A

ACA (Affordable Care Act)

Federal law that created Marketplace insurance and expanded access to health coverage.

Additional Coverage

Benefits Medicare doesn’t cover, like dental, vision, or hearing.

Agent

A licensed professional (like Part ABC) who helps you choose and enroll in coverage.

Annual Enrollment Period (AEP)

Medicare’s yearly window (Oct 15–Dec 7) to enroll or change plans.

B

Balance Billing

When a provider bills you for the difference between what they charge and what Medicare approves (illegal with Medicare-participating providers).

Beneficiary

The person receiving Medicare or health insurance benefits.

Benefit Period

How Medicare measures hospital and skilled nursing services, not the same as a calendar year.

C

Carrier

The insurance company that administers your policy.

Claim

A request for payment submitted to an insurance company after you get care.

Coinsurance

The percentage you pay for covered services after your deductible.

Copay

A fixed amount (like $20) you pay for a service at the time of care.

Creditable Coverage

Insurance that’s considered “good enough” by Medicare (important for avoiding penalties).

D

Deductible

The out-of-pocket amount you must pay before your plan starts covering costs.

Drug Formulary

The official list of prescription drugs covered by a Part D or Advantage plan.

Dual Eligible

Someone who qualifies for both Medicare and Medicaid.

E

Eligibility

Requirements you must meet to qualify for coverage (like turning 65 for Medicare).

Enrollment Period

A specific window of time to enroll, switch, or drop coverage.

Exclusions

Services or items your insurance does not cover.

F

Final Expense Insurance

A small life insurance policy meant to cover funeral, burial, and related costs.

Formulary Tiers

Levels of prescription drugs with different copay/coinsurance amounts.

G

Generic Drug

A medication with the same active ingredients as a brand name drug, usually at a lower cost.

Guaranteed Issue

A rule that requires insurance companies to sell you a policy regardless of health conditions (important for Medigap).

Group Health Insurance

Coverage offered by an employer or organization to its employees or members.

H

Health Maintenance Organization (HMO)

A type of Medicare Advantage or ACA plan that limits you to a network of providers, usually requiring referrals.

High Deductible Health Plan (HDHP)

A plan with lower monthly premiums but higher out-of-pocket costs before coverage kicks in.

Hospital Insurance (Part A)

Medicare coverage for inpatient hospital stays, skilled nursing care, hospice, and some home health care.

I

ICHRA (Individual Coverage HRA)

An employer benefit that reimburses employees tax free for individual health insurance premiums.

Income Related Monthly Adjustment Amount (IRMAA)

An extra charge added to Medicare Part B and Part D premiums for higher-income beneficiaries.

In Network

Providers or facilities that contract with your insurance plan to offer lower rates.

J

Job-Based Insurance

Health coverage offered through your or a spouse’s employer.

Joint Commission

An organization that accredits hospitals and health care facilities, ensuring quality standards are met.

K

Kidney Disease (ESRD)

End-Stage Renal Disease; people with permanent kidney failure may qualify for Medicare before age 65.

Key Person Insurance

A life insurance policy that helps protect a business financially if an important employee passes away.

L

Lifetime Reserve Days

Extra hospital days Medicare Part A covers after you’ve used your standard benefit period (you have 60 for your lifetime).

Long-Term Care Insurance

Coverage that helps pay for services like nursing homes, assisted living, or home health when you can’t do everyday activities.

Loss Ratio

The percentage of premiums an insurer spends on claims versus admin/profit.

M

Medicaid

A state and federal program providing health coverage for people with limited income/resources.

Medicare

Federal health insurance for people 65+ or with certain disabilities.

Medicare Advantage (Part C)

Private plans that bundle Parts A, B, and usually D into one.

Medicare Supplement (Medigap)

Plans that help cover out-of-pocket costs not paid by Original Medicare.

MOOP (Maximum Out-of-Pocket)

The most you’ll pay for covered services in a year under a Medicare Advantage or ACA plan.

N

Network

The doctors, hospitals, and providers contracted with your insurance plan.

Non-Preferred Drug

A brand-name drug that costs more because it isn’t on your plan’s preferred formulary tier.

Notice of Creditable Coverage

A document showing your drug coverage is as good as or better than Medicare’s standard.

O

Open Enrollment Period (OEP)

The window when you can enroll in or change coverage. For Medicare Advantage, Jan 1–Mar 31; for ACA, Nov 1–Jan 15 in most states.

Out-of-Network

Providers not contracted with your plan, usually at higher cost.

Out-of-Pocket Costs

The expenses you pay directly (deductibles, copays, coinsurance) that aren’t covered by insurance.

P

Part A

Hospital insurance under Medicare.

Part B

Medical insurance under Medicare (doctor visits, outpatient care).

Part C (Medicare Advantage)

Private Medicare plans that combine A and B, often D.

Part D

Prescription drug coverage through Medicare approved private plans.

Premium

The monthly amount you pay to keep your coverage active.

Preventive Services

Screenings, vaccines, and checkups covered at no cost to you.

Provider

A doctor, hospital, or health professional who delivers care.

Q

Qualifying Life Event (QLE)

A change (marriage, job loss, moving) that lets you enroll outside normal enrollment periods.

Qualified Health Plan (QHP)

ACA marketplace plans that meet government standards.

QMB (Qualified Medicare Beneficiary)

A program that helps pay Medicare premiums and cost-sharing for low income beneficiaries.

R

Referral

A written order from your primary doctor to see a specialist in HMO plans.

Reinsurance

Insurance that insurers buy to protect themselves from very large claims.

Rider

An add on benefit you can purchase to customize an insurance policy.

S

SEP (Special Enrollment Period)

A time outside open enrollment when you can make plan changes due to certain events.

Skilled Nursing Facility (SNF)

A rehab facility that provides medical and nursing services after a hospital stay.

Supplemental Benefits

Extra services Medicare Advantage plans may offer (vision, hearing, dental, gym memberships).

Summary of Benefits

A document showing what a plan covers and costs.

T

Telehealth

Getting care from a doctor remotely by phone or video.

Tiered Network

A system where providers are ranked by cost/quality, affecting what you pay.

Trustee

Person or entity managing funds for someone else’s benefit (important for life insurance and estate planning).

U

Underwriting

The process insurers use to decide eligibility and pricing for a policy.

Urgent Care

Non emergency care for immediate issues (like stitches or infections).

Usual, Customary, and Reasonable (UCR)

The typical fee charged for a service in your area, used by insurers to set payment limits.

W

Waiting Period

The time before your coverage or benefits take effect.

Wellness Visit

A yearly check in with your doctor to review your health and prevent problems.

Whole Life Insurance

A permanent life insurance policy that lasts your lifetime and builds cash value.

X

X-Ray Services

Covered by most insurance, in Medicare, usually Part B if medically necessary.

Medicare & Health Insurance Glossary .

Insurance Terms, Demystified

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