Insurance terms

Also called Obamacare plans, these are health insurance policies that meet all the coverage requirements laid out in the 2010 Affordable Care Act. This sweeping health reform law set new standards for insurance to better protect consumers. All ACA plans must offer essential health benefits, cover preexisting conditions, have no annual/lifetime dollar limits, and meet other requirements. This improved-quality coverage comes with an individual mandate to have insurance or face a tax penalty.

Supplemental insurance that covers expenses if you suffer an unexpected injury from an accident, such as broken bones from a bike crash, concussions on the basketball court, burns from a cooking mishap, and more. Accident insurance helps cover costly medical bills, ambulance fees, or unpaid time off work to recover that your regular medical insurance may not address.

These are healthcare teams that work together to provide coordinated care, aiming to improve quality and cut costs by sharing responsibilities and rewards.

These professionals use statistics and analytics to calculate risk and forecast future costs. Health insurance companies rely on actuaries to crunch the numbers on historical claims data and health trends to accurately predict future expenses. This guides pricing and ensures enough premium payment is collected upfront to cover upcoming medical bills that could randomly hit.

An insurance claims adjuster is someone charged with evaluating an insurance claim to determine if and how much an insurance company must pay for the claim under review. An adjuster may be a representative of the insurance company or they may be independent. A claimant can also hire a public adjuster to do their own investigation on the claim, apart from the insurance company.

This is an agreement between doctors and hospitals that allows physicians to admit patients to that hospital for medical treatment or care.

These discussions take place between healthcare providers and individuals to determine preferences for future medical care. It includes conversations about end-of-life care wishes, ensuring that healthcare aligns with a person’s values and desires.

An advance directive is a legal document allowing individuals to spell out their healthcare wishes. It may include instructions about life-sustaining treatments and appointing someone to make healthcare decisions on their behalf if they cannot communicate.

This can be the first or binder payment of an insurance policy, or it may be a payment made before the scheduled first payment for a policy that the insurance company makes available to the policyholder, typically, for a discount or as part of a promotion.

This government subsidy helps reduce the cost of health insurance premiums for eligible individuals or families with lower incomes.

With respect to health insurance, an adverse benefit determination refers to a situation where the insurance company denies a benefit, refuses payment for a service already received, or rescinds health coverage.

Adverse selection is a situation in which those who expect to need more healthcare services are the ones signing up for insurance. It can lead to imbalanced risk pools and potentially higher costs for insurers, affecting the stability of insurance plans.

The ACA is a comprehensive healthcare reform law aimed to improve healthcare accessibility, affordability, and quality in the United States. Sometimes known as Obamacare, it introduced measures such as health insurance marketplaces, subsidies, and protections against insurance denials due to preexisting conditions.

In healthcare, an agent is a licensed individual who assists in finding and purchasing health insurance plans that match a person's needs. They help buyers navigate the various insurance options available in the market.

This is the maximum dollar amount a health insurer agrees to pay for any medical service, treatment, test, etc. Anything above this agreed rate will be billed to patients as "balance billing." Rate negotiations between health providers and insurance carriers establish allowed amounts for every covered service, from a 15-minute doctor visit to an organ transplant surgery.

This legislative package provided economic relief during the COVID-19 pandemic. It included measures to expand and increase subsidies for health insurance plans under the ACA, reducing costs for many individuals and families.

This refers to the maximum amount an insurance plan will pay for covered services in one year. The ACA prohibited most health insurance plans from imposing annual limits on essential health benefits to ensure adequate coverage for individuals.

If a claim is denied by the insurance company, the insured person can request they take a second look and reconsider covering it. Submitting a formal appeal with evidence from your doctor allows you to contest your insurer's decision. Health plans must outline the appeals process, which starts with an internal review and can escalate to external third parties or a court. Appeals allow you to stand up for your right to fair coverage.

With respect to health insurance, an application is a form providing the insurer with certain information necessary to underwrite one’s health risks. It is typically attached to the insurance contract as part of the “entire contract.”

These plans allow small businesses or self-employed individuals to join together to purchase health insurance. It aims to give them access to more affordable coverage by leveraging the buying power of a larger group.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.