Language desk / glossary

Every term, plainly bounded

62 health-insurance words with a short definition and an illustration. Illustrations are not plan prices, quotes, or coverage promises. Open a term for its source route and review date.

• DeductibleThe amount you pay for services subject to the deductible before the plan starts sharing those costs; some services may be covered earlier.
• CoinsuranceYour share of a covered service's allowed amount, stated as a percentage.
• CopayA fixed amount a plan requires for a particular covered service or prescription.
• Out-Of-Pocket MaximumThe annual cap on your cost sharing for covered in-network care; premiums and excluded or out-of-network charges generally do not count.
• PremiumWhat you pay on a regular schedule to keep the plan active, whether you use care or not.
• Explanation Of Benefits (EOB)A summary from your insurer of what was billed, what the plan processed, and what you may owe. It is not a bill.
• Prior AuthorizationApproval your plan requires before it will cover certain care.
• FormularyThe list of drugs your plan covers, grouped into cost tiers and subject to plan rules.
• NetworkThe doctors, facilities, and other providers that contract with a plan.
• HMOA plan type that generally centers care on a network and may require a primary-care referral for specialists.
• PPOA plan type that can cover in-network and out-of-network care under different cost rules.
• HDHPA high-deductible health plan that must meet current federal rules to be HSA-eligible.
• HSA (Health Savings Account)A tax-advantaged account for qualified medical expenses that is available only when eligibility rules are met.
• Premium Tax CreditA federal tax credit that can lower the cost of Marketplace coverage when eligibility rules are met.
• Open EnrollmentThe scheduled period when eligible people can enroll in or change Marketplace coverage without a qualifying life event.
• Special Enrollment PeriodA limited enrollment window that can follow a qualifying life event.
• Metal TierA Marketplace category—Bronze, Silver, Gold, or Platinum—based on how plan and member costs are split on average.
• Summary Of Benefits And Coverage (SBC)A standardized plan summary designed to support side-by-side comparison.
• ClaimA request for payment that a member or provider sends to an insurer after care.
• DenialA decision that a plan will not pay some or all of a claim or requested service.
• Coordination Of BenefitsRules that determine which plan processes a claim first when a person has more than one plan.
• Allowed AmountThe maximum amount a plan recognizes for a covered service when calculating payment and cost sharing.
• Balance BillingWhen a provider bills a patient for the difference between its charge and the amount recognized by a plan.
• In-NetworkA provider or facility that currently contracts with a plan.
• ReferralA direction or approval from a primary-care clinician to see a specialist, required by some plans.
• Catastrophic PlanA Marketplace plan category with restricted eligibility and high member cost exposure before many benefits are paid.
• COBRAA federal continuation-coverage right that may let eligible people temporarily keep group health coverage after certain events.
• FSA (Flexible Spending Account)An employer-established account funded before taxes for eligible expenses; unused money can be forfeited, although a plan may offer a limited carryover or grace period.
• Actuarial ValueThe share of covered costs a plan is designed to pay on average across a standard population.
• Essential Health BenefitsFederally specified categories of benefits that non-grandfathered individual and small-group plans generally must cover.
• EPOA plan type that generally covers care only inside its network except for emergencies.
• POS PlanA plan type that combines network rules, primary-care coordination, and some out-of-network coverage.
• Out-Of-NetworkA provider or facility without a current contract with the plan.
• Preventive CareSpecified screenings, vaccines, and counseling that many plans cover without cost sharing when federal and plan requirements are met.
• Primary Care Physician (PCP)A clinician who handles routine care and may coordinate referrals under the plan.
• SpecialistA clinician focused on a particular body system, condition, or type of care.
• Cost-Sharing Reduction (CSR)Marketplace savings that can lower deductibles, copayments, coinsurance, and the out-of-pocket maximum for eligible enrollees in a Silver plan.
• Federal Poverty Level (FPL)An income guideline used in eligibility rules for Marketplace savings and other programs.
• Medically NecessaryA plan standard used to decide whether care is appropriate under its coverage rules.
• ExclusionA service, item, or circumstance the plan document says it does not cover.
• Grace PeriodA limited time to pay overdue premiums before coverage can end; the rules depend on coverage and financial-help status.
• Waiting PeriodA period that must pass before specified coverage or benefits begin.
• Pre-Existing ConditionA health condition present before new coverage begins. ACA-compliant plans cannot deny enrollment or charge more because of it.
• Guaranteed IssueA rule requiring an insurer to accept eligible applicants without using health status to deny enrollment.
• Lifetime MaximumA lifetime dollar cap on plan payment. ACA rules prohibit these caps for essential health benefits in covered plans.
• Generic DrugAn FDA-approved medicine with the same active ingredient and required bioequivalence to its brand-name counterpart; inactive ingredients can differ.
• Brand-Name DrugA medicine marketed under a brand name; formulary placement and cost sharing depend on the plan.
• Specialty DrugA plan designation for certain complex or high-cost medicines that can carry special pharmacy, authorization, or cost-sharing rules.
• Step TherapyA drug-coverage rule that requires trying a preferred treatment before the plan covers another treatment.
• Quantity LimitA drug-coverage rule that limits the amount a plan covers during a stated period.
• TelehealthCare delivered by phone, video, or another remote method; coverage, network, and cost sharing vary by plan and service.
• Urgent CareCare for problems needing prompt attention that are not life-threatening; hours, capabilities, network status, and prices vary.
• Emergency Room (ER)A hospital department for emergency conditions. Cost sharing can apply even when surprise-billing protections limit certain out-of-network charges.
• HRA (Health Reimbursement Arrangement)An employer-funded arrangement that reimburses eligible medical expenses under the employer plan's rules.
• Embedded DeductibleA family-plan design with an individual deductible inside the family deductible.
• Family DeductibleThe combined deductible rule for people covered together on a family plan.
• MedicaidA joint federal-state program covering eligible people under rules that vary by state and eligibility group.
• MedicareFederal health coverage for older adults and certain younger people with disabilities or specified conditions.
• CHIP (Children'S Health Insurance Program)Federal-state coverage for eligible children and, in some states, pregnant people whose household income is too high for Medicaid.
• Short-Term Health PlanTemporary coverage that may not include the ACA's full consumer protections, benefit package, or pre-existing-condition rules.
• AppealA formal request for a plan to reconsider a denied claim or coverage decision.
• External ReviewAn independent review that may be available after a plan upholds certain denials.

Every term page links its claim-level official source · Reviewed by the MedicalRecords.com editorial team · Last reviewed August 11, 2026