinds of legend drugs: brand name and generic. Other drugs are called over-the-counter (OTC) drugs. OTC drugs do not need a doctor's permission.
A mail service pharmacy mails your prescription drugs right to your house.
A mail order pharmacy mails your prescription drugs right to your house.
A maintenance medication is a prescription drug you take on a regular basis. You may need to take it for a long time. This is different from a prescription drug that you take to treat a temporary illness.
A non-formulary drug is a medication that is not on your health plan's drug list. Your plan will only cover it if you get a prior authorization.
Over-the-counter (OTC) drugs are a type of medication. You can buy OTC drugs without a prescription.
Most health plans have a group of pharmacies that have contracts with them. These are participating pharmacies. You typically pay less for your prescription drugs when you use participating pharmacies, which are also called in-network pharmacies.
A pharmacy is a place where you can get prescription drugs. Examples of pharmacies are CVS, Walgreens, pharmacies in your local grocery store, and even mail order pharmacies.
The preferred drug list is a part of your plan's formulary, or drug list. It lists prescription drugs that are usually covered at a lower out-of-pocket cost to you.
Most health plans have a group of pharmacies that have contracts with them. These are preferred pharmacies. You typically pay less for your prescription drugs when you use preferred pharmacies. These pharmacies are also called in-network pharmacies.
A prescription is a note from your doctor that gives you permission to get a certain medication. All prescription drugs need a doctor's permission. Over-the-counter (OTC) drugs are those you can buy on your own without a prescription.
A prescription drug is a type of medication that you can only get with a doctor's permission. There are two kinds of prescription drugs: brand nameand generic. Other drugs are called over-the-counter (OTC) drugs. You can buy OTC drugs on your own without a prescription.
A prescription drug list is a list of the prescription drugs that your health plan helps pay for. Different plans have different drug lists. Cigna calls this a "formulary" or "drug list."
A prescription medication is a type of medication that you can only get with a doctor's permission. There are two kinds of prescription medications: brand name and generic. Other drugs are called over-the-counter (OTC) drugs. You can buy OTC drugs on your own without a prescription.
Some prescription medications have quantity limits. That means that you can't buy more than a certain amount in a month.
A retail pharmacy is a pharmacy in a store or other retail location. You can get prescription drugs there. For example, a CVS or a Walgreens has a retail pharmacy. This is different from a pharmacy in a hospital or a mail-order pharmacy.
An Rx is a note from your doctor that gives you permission to get a certain medication. All prescription drugs need a doctor's permission. Over-the-counter (OTC) drugs are those you can buy on your own without an Rx, or prescription.
A specialty drug is a type of prescription drug. They usually cost more than other drugs. They are often used to treat very serious diseases or come in a form that's different from a pill or capsule. For example, you may need to inject certain kinds of specialty drugs.
Step therapy is a program to help you save money on prescription drugs. If you have step therapy, your health plan may require you to use one or more lower cost drugs first. If those don't work, you may be approved for a more expensive drug.
A therapeutic alternative is a type of prescription drug. It is not the exact drug that you were prescribed. But it is close enough that your doctor may give it to you to treat the same thing.
Spending Accounts[edit | edit source]
This is a feature of some Flexible Spending Accounts (FSAs). The carryover means if there's money left in your account at the end of the year, a certain amount will be available for use next year.
Date posted is the date that money comes out of your Health Savings Account (HSA), if you have one as part of your plan. This happens when you submit a receipt to get paid back or pay for a covered service using your HSA debit card.
If you have a Dependent Care Flexible Spending Account (Dependent Care FSA), you can pay for eligible services for your dependents with pre-tax dollars. For example, you can pay for child care with a DCFSA.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). You can use your account to pay for eligible medical expenses.
This is important if you have a Health Savings Account (HSA) or Flexible Spending Account (FSA). You may get a message that you have expenses requiring verification. That means you need to show that your expense can be paid back by your spending account. You can do that by submitting a receipt for the things you paid for.
A Flexible Spending Account (FSA) is a spending account that comes with some health plans. If you have an FSA you can put pre-tax money in it. You can pay for certain health care or dependent care costs with that money. Some plans allow a certain amount of funds left over at the end of the plan year to carry over into the next plan year.
A Health Care Spending Account is a spending account that comes with some health plans. If you have one you can put pre-tax money in it. You can pay for certain health care or dependent care costs with that money. Some plans allow a certain amount of funds left over at the end of the plan year to carry over into the next plan year. Cigna calls this a "Flexible Spending Account (FSA)."
A Health Reimbursement Account (HRA) is a type of spending account. If you have a health plan through your employer, you might have one. Your employer puts money in an HRA, so you can pay for certain medical expenses. They can be for you or your covered dependents. Some employers allow HRA dollars to roll over from year to year.
A Health Savings Account (HSA) is a type of spending account. You could have one if you buy a qualified high-deductible health plan on your own or enroll in one through an employer. You or your employer can contribute to your HSA account without paying federal taxes and most state taxes. You can use the money to pay for eligible health care expenses or save for retirement. You can also take it with you if you leave your job or change health plans.
A Limited Purpose Health Reimbursement Account (LPHRA) is a type of Health Reimbursement Account (HRA). You can usually only use it to pay for dental and vision care. In some cases you may be able to use it for other qualified health care expenses, after you meet your health plandeductible.
A Limited Purpose Flexible Spending Account (LPFSA) is a type of Flexible Spending Account (FSA). You can usually only use it to pay for dental and vision care. In some cases you may be able it use it for other qualified health care expenses, after you meet your health plan deductible.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). A nonqualified amount is something you can't use your spending account for. Gas for your car, for example, is a nonqualified amount. Even if you use your car to go to the doctor, you can't pay for the gas through your spending account.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). A nonqualified expense is something you can't use your spending account for. Gas for your car, for example, is a nonqualified amount. Even if you use your car to go to the doctor, you can't pay for the gas through your spending account.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). The paid-to-date amount is how much money you have used in your spending account at any given time.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). Your pending transactions are any actions that aren't finished yet. For example, you might put money in the account but it is not available yet. That is a pending transaction.
This is important if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA). The things you can use your account to pay for are called qualified expenses. The money you pay for those expenses is called the qualified amount.
If you have a Health Reimbursement Account (HRA) or a Health Savings Account (HSA) you might pay for health care yourself, and then get a reimbursement. The reimbursement is the money being paid back to you from the money available in your spending account.
This is a feature of Health Savings Accounts (HSAs). The rollover means that any unused money left in your HSA at the end of the year can be used next year. Some Health Reimbursement Accounts (HRAs) and Flexible Spending Accounts (FSAs) may also allow money to roll over, depending on the terms.
This is important if you have a Health Reimbursement Account (HRA) or Health Savings Account (HSA). Your transaction date is either the date that you submitted a claim to be paid back (reimbursed), or the date you paid for a covered health care expense.
Additional Health Terms[edit | edit source]
Acute care is care for life-threatening medical problems. This includes things like heart attack and stroke. It might also be for a severe burn or injury. Cigna calls this "emergency care."
Ambulatory care is a general term. It means you don't need to be admitted to a hospital to receive care. For example, a visit to a doctor's office is a type of ambulatory care.
Ancillary care helps diagnose or support you. There are three kinds of ancillary care: diagnostic, therapeutic, and custodialcare. For example, physical therapy is ancillary care. So is lab work. Other types of care are primary care and secondary care.
Your anniversary date is the first day of a new plan year. If you renew a health plan, your anniversary date is the day and month your plan began. It's the same every year.
Behavioral care services are used to treat mental health and substance use disorders. They include services like therapy and support groups. Cigna calls these "behavioral health services."
Behavioral health is how healthy your emotions and actions are. Behavioral health care includes care for mental illnesses and substance use disorders. If your health plan covers behavioral health, it will help pay for services like therapy and substance use rehabilitation programs.
Behavioral health services are used to treat mental health and substance use disorders. They include services like therapy and support groups.
A Cadillac tax is a tax on high-cost health plans you get through your employer. It will begin in 2022. The tax will be 40% of plans that charge more than $10,200 for single coverage, or $27,500 for family coverage. The employer or person who pays for the plan will pay the tax.
Cigna rates hospitals based on quality and cost-efficiency. A Center of Excellence is a hospital that rated high in both categories. Cigna customers can use Cigna's provider directory to find Centers of Excellence.
A certificate of creditable coverage shows that you have been covered by a health plan that meets the requirements for creditable coverage. Individual and group plans are both types of creditable coverage. If you had these plans in the past, you can get a certificate. Some health insurance carriers will ask you for a certificate of creditable coverage before you can sign up for a plan.
Chemical dependency is an illness. It means that you are using alcohol or drugs in a way that is harmful to your life. The impact may be physical, mental, or social. Your health plan may help cover your care and recovery if you have behavioral health benefits.
A complaint is when you tell your health insurance carrier that you have a problem with your plan or coverage. For example, if your plan denies a claim for a service and you disagree with that, you have a complaint. In that case, you can file an appeal.
Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law. It allows certain individuals to keep their health care coverage if they lose their job.
A convenience care clinic is a walk-in medical clinic in a pharmacy (CVS, Walgreens) or grocery/department store (Target, Walmart). They provide immediate care for minor illnesses, such as cold and flu, minor cuts and burns, rashes, UTI, and more. You can also get your flu, shingles, and pneumonia vaccines here. Wait times are usually shorter than an Emergency Room (ER) or Urgent Care Center. Cost is about the same as a visit to your doctor, but may vary depending on your plan.
A conversion option is the option to convert your coverage to an individual plan if you become no longer eligible for coverage through your group health plan.
Coordination of benefits (COB) happens when you’re covered under more than one health plan. The health plans work with each other to pay for covered health services.
A coverage end date is the day your health plan ends. If you see a doctor the day after your end date, your health plan will not pay for the service. Cigna calls this your "coverage termination date."
A coverage termination date is the day your health coverage ends. If you see a doctor the day after your coverage termination date, your health plan will not help you pay for the service.
Health plans that meets certain requirements are creditable coverage. For example, individual and group plans are types of creditable coverage. Sometimes when you buy a plan you need to show that you had prior creditable coverage. This proves that you paid your premiums in the past, and that health plans will cover you. Then you can get a certificate of creditable coverage.
Custodial care is a type of health care provided if you need help with daily care. It can include bathing, dressing, eating, and using the bathroom.
This is important if you have life insurance. The death benefit is the amount of money your beneficiaries will get if you die.
Diagnostic care is how doctors and other health care providers diagnose a disease or condition. It may include tests or other services. It is different from preventive care.
Diagnostic tests and tools are used for diagnostic care. Doctors and other health care providers use these to help diagnose a disease or condition.
Disenrollment is when you choose to leave your health plan before your plan year ends. If you need to leave your plan because you are no longer eligible, it is not disenrollment.
Some people have more than one type of health plan. For example, they might be covered through a group health plan at work, and their spouse's plan as a dependent. If both plans cover some of the same health care services, they have duplicate coverage.
Durable medical equipment (DME) includes things like wheelchairs and walkers. It is usually covered by health plans. This is equipment that can withstand a lot of use. It serves a medical need, and can be used in your home.
Durable power of attorney is a legal document. It lets you choose someone you trust to make decisions on your behalf. That means they can make decisions about your medical care if you are unable to make them yourself.
Your Electronic Health Record (EHR) is a digital record of your medical history. Your doctor or health care provider adds to your EHR every time you have an appointment. They can share it with your permission. That way other doctors you see will have your information.
Your Electronic Medical Record (EMR) is a digital record of your medical history. Your doctor or health care provider adds to your EMR every time you have an appointment. They can share it with your permission. That way other doctors you see will have your information.
Emergency care means care for life-threatening medical problems, like a heart attack or stroke. It might also be a severe burn or injury. With most health plans, if you get emergency care at an out-of-network hospital, you'll pay in-network rates.
An emergency room (ER) is a type of medical facility usually associated with a hospital. At the ER nurses, doctors, and support staff provide immediate care for life-threatening medical problems. These may include chest pain, numbness and weakness, trouble breathing, etc. If you have a non-life-threatening condition, you may want to go to an Urgent Care Center or Convenience Care Clinic instead. Talk to your doctor about your options.
Emergency room care means care for life-threatening medical problems. This includes things like chest pain, numbness and weakness, trouble breathing, a serious burn, etc. With most health plans, if you get emergency room care at an out-of-network hospital, you'll pay in-network rates. Cigna calls this "emergency care."
Emergency services means care for life-threatening medical problems. This includes things like chest pain, numbness and weakness, trouble breathing, a serious burn, etc. With most health plans, if you get emergency services at an out-of-network hospital, you'll pay in-network rates. Cigna calls this "emergency care."
An Employee Assistance Program (EAP) offers short-term counseling and resources. It can help you manage stress, grief, and substance use.
This is important if you are an employer buying a plan for your company. An employee census is a list of the employees at your company. You will need this list to get a quote for the price of the plan.
The employee enrollment period is a time when you can buy or change your health plan if you get your health plan through your job. It can be any time during the year, depending on when your company first enrolled.
This is important if you get health insurance through your job. The employer contribution is the amount the company pays. It can be a maximum dollar amount. Or it can be a percentage of the total cost of your health insurance.
This is important if you buy a health plan on your own and aren't offered one through an employer. Enhanced direct enrollment allows you to shop and enroll in a health plan and also apply for federal financial assistance directly from your insurance carrier. They can process your eligibility and any changes to your plan, with no need to go through HealthCare.gov for any part of the application process.
Essential health benefits are services that health plans have to cover. The Affordable Care Act (ACA) lists them. There are 10 types of essential health benefits. They include things like emergency care, preventive care, and prescription drugs.
An excise tax is a tax on high-cost health plans you get through your employer. It will begin in 2022. The tax will be 40% of plans that charge more than $10,200 for single coverage, or $27,500 for family coverage. The employer or person who pays for the plan will pay the tax.
An exclusionary rider is part of your health insurance. It clarifies something your health plan does not cover.
An experimental procedure or service is usually a new kind of drug, treatment, or test. It is unproven, and may not be covered by your health plan.
This is important if you have group insurance and a disability or health condition. In this case, you may be able to get an extension of benefits. The extension means your coverage continues past your termination date. It can help you pay for care for your condition.
This is important if you have group insurance and a disability or health condition. In this case, you may be able to get an extension of coverage. The extension means your coverage continues past your termination date. It can help you pay for care for your condition.
This is important if you have life insurance. The face amount is the amount of money your beneficiaries will get if you die.
The Family and Medical Leave Act (FMLA) is a federal law. It requires covered employers to allow eligible employees up to 12 work weeks of job-protected leave for specific medical or family-related reasons. Leave may be paid or unpaid.
This is important if you buy your own health plan through the Health Insurance Marketplace. Depending on your income and household size, you may be eligible for federal financial assistance. This means you can get help from the federal government to cover health care costs. There are two types of assistance: Tax credit subsidies, which lower your premium and cost-sharing reductions, which lower your out-of-pocket costs.
If you miss an insurance premium payment, you may still have coverage for a certain period of time. That time is called a grace period. During the grace period you can pay your premium late. If you wait too long, your grace period will end and your coverage will lapse.
Grandfathered health plans are health plans that were in place before March 23, 2010 when the Affordable Care Act (ACA) was signed. Grandfathered plans are not required to comply with some of the ACA provisions and can make routine changes to the plans without losing grandfathered status. However, plans will lose their grandfathered status if they make changes that significantly cut benefits, increase out-of-pocket spending for individuals, or reduce what the employer contributes toward the cost of the plan.
A plan with grandfathered status is a health plan that was in place before March 23, 2010 when the Affordable Care Act (ACA) was signed. Grandfathered plans are not required to comply with some of the ACA provisions and can make routine changes to the plans without losing grandfathered status. However, plans will lose their grandfathered status if they make changes that significantly cut benefits, increase out-of-pocket spending for individuals, or reduce what the employer contributes toward the cost of the plan.
If you have a problem with how you are treated by a doctor or other health care provider you can file a grievance. You can also have a grievance with your health plan, if they do not pay for a claim. If you have a grievance with your health plan, you can file an appeal.
If you have a problem with how you are treated by a doctor or other health care provider you can file a grievance. You can also have a grievance with your health plan, if they do not pay for a claim. If you have a grievance with your health plan, you can file an appeal. This is the grievance procedure.
If you get your health plan through your job, you may have a group certificate. This is a document that explains what care and services your health plan will cover.
This is important if you have life insurance. The guarantee issue maximum is the most money you can qualify for without proof of good health. If you can have proof of good health, you may qualify for more.
This is important if you have life insurance. The guaranteed issue amount is the most money you can qualify for without proof of good health. If you can have proof of good health, you may qualify for more.
A guaranteed renewal is an agreement between you and your health plan. With a guaranteed renewal, you keep the same policy at the end of your plan year. All you need to do is continue to pay your premiums.
This is a health care benefit. If you have guest privileges in your plan, you can access in-network services if available, even if you are living outside of your home network area. You may only have guest privileges if you are there for 90 days or longer.
A health care facility is a place where you get care. Examples include a hospital, doctor's office, or a lab for bloodwork.
Health care reform often refers to the changes in health care that came about with the Affordable Care Act (ACA), signed by President Obama. The law helps make it easier to get health insurance and get help paying for it, if needed. Health care reform may also have a broader definition around the affordability and financing of health care and how it's accessed or delivered.
The Health Insurance Portability and Accountability Act (HIPAA), is a federal law. HIPAA sets rules to protect your health information. Part of HIPAA says your health care provider can't share your information without your permission. This is even true if they want to share with your other providers.
Health maintenance care is any type of health care service that helps detect health problems before there are any symptoms. Health maintenance care includes most vaccines and annual check-ups. Most plans pay for health maintenance care. Cigna calls this "preventive care."
A health proxy is a legal document. It lets you choose someone you trust to make decisions on your behalf. That means they can make decisions about your medical care if you are unable to make them yourself.
Home health care is a way to describe services you might need if you can't leave your home. For example, nursing services and therapy are types of home health care. So are medical supplies and some outpatient services.
Immunizations Without Cost Share are a part of preventive care. Most plans pay for certain preventive care services, such as immunizations. That means, depending on your plan, you can get vaccines without paying anything out-of-pocket.
Most health plans have a group of hospitals that have contracts with them. These are in-network hospitals. You typically pay less when you get care at in-network hospitals.
Most health plans have a group of doctors and other health care providers who have contracts with them. These providers are called in-network providers. You typically pay less when you see in-network providers.
An investigational procedure or service is usually a new kind of drug, treatment, or test. It is unproven, and may not be covered by your health plan.
If you have a lapse in coverage it means that you lost your health insurance. It usually happens because you did not pay your premium.
A late applicant is someone who starts a new job that offers health insurance, but waits more than the time allowed (usually 31 days) to sign up. You can still sign up for insurance through your new job during open enrollment. Cigna calls this a "late enrollee."
A late enrollee is someone who starts a new job that offers health insurance, but waits more than the time allowed (usually 31 days) to sign up. You can still sign up for insurance through your new job during open enrollment.
A late entrant is someone who starts a new job that offers health insurance, but waits more than the time allowed (usually 31 days) to sign up. You can still sign up for insurance through your new job during open enrollment. Cigna calls this a "late enrollee."
If you have a claim in process, your health plan may ask for a letter of medical need. This means they need your health care provider to show that you needed their services. Cigna calls this "proof of necessary treatment," or "proof it is medically necessary."
This is important if you have a group health plan through your job. If you and all the other employees get the same benefit amounts, it is a level amount. The level amount schedule is the list that explains the benefits.
Managed Behavioral Health refers to mental health and substance use disorder services. These services can include things like therapy, support groups, and intensive outpatient care. Plans vary, but you may need a precertification from your health plan and may need to stay in-network to receive coverage for services.
The maximum allowance is part of every health plan. It is the amount a health plan will pay a health care provider for a certain service. The maximum allowance is usually based on how much that service usually costs. It may vary in different cities or states.
Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medical equipment includes things like wheelchairs and walkers. It is usually covered by health plans. This is equipment that can withstand a lot of use. It serves a medical need, and can be used in your home.
Your medical history is information you have told your doctor or health care provider. It helps your doctor care for you. For example, it might include your family history. It could also list illnesses you've had, and prescription drugs you've taken.
If you have a claim in process, your health plan may ask for proof of medical necessity. This means they need your health care provider to show that you needed their services. Cigna calls this "proof of necessary treatment," or "proof it is medically necessary."
If you have a claim in process, your health plan may ask for proof that it is medically necessary. This means they need your health care provider to show that you needed their services. Cigna calls this "proof of necessary treatment."
A member representative is a person that is allowed to make health care decisions for you. It could be a family member or friend. You can even hire someone to be your member representative if there is no one else you trust to make these decisions. Cigna calls this person the "patient advocate."
Mental health is your emotional and psychological health. If your health plan covers mental health, it will help pay for therapy and other care. Depending on your plan, you may need a referral from your primary care provider (PCP) to receive coverage for mental health services.
Mental health services are used to treat mental health disorders. They include things like therapy and support groups. Cigna calls these "behavioral health services."
The National Committee on Quality Assurance (NCQA) is an independent, nonprofit group that reviews the quality of managed care plans, behavioral health organizations, new health plans, disease management programs, provider organizations, and other health-related programs. Cigna is reviewed by the NCQA in the following areas: Health Plan, Disease Management, Wellness and Health Promotion, Managed Behavioral Healthcare Organization, Physician and Hospital Quality, and Patient-Centered Connected Care.
If you have a claim in process, your health plan may ask for proof of necessary treatment. This means they need your health care provider to show that you needed their services. Cigna calls this "proof it is medically necessary."
A non-participating health care provider is not contracted with a health plan. That means they are not in-network, and you may need to pay more to see them.
A non-preferred provider is not contracted with a health plan. That means they are not in-network, and you may need to pay more to see them. Cigna calls them "non-participating health care providers."
Most health plans have a group of doctors and other providers who have contracts with them. Providers who do not have contracts are Out-of-Network (OON). With some plans you’ll pay more for out-of-network services.
Outpatient care is a type of health care service. You don't need to stay overnight for outpatient care, only for inpatient. For example, an outpatient surgery means you go home from the hospital the same day as your surgery. Doctor's appointments are also outpatient care.
Most health plans have a group of hospitals that have contracts with them. These are participating hospitals. You typically pay less when you get care at participating hospitals, which are also called in-network hospitals.
Most health plans have a group of doctors and other health care providers who have contracts with them. These providers are called participating providers. You typically pay less when you see participating providers, which are also called in-network providers.
A patient advocate is a person that is allowed to make health care decisions for you. It could be a family member or friend. You can even hire someone to be your patient advocate if there is no one else you trust to make these decisions.
Your Personal Health Record (PHR) is information you have told your doctor or health care provider. It helps your doctor care for you. For example, it might include your family history. It could also list illnesses you've had, and prescription drugs you've taken.
Personally Identifiable Information (PII), or P.I.I., is information that can be used to identify you. Your name, phone number, and address are some examples of PII.
A plan sponsor is a company or entity that manages a benefits plan, such as a group health plan. For your health plan, this might be your employer, a labor union, or government group.
Some group health plans are portable. That means that you can keep your plan even if you leave or lose your job.
Post-acute care is another word for short-term health care services. It may be needed after you have surgery. You may also need post-acute care if you are diagnosed with a chronic condition.
Power of Attorney (POA) is a legal document. It lets you choose someone you trust to make decisions on your behalf. For example, with a POA you can authorize another individual to make decisions about your medical care if you are unable to make them yourself. This is called a Health Care Power of Attorney.
A pre-existing condition means you were diagnosed with the condition before you enrolled in a health plan. A pre-existing condition could be a mental or physical illness, injury, or a disability. Plan documents usually define what is considered to be a pre-existing condition.
Pre-existing condition exclusions or limitations are things your plan does not cover because the condition is pre-existing. A pre-existing condition is one you were diagnosed with before you enrolled in a health plan. A pre-existing condition could be a mental or physical illness, injury, or a disability. Plan documents usually define what is considered to be a pre-existing condition.
Most health plans have a group of doctors and other health care providers who have contracts with them. These providers are called preferred care providers. You typically pay less when you see preferred care providers. These providers are also called in-network providers.
This is important if you buy your own health plan from the Health Care Marketplace. If you have a low income, you may be eligible for lower premiums when you enroll in a health plan. This is called a premium tax credit. The premium tax credit is one way the Affordable Care Act (ACA)helps to make health care more affordable.
The prevailing charge is part of every health plan. It is the amount a health plan will pay a health care provider for a certain service. The prevailing charge is based on how much that service usually costs. It may vary in different cities or states.
Preventive care is any type of health care service that helps detect health problems before there are any symptoms. Preventive care includes most vaccines and annual check-ups. Most plans help pay for preventive care.
Primary care is basic health care. It includes preventive care like annual checkups and some other types of routine care. You typically get this care from your Primary Care Provider (PCP).
Your primary coverage is the health plan that pays your expenses first. If you have one health plan, that is your primary coverage. If you have several health plans, check your plan documents for the Coordination of Benefits. It will explain which plan is your primary coverage.
A prosthetic device replaces a part of your body. You might need one if you permanently damage or lose a part of your body. An artificial leg is one type of prosthetic device.
Protected Health Information (PHI) is information that can identify you. Some types of PHI are your name, your address, or your Social Security number. Your health insurance carrier has to meet legal and security standards to help protect your PHI.
A provider directory is a listing of health care providers. It includes doctors, dentists, facilities, and hospitals. All the providers listed have contracted with your health plan. That means they are covered by your health plan. You can check the provider directory to see if your doctor is covered by your plan.
Most health plans have a group of doctors and other health care providers who have contracts with them. This is the provider network. The providers are in-network providers. You typically pay less when you see in-network providers.
A purchaser is someone who helps pay for a group health plan. It might be your employer, a labor union, or government group.
A qualified health plan is coverage offered through a federal or state Health Care Marketplace. Under the PPACA, qualified health plans may not limit an individual from purchasing the plan because of a pre-existing condition. Qualified health plans also cannot have lifetime maximums or annual limits on the dollar amount of essential health benefits.
The reasonable charge is part of every health plan. It is the amount a health plan will pay a health care provider for a certain service. The reasonable charge is based on how much that service usually costs. It may vary in different cities or states.
At open enrollment you may be able to sign up for the same health plan as last year, or get a new plan. If you sign up for the same health plan, then you are renewing your plan.
A rider is a change to your plan. You might buy a rider that adds benefits to your insurance. Or a rider might add an exclusion to your insurance.
Routine care is usually the care you get from your Primary Care Provider (PCP) and also the care you get from other doctors your PCP refers you to.
Secondary care is health care from specialists. Specialists are providers who are not your Primary Care Provider (PCP). They include cardiologists and therapists. Some health plans require a referral from your PCP in order to receive coverage for care provided by a specialist.
If your health plan has a network of health care providers, these providers may all be in one geographic area (a group of towns or areas of the state). This geographic area is called the service area.
Short-term rehabilitation includes many types of services. You may receive them after an illness. They can also help with an injury. They include hearing, speech, breathing, and cognitive therapies. Coverage will vary by health plan.
Skilled care is a type of care you get in a hospital or nursing facility when giving care is too hard in your own home. For example, if you have a stroke, you may need skilled care.
The Small Business Health Options Program (SHOP) is a program to give small business more health insurance options. In most states, a small business is any company that has 50 or less employees. Employers can sign up for health insurance at any time during the year. Employers can choose how much they want to pay in plan premiums. They can also choose what types of plans to offer. They may offer medical, dental, vision, and others.
A specialist is a type of health care provider. They treat a specific type of illness or a specific area of the body. You may need a referral from a Primary Care Provider (PCP) to receive coverage for care provided by a specialist, depending on your health plan.
A sponsor is a company or entity that manages a benefits plan, such as a group health plan. For your health plan, this might be your employer, a labor union, or government group.
For coverage to apply, some plans require a referral to see a specialist. If you need to see the same specialist many times, you may get a standing referral. That means your referral lasts for many visits.
Stop-loss coverage is something employers can buy. It limits financial liability for the self-funded employer, in case the employees have a lot of covered health care costs. It means the stop-loss insurance carrier will pay for covered claims over a certain amount. That way the employer's liability is capped.
Substance abuse means that you are using alcohol or drugs excessively or in a way that could be very harmful for your health. The impact may be physical, mental, or social. Your health plan may help cover you for care and recovery through your behavioral health benefits.
Substance use disorder is an illness. It means that you are using alcohol or drugs in a way that is harmful to your life. The impact may be physical, mental, or social. Your health plan may help cover you for care and recovery through your behavioral health benefits.
Telemedicine is a way that providers can treat patients who are not in the same place as them. They use video, phone, and email to meet with the patient and treat them. This is for non-life threatening problems.
A third-party administrator (TPA) is a company that manages health care benefits. They do this for group health plans. TPAs are often health insurance carriers.
This is important if you change health plans. If you are seeing a specialist who isn't covered by your new plan, you may need transition of care. That means your new plan will agree to cover your specialist or provider for a certain amount of time. That will give you time to find a new provider who is covered under your new plan.
This is important if you change health plans. If you are seeing a specialist who isn't covered by your new plan, you may need transitional care. That means your new plan will agree to cover your specialist or provider for a certain amount of time. That will give you time to find a new provider who is covered under your new plan.
An urgent care center is a walk-in medical clinic. You can receive care for non-emergency medical problems like fever, flu, minor cuts, and broken bones, etc. It's staffed by doctors, nurses, and other medical staff. Typically lower cost, shorter wait times than an emergency room (ER). Some may be open late, and on weekends and holidays.
Usual, customary, and reasonable (UCR) is part of every health plan. It is the amount a health plan will pay a health care provider for a certain service. UCR is based on how much that service usually costs. It may vary in different cities or states.
This is important if you get your health plan through your job. You may not have health insurance the day you start your job. An eligibility waiting period is the time between when you start your job and the date you are covered by your employer's health plan. It may also apply to a disability income plan. In that case, it’s the time between when you are injured and when payments from the plan begin. Waiting periods may also apply to other forms of coverage. For example, your dental coverage may have a waiting period. That means there may be a gap between when you enroll in the dental plan and when certain services are covered.
Worker's compensation refers to the legal rights of an employee if they are injured or become ill because of their job.
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