Affordable Care Act

Definition: The ACA, also known as Obamacare is a U.S. federal law enacted in 2010 to expand access to health insurance, protect patients, and reduce healthcare costs.
Source: U.S. Department of Health and Human Services. Affordable Care Act.

Benefit Period
Definition: A benefit period is the duration of time during which an insurance policyholder can receive covered healthcare services before the deductible or out-of-pocket maximum resets.
Source: Centers for Medicare & Medicaid Services (CMS). Benefit Period.

Coinsurance
Definition: Coinsurance is the percentage of healthcare costs that an insured individual pays after meeting their deductible, with the insurer covering the remaining percentage.
Source: U.S. Department of Labor. Coinsurance.

Copayment (Copay)
Definition: A copayment is a fixed fee paid by an insured individual for healthcare services, such as doctor visits or prescriptions, at the time of service.
Source: Centers for Medicare & Medicaid Services (CMS). Copayment.

Cost Sharing
Definition: Cost sharing refers to the portion of healthcare costs that insured individuals pay out-of-pocket, including deductibles, copayments, and coinsurance.
Source: Kaiser Family Foundation (KFF). Cost Sharing.

Deductible
Definition: A deductible is the amount an insured individual must pay out-of-pocket for covered healthcare services before their insurance begins to pay.
Source: Centers for Medicare & Medicaid Services (CMS). Deductible.

Dependent Coverage
Definition: Dependent coverage allows health insurance policyholders to extend coverage to eligible family members, such as children or spouses.
Source: U.S. Department of Labor. Dependent Coverage.

Employer-Sponsored Insurance (ESI)
Definition: ESI is health insurance provided by employers as part of employee benefits, often with shared costs between employers and employees.
Source: Kaiser Family Foundation (KFF). Employer-Sponsored Health Coverage.

Essential Health Benefits (EHB)
Definition: EHB are a set of 10 categories of healthcare services, such as preventive care and maternity services, that all ACA-compliant plans must cover.
Source: U.S. Department of Health and Human Services. Essential Health Benefits.

Exclusive Provider Organization (EPO)
Definition: An EPO is a type of health insurance plan that covers services only if patients use providers within the plan’s network, except in emergencies.
Source: National Association of Insurance Commissioners (NAIC). EPO Plans.

Explanation of Benefits (EOB)
Definition: An EOB is a document provided by insurers detailing the services received, costs billed, and amounts covered or owed by the policyholder.
Source: Centers for Medicare & Medicaid Services (CMS). Explanation of Benefits.

Formulary
Definition: A formulary is a list of prescription drugs covered by a health insurance plan, often organized into tiers based on cost-sharing requirements.
Source: U.S. Department of Health and Human Services. Formulary.

Health Maintenance Organization (HMO)
Definition: An HMO is a type of health insurance plan requiring members to use in-network providers and obtain referrals for specialist care.
Source: National Association of Insurance Commissioners (NAIC). HMO Plans.

High-Deductible Health Plan (HDHP)
Definition: An HDHP is a health insurance plan with lower premiums and higher deductibles, often paired with a Health Savings Account (HSA).
Source: Internal Revenue Service (IRS). HDHP Definition.

Medicaid
Definition: Medicaid is a joint federal and state program providing health coverage to low-income individuals and families, including children, pregnant women, and the elderly.
Source: Centers for Medicare & Medicaid Services (CMS). Medicaid Overview.

Medicare
Definition: Medicare is a federal health insurance program for individuals aged 65 and older, as well as certain younger people with disabilities.
Source: Centers for Medicare & Medicaid Services (CMS). Medicare Overview.

Network
Definition: A network is a group of healthcare providers and facilities contracted with an insurance plan to deliver services at negotiated rates.
Source: National Association of Insurance Commissioners (NAIC). Network Definitions.

Out-of-Pocket Maximum
Definition: The out-of-pocket maximum is the maximum amount an insured individual must pay for covered services in a policy year, after which the insurer covers all additional costs.
Source: U.S. Department of Health and Human Services. Out-of-Pocket Maximum.

Premium
Definition: A premium is the amount an insured individual or employer pays regularly to maintain health insurance coverage.
Source: Centers for Medicare & Medicaid Services (CMS). Premiums.

Preferred Provider Organization (PPO)
Definition: A PPO is a type of health insurance plan offering flexibility to see in-network and out-of-network providers, typically at different cost-sharing levels.
Source: National Association of Insurance Commissioners (NAIC). PPO Plans.

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