Glossary of Insurance Terms
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Copay: Regardless of the cost of the service, a copayment is a predetermined (flat) fee that an individual pays for health services, in addition to what the insurance covers.
Co-insurance: Co-insurance is often specified by a percentage. Depending on your plan you may be responsible for a certain percentage, while your health insurance plan pays the remaining percentage.
Deductible: The amount an individual must pay for health care expenses before insurance covers the cost.
Out-of-pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own pocket before an insurance company will pay for health care expenses.
Benefit Maximum: A benefit maximum is a limit on a covered service. A service may be limited by dollar amount, duration or number of visits.
Formulary: A list of prescription drugs used by a prescription drug plan or another insurance plan offering prescription drug benefits. Also referred to as a drug list.
Preventative Care: This refers to certain services such as physical exams, preventative mammograms, Well Baby and Well Child Checkups and immunizations (excluding immunizations required for travel) that are recognized by the federal government to prevent illness and promote ongoing health and wellness.
Out-of-Network: Refers to physicians, hospitals or other health care providers who are not contracted with your health plan, which could result in greater cost of services or less savings for you.
Prior Authorization: A prior authorization is sometimes required for certain services to ensure you are receiving the most medically appropriate and cost-effective care or if you are seeking care from an out-of-network or non-plan provider.
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Frequently Asked Insurance Questions
Q. When is open enrollment?
You have through August 15, 2021 to enroll in or change your individual health insurance plan due to the coronavirus disease 2019 (COVID-19) emergency.
Q. What qualifies you for a Special Enrollment Period?
Life changes that can qualify you for a Special Enrollment Period
1. Loss of health insurance
You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.
Coverage losses that may qualify you for a Special Enrollment Period:
- Losing job-based coverage
- Losing COBRA coverage
- Losing individual health coverage for a plan or policy you bought yourself
- Losing eligibility for Medicaid or CHIP
- Losing eligibility for Medicare
- Losing coverage through a family member
2. Changes in household size
You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:
- Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
- Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward.
- Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
- Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
3. Changes in residence
Household moves that qualify you for a Special Enrollment Period:
- Moving to a new home in a new ZIP code or county
- Moving to the U.S. from a foreign country or United States territory
- A student moving to or from the place they attend school
- A seasonal worker moving to or from the place they both live and work
- Moving to or from a shelter or other transitional housing
Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.
Important: You must prove you had qualifying health coverage for one or more days during the 60 days before your move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.
4. More qualifying changes
Other life circumstances that may qualify you for a Special Enrollment Period:
- Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
- Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
- Leaving incarceration
- AmeriCorps VISTA members starting or ending their service
Q. What happens when the Marketplace needs documents to confirm a Special Enrollment Period?
When you apply for Marketplace coverage and qualify for a Special Enrollment Period, you may be asked to provide documents to con rm the events that make you eligible. You must send the documents before you can start using your coverage.
- You’ll learn if you have to provide documents after you submit your application. Details and instructions appear on your eligibility results screen and in a notice you can download or receive in the mail.
- It’s best to pick a plan first and submit your documents afterwards. After you pick a plan, you have 30 days to send the documents.
- Your coverage start date is based on when you pick a plan. But you can’t use your coverage until your eligibility is confirmed and you make your first premium payment.
- If your eligibility results don’t say you need to provide documents, you don’t have to. Simply pick a plan and enroll.
Q. What are the different types of insurance plans?
Information provided by healthcare.gov
Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.