Shopping for Health Insurance?We can help you!
You should also refer to your specific policy’s definitions to ensure you have the precise meaning for your needs):
A sudden, unforeseeable event that causes injury to one or more people covered under the policy.
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference (also known as Balance Billing).
Some short-term medical plans are filed as an association group plan in various states and require monthly fees.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider (one in your network) may not balance bill you for covered services.
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's contract or certificate.
A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
An enrollee begins to pay for coinsurance after their deductible has been met. A coinsurance fee refers to a percentage of a healthcare cost that they will be charged. For instance, an in-network doctor’s visit may have a 30% coinsurance rate. If the visit costs $100 total, the consumer will be responsible for paying $30, and the insurance company pays the remaining $70. Generally, the lower the member’s coinsurance percentage, the higher the premium the member must pay.
A disease or other anomaly existing at or before birth, whether acquired during development or by heredity.
A copayment is similar to coinsurance, but instead of being figured as a percentage of a service’s cost, it is calculated as a flat fee for a medical service. For instance, your plan may charge a $33 copay for visiting an in-network specialist. As with coinsurance, in many cases copayments will not begin until the consumer has met their deductible. Generally, the more copays that are not after deductible (a.k.a. “first dollar”), the higher the premium the member will pay.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.
The length of time which the Insured selected in the Insured’s application and approved by the insurance company.
An Insured and his/her eligible dependents for whom coverage is in effect under a policy.
Under HIPAA, Continuous Coverage applies when a person is transitioning from an existing health insurance plan to an employer-sponsored group health plan. With Continuous Coverage, conditions treated under the prior plan will continue to be treated under the employer plan without the being subject to a waiting period. Policy holders can contact their insurance carrier to request a Certificate of Creditable Coverage for use when transitioning from Short-Term to an employer-sponsored group health plan. For more information, see the FAQ or visit the Help Center.
A deductible is the amount an enrollee must pay for covered medical services before an insurance plan will start covering costs. Generally, the lower the deductible, the higher the premium the member must pay.
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. Short-term medical plans generally do not have regular dental coverage but do cover restoration and replacement of natural teeth lost or damaged because of an Injury covered under the policy. Stand-alone dental plans are available on AgileHealthInsurance.com.
The lawful spouse or a child for whom the subscriber or insured is paying for or providing access to health insurance benefits.
Durable Medical Equipment (DME):
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, or crutches.
The date the insured’s (and eligible dependents’ if applicable) coverage under a policy is effective.
Emergency Room Care:
Emergency services you get in an emergency room.
Health care services that your health insurance or plan doesn’t pay for or cover.
Essential Health Benefits:
A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Plans must offer dental coverage for children. Dental benefits for adults are optional. Short-term medical plans do not cover all 10 of the essential health benefits.
Health care services that your health insurance or plan doesn’t pay for or cover.
Most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee. Exemptions are granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances.
A treatment, drug, device, procedure, supply or service and related services (or any portion thereof, including the form, administration or dosage) for a particular diagnosis or condition that is not clinically approved. Most health insurance policies do not cover experimental treatment. The fact that a procedure, service, supply, treatment, drug, or device may be the only hope for survival will not change the fact that it is otherwise experimental in nature.
Formulary (or Drug List):
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Most short-term medical plans do not include prescription drug coverage.
The amount of time a member is allowed to be delinquent with their monthly premium payment after the first payment is made. It is general 31 days.
A requirement that ACA health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Most short-term medical plans are not guaranteed issue.
A requirement that an ACA health insurance issuer must offer to renew a policy as long as the member continues to pay premiums. Short-term medical plans are not guaranteed renewable.
Legal entitlement to payment or reimbursement for your health care costs, generally under the contract with a health insurance company.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
Home Health Care:
Health care services a person receives at home.
Home Health Care Plan:
A program for continued care and treatment of an individual established and approved in writing by the individual’s attending doctor.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families. This is generally not covered in a short-term medical plan.
An institution operated by law for the care and treatment of injured or sick persons; has organized facilities for diagnosis and surgery or has a contract with another hospital for these services; and has 24-hour nursing service.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care:
Care in a hospital that usually doesn’t require an overnight stay.
Individual Health Insurance Policy:
Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.
Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Most health insurance plans don’t pay for long-term care.
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels. Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states. You can apply anytime. If you qualify, your coverage can begin immediately, any time of year.
A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
A process used by insurance companies to try to figure out your health status when you're applying for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits. Most short-term medical plans are subject to medical underwriting.
Mental and Nervous Disorder:
A “biologically-based” mental disorder, including Schizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoia and other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and dementia, Affective disorders, and any other "biologically-based" mental disorders appearing in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
Minimum Essential Coverage (MEC):
Any insurance plan that meets the Affordable Care Act requirement for having health coverage. To avoid the penalty for not having insurance you must be enrolled in a plan that qualifies as minimum essential coverage (sometimes called “qualifying health coverage”). Short-term medical plans do not qualify as minimum essential coverage.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. It is annotated on your insurance card.
Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
Out-Of-Pocket Maximum (Or Limit):
Your out-of-pocket limit is the maximum amount you pay for deductibles, coinsurance, and copayments within your coverage period. After this amount is reached, the plan pays 100% of covered medical services delivered in-network for the remainder of the policy term. Costs that do not have to be counted towards your out-of-pocket maximum include: premiums, out-of-network costs, and uncovered medical services. Generally, the lower the out-of-pocket maximum, the higher the premium the member must pay.
A person who incurs medical expenses at Doctor’s offices and freestanding clinics, and at hospitals when not admitted as an inpatient.
A payment (“fee,” “fine,” “individual mandate”) you make if you don’t have health insurance that counts as qualifying health coverage. The penalty in 2016 and 2017 for not having health coverage is $695 for each person on your tax return who isn’t covered ($347.50 per child), or 2.5% of your household income, whichever is more. You owe a fee for any month you, your spouse, or your tax dependents don’t have qualifying health coverage. You’ll pay the fee when you file your federal income tax return. If you’re uncovered just some months of the year, you pay 1/12 of the penalty for each month you’re uninsured. If you’re uncovered for only 1 or 2 consecutive months, you don’t have to pay the fee at all. People with very low incomes and others with special circumstances may be eligible for exemptions from the requirement to have health insurance. If you qualify for an exemption, you won’t have to pay the fee.
Policy Maximum Benefit:
The maximum dollar amount for medical services that the member’s insurance company will pay during the term of the policy. Traditionally, $1,000,000 has been the standard. However, a lower policy maximum will drive lower premiums.
Policy term is the maximum duration of the initial coverage period offered by the plan. You can purchase a plan for one month up to the maximum duration and you can cancel your policy at any time. We suggest purchasing the maximum duration available. Short-term plans are not guaranteed renewable, but we can help you reapply or find a new plan.
A health problem you had before the date that new health coverage starts.
The amount of money that the member must pay for their insurance policy. Generally, the more benefits provided will mean a higher premium for the member.
Drugs and medications that, by law, require a prescription.
Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.
Prior Authorization (Preauthorization):
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
Qualifying Health Insurance (or Coverage):
Coverage that is compliant with the Affordable Care Act so that policyholders are not liable to the shared responsibility tax.
Qualified Health Plan:
An insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.” Short-term medical is not a qualified health plan.
A process that allows state insurance departments to review rate increases before insurance companies can apply them to you. Short-term medical plans are term insurance so a member will not receive a rate increase during the term of their policy.
The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
The person who is the primary insured or the policyholder.
Health coverage available at reduced or no cost for people with incomes below certain levels. Examples of subsidized coverage include Medicaid and the Children’s Health Insurance Program (CHIP). Marketplace insurance plans with premium tax credits are sometimes known as subsidized coverage too. Short-term medical plans do not have subsidized coverage.
The overindulgence in and dependence on a psychoactive leading to effects that are detrimental to the individual's physical health or mental health, or the welfare of others.
Skilled Nursing Care:
Also known as custodial or convalescence care services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Surgery or Surgical Procedure:
An invasive diagnostic procedure; or the treatment of injury or sickness by manual or instrumental operations performed by a doctor while the patient is under general or local anesthesia.
UCR (Usual, Customary, and Reasonable):
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent Care Center:
A medical facility separate from a hospital emergency department where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate, non-routine urgent care for an Injury or Sickness presented on an episodic basis.
A health benefit that at least partially covers vision care, like eye exams and glasses. Generally, short-term medical plans do not include a vision benefit. A “stand-alone” plan is available for purchase when someone buys a short-term medical plan.
A program intended to improve and promote health and fitness. Coverage in a short-term medical plan varies plan to plan. Some have no wellness benefits while other plans have varying benefits.