Glossary of Terms

Glossary of Terms: Individual & Family Health Insurance Exchange Plans

Confused about your coverage? Don’t be. You can find definitions for health insurance terms here, helping you understand everything from the Affordable Care Act to deductibles and premiums.

If you have a question on these terms or your coverage, contact us or call 1-844-282-3100 to connect with our member services team. We’re here to help.

Affordable Care Act (ACA): a law passed in 2010 to offer more health insurance options, discounts and broader Medicaid coverage. Also known as Obamacare.

Appeal: a request asking your health plan to review a ruling on coverage or payment. Learn more about appeals and grievances.

Brand Name Drug: a drug sold under a specific, trademarked brand name.

Claim: a request for payment from your health insurance provider for services, procedures or a drug. Coinsurance: how health care costs are split with your insurance after your deductible is met.

Copayment: what you pay for a service when you receive it, like a doctor’s office visit or getting a prescription filled. Deductible: the amount you must pay before your health insurance kicks in.

Dependent: a child or other person who is claimed by another for a personal tax exemption.

Exchange: a resource where you can learn about and shop for health insurance plans. Also known as a health insurance marketplace.

Formulary: a list of generic and brand name drugs chosen and covered by a health insurance plan.

Generic Drug: a drug with the same ingredients as a brand name drug but without the trademarked name. Generic drugs are usually covered by a health plan instead of brand name ones.

Grievance: a formal complaint about service and quality of a health plan or provider. Learn more about appeals and grievances.

Maximum Out-of-Pocket: a set amount capping what a member can spend on deductibles, coinsurance and copays for the policy period. After you meet the maximum out-of-pocket, your insurance will cover 100% of expenses.

Open Enrollment: a yearly period where people can buy health insurance in an exchange or marketplace. The 2017 enrollment window is November 1, 2016 - January 31, 2017.

Premium: a monthly, quarterly or annual amount you pay for health insurance coverage.

Primary Care Provider: the doctor or nurse practitioner that is your main provider of health services.

Qualifying Life Event: a change in your life such as a birth, marriage or divorce that can qualify you for changes to your plan outside of enrollment periods.

MM161 & MM162
Last Updated: 2/23/17