Health insurance glossary

Terms and definitions

Here are definitions of a few key terms to help you better understand how we talk about healthcare.

Accident benefit

Coverage for care when members have an accident. Standard cost-sharing applies after reaching the dollar maximum or after 90 days, whichever comes first.

Advanced premium tax credit (APTC)

A federal tax credit that can help members pay for their medical plans when they apply through HealthCare.gov. You may qualify for this type of financial assistance based on household size and income.

Affordable Care Act (ACA)

The Affordable Care Act (ACA) — sometimes referred to as Obamacare — is a federal law that offers certain protections, such as no pre-existing condition restrictions. It also requires people to have health insurance (with some exceptions). To learn more, visit HealthCare.gov.

Alternative care

Medically necessary spinal manipulations and acupuncture services.

Balance billing

Charges for out-of-network care beyond what your health plan allows. Out-of-network providers may bill members the difference between the maximum plan allowance and their billed charges. In-network providers don’t do this.

Brand tier medications

Brand tier medications have been reviewed by Moda Health and found to have no significant therapeutic advantage over their preferred tier alternatives. These products generally have safe and effective options available under the value, select and/or preferred medication tiers.

Coinsurance

The percentage members pay for a covered healthcare service after they meet their deductible. For example, they may pay 20 percent of an allowed $200 charge, or $40.

Copay (copayment)

The fixed amount members pay for a specific covered healthcare service, product or treatment, usually at the time of receiving it. For example, they might pay $25 for a doctor visit.

Cost-sharing reductions

A type of federal financial assistance that lowers out-of-pocket costs, like deductibles, copays and coinsurance. This reduction may be available to people who apply through HealthCare.gov and who qualify based on household income. Members of a federally recognized tribe might be eligible for other cost-sharing benefits.

Deductible

The amount members pay in a calendar year for care that requires a member contribution before the health plan starts paying. Fixed-dollar copays and prescription medications may not apply toward the deductible. Disallowed charges do not apply toward the deductible.

Dental annual maximum

The maximum dollar amount a dental plan will pay toward the cost of dental care for members ages 19 and older within a calendar year.

Evidence-based practices

Healthcare options or decisions that research shows work best, are most cost-effective and consider the patient’s needs and experience.

Inpatient care

Care people receive while they are checked in to a hospital or facility. Usually, people are admitted to a hospital only if they are seriously hurt or sick.

Metal category

Medical plan levels defined by the Affordable Care Act (ACA). Categories include Gold, Silver and Bronze. Plan benefits range in coverage and cost based on the metal level. Generally, Gold plans offer more coverage but have higher premiums. Silver plans fall in the middle, while Bronze plans offer less coverage with lower premiums.

Out-of-pocket costs

What members pay in a calendar year for care after their health plan pays its portion. These expenses may include deductibles, copays and coinsurance for covered services.

Out-of-pocket maximum

The most members pay in a calendar year for covered care and services before benefits are paid in full up to the allowable amount or up to any visit or dollar limit. Once members meet their out-of-pocket maximum, the plan covers eligible expenses at 100 percent. The out-of-pocket maximum includes deductibles, coinsurance and copays. It does not include disallowed charges or balance billing from out-of-network providers. For dental plans, an out-of-pocket maximum only applies to members under age 19.

Outpatient care

Care received from a doctor's office or other provider, without being checked into a hospital or facility.

Pediatric dental care

Dental care for members under age 19, which may be included in a medical or dental plan.

Pediatric vision benefit

A medical plan benefit that covers vision care for members under age 19.

Pre-existing condition

Under the Affordable Care Act, if you were sick or had a health problem before applying for health coverage, you won’t be denied based on that reason.

Preferred tier medications

Preferred medications, including specialty preferred medications, that have been reviewed by Moda Health and found to be clinically effective at a favorable cost when compared with other medications in the same therapeutic class and/or category.

Preferred provider

A person or place contracted with a provider network to provide care. By choosing a preferred provider, members’ out-of-pocket expenses will be less than if they choose a provider outside the network.

Preferred provider organization (PPO)

A type of provider network. For our plans, a PPO network includes providers contracted with us to offer in-network coverage at agreed-upon rates, with no balance billing.

Premium

The monthly amount members pay to be covered by a health or dental plan.

Preventive care

Routine, in-network medical care that helps keep members healthy. Services include periodic health exams, well-baby care, women’s annual exams, preventive health screenings and immunizations.

Primary care provider (PCP)

The healthcare provider who treats members or coordinates their care to keep them healthy. Examples of a PCP include an M.D. (Doctor of Medicine), D.O. (Doctor of Osteopathic Medicine), nurse practitioner or physician assistant. These providers may practice primary care in the specialties of internal medicine, family medicine, general practice, geriatric medicine, pediatrics and women’s health, among others.

Provider

Any group or professional that provides members with care. Examples are hospitals, doctors and rehabilitation centers.

Select tier medications

Generic medications that represent the most cost-effective option within their category, and brand name medications that are both clinically favorable and cost-effective.

Special enrollment

The period outside of open enrollment that allows those who qualify to enroll in a new or different health plan and/or to add members. Certain life events like getting married, having a baby or moving to a new state could make members or covered dependents eligible for special enrollment.

Specialist

A medical provider specializing in a specific type of health condition or care. Specialists might include cardiologists, dermatologists, oncologists, urologists and many others.

Special prescription fulfillment

Special handling for certain medications that require dispensing through an exclusive specialty pharmacy provider. These medications may include specialty tier and other tier medications that are often used to treat complex chronic health conditions.

Specialty tier medications

Prescription medications that are often used to treat complex chronic health conditions. Specialty treatments may require special handling techniques, careful administration and a unique ordering process. Specialty medications may require prior authorization.

Urgent care

Immediate, short-term medical care provided for minor but urgent medical conditions that aren’t severe enough to require emergency room care.

Value tier medications

Commonly prescribed medications used to treat chronic medical conditions and preserve health.

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