Healthcare Words


To find the definition of a term, click on the corresponding first letter of the word above.


Accountable Care Organization

A group of healthcare providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving healthcare quality goals and outcomes that result in cost savings.

Actuarial Value

The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70 percent, on average, you would be responsible for 30 percent of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual healthcare needs and the terms of your insurance policy.

Affordable Care Act

The comprehensive healthcare reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Healthcare and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Affordable Coverage

Coverage where the employee’s required contribution for self-only coverage for the lowest cost plan offered by the employer does not exceed 9.5 percent of the employee’s household income for the year.

Allowance or Allowed Amount

The most an insurer would pay for a healthcare service.

Annual Limit

A cap on the benefits your insurance company will pay in a year while you're enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated healthcare costs for the rest of the year.


A request for your health insurer or plan to review a decision or a grievance again.


Insurers may recommend that you or your doctor get approval for some services,such as surgery or a hospital stay, before you actually receive the service.



A service or category of services covered by a health plan.

Brand-name Drug

A prescription drug marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it.


Case Management

Also known as care management or care coordination, it is a process of coordinating care between an insurer and your healthcare providers (often your primary care doctor and/or specialist) to help manage a specific medical condition or set of conditions. The case manager at the insurer is often a nurse, dietician, social worker or other medical professional.

Children’s Health Insurance Program

Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.


A request for payment for a healthcare service. Claims are usually filed by the healthcare provider, but may also be filed by the member.


A federal act (Consolidated Omnibus Budget Reconciliation Act of 1985) which requires group healthcare plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event which causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming an over-aged dependent, Medicare eligibility, death, or divorce of a covered employee. Members should contact their employers to enroll in COBRA coverage.


A percentage of a covered service that you are responsible for paying. For example,if your plan has 20% coinsurance for a healthcare service, you would pay 20% of the cost and your plan would pay the remaining 80%. Coinsurance may be lower for in-network services.

Community Rating

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

Coordination of Benefits

The practice of ensuring that insurance claims are not paid multiple times, when you are covered by more than one health plan at the same time.


A fixed dollar amount you are required to pay for covered services at the time you receive care. For example, you may have a $20 copayment for doctor’s office visits.

Cost Sharing

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and the Children’s Health Insurance Program also includes premiums.

Cost-sharing Reduction Program

A discount that lowers the amount you have to pay out-of-pocket for deductiblescoinsurance, and copayments. You can get this reduction if you get health insurance through HealthSource RI, your income is below a certain level, and you choose a health plan from the Silver plan category (See Health Plan Levels). If you're a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.

Coverage Period

Length of time an individual is covered by benefits under a plan.

Covered Service

A healthcare service covered by your plan.



The amount you pay each year before your health plan starts to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible. The deductible may not apply to all services.

Department of Health & Human Services

The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the health insurance marketplaceMedicaid, and the Children’s Health Insurance Program (CHIP). For more information, visit


A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.


Someone chosen to make decisions about healthcare for another person who is unable to make decisions for themselves.

Durable Medical Equipment

Equipment and supplies ordered by a healthcare provider for everyday or extended use. Coverage for durable medical equipment may include: oxygen equipment, wheelchairs, crutches or blood testing strips for people with diabetes.


Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Essential Health Benefits

A set of healthcare service categories that must be covered by certain plans, starting in 2014. The Affordable Care Act ensures health plans offered in the individual and small group markets offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Explanation of Benefits

An explanation of benefits is a statement you receive after a claim payment has been processed by your health plan. It explains whether the service is covered,how much was paid, and how much you owe, if applicable. If a service was not paid for, the explanation of benefits will give the reasons for denying payment and will tell you how to file an appeal, if you so choose. An explanation of benefits is not a bill; if you owe money, you should wait to get a bill from your doctor.



A place where healthcare services are provided (as opposed to an individual doctor). A hospital is a healthcare facility.

Federal Poverty Level

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

Federally Recognized Tribe

Any Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe. Read the current list of federally recognized tribes.

Fee for Service

A method in which doctors and other healthcare providers are paid for each service performed. Examples of services include tests and office visits.

Flexible Spending Account (FSA)

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.


There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year. (Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.)


A list of drugs that your health plan covers. The list is created by a panel of doctors and pharmacists. Both brand-name and generic medications may be included on the formulary. Drugs may be organized into price “tiers” or categories, where the copayment for any drugs within a specific tier is the same.

Full-Time Employee

An employee working an average of at least 30 hours of service per week. Hours of service include paid time out of work due to vacation, holiday, and illness as well as other kinds of paid leave.

Full-Time Equivalent Employee

Part-time employees (those working less than 30 hours per week) who are counted to determine employer size. To determine the number of full-time equivalent employees, the employer adds up all of the hours worked by part-time employees in a month and divides by 120.


Generic Drug

Once a company’s patent on a brand-name prescription drug has expired, other drug companies are allowed to sell the same formulation of the same active ingredients. Because more manufacturers can produce generic drugs and the research and development costs are lower,generics are typically less expensive than the brand name version. Most plans have a lower copayment for them.

Grace Period

A three-month grace period mandated by the Affordable Care Act for individual members who receive a premium subsidy from the government and are delinquent in paying their portion of premiums. This grace period only applies to individuals who meet all of the following: enroll through HealthSource RI (or their state’s health insurance marketplace/exchange); receive a premium subsidy in the form of a tax credit and/or cost-sharing reduction; and have paid for at least one month of coverage. 

Grandfathered Health Plan

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).


A complaint that you communicate to your health insurer or plan.

Group Health Plan

In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Guaranteed Issue

A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn't limit how much you can be charged if you enroll.


Habilitative (Habilitation Services)

Healthcare services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance Marketplace

A health insurance market where individuals, families, and small businesses can learn about their health coverage options, compare health insurance plans based on costs, benefits, and other important features, choose a plan, and enroll in coverage. The health insurance marketplace also includes information on programs that help people pay for coverage, including ways to save on monthly premiums and out-of-pocket costs, and other programs like Medicaid and the Children’s Health Insurance Program (CHIP). Individuals and families can apply for coverage online, by phone, or with a paper application. The health insurance marketplace in Rhode Island is HealthSource RI.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A federal act that allows people to be eligible for similar health coverage if they change jobs or their situation changes. It also includes standards for privacy to protect patients.

Health Maintenance Organization (HMO)

An organization that provides healthcare coverage to its members through a network of doctors, hospitals, and other healthcare providers. HMO plans usually require that all of a member’s care, including their annual exam, any diagnostic tests and referrals to specialists be coordinated through the member’s primary care physician (PCP).

Health Plan Levels

Plans in the health insurance marketplace (the marketplace in Rhode Island is HealthSource RI) that are primarily separated into four health plan categories—Bronze, Silver, Gold, or Platinum—based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you'll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60 percent (Bronze), 70 percent (Silver), 80 percent (Gold), and 90 percent (Platinum). This isn't the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.

Health Reimbursement Arrangement (HRA)

An employer-funded group health plan from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. HRAs are sometimes called Health Reimbursement Accounts.

Health Savings Account (HSA)

A special savings account that can be used with certain high-deductible health plans to pay for medical expenses. Contributions to the HSA are tax-deductible,and withdrawals to pay for qualifying medical expenses are tax-free. Money can stay in the account from year to year, and any interest or investment returns accrue tax-free. Penalties may apply when money is used to pay for anything other than qualifying medical expenses.

Health Status

Refers to your medical conditions (both physical and mental health), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, and disability.

HealthSource RI

A health insurance marketplace (also called an exchange) set up by the state of Rhode Island. Through HealthSource RI, individuals, families, and small businesses can learn about their health coverage options, compare health insurance plans based on costs, benefits, and other important features, choose a plan, and enroll in coverage. The health insurance marketplace also includes information on programs that help people pay for coverage, including ways to save on monthly premiums and out-of-pocket costs, and other programs like Medicaid and the Children’s Health Insurance Program (CHIP). Individuals and families can apply for coverage online, by phone, or with a paper application. Learn more about HealthSource RI. 

High-deductible Health Plan (HDHP)

A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

Hospital Readmissions

A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn't properly organized, or that you weren't fully treated before discharge.



Services provided by a doctor or other healthcare provider who has a contract with the insurance company. These services are provided at negotiated rates that are typically less than you would pay on your own.


Large Employer

An entity that has at least 50 full-time employees or a combination of full-time and full-time equivalent employees. 

Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance company. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.



A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.

Medical-loss Ratio

A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers' medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80 percent. A medical loss ratio of 80 percent indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

Medicare Advantage Plan

Also known as Medicare Part C, a Medicare Advantage plan allows you to get Medicare coverage through a private insurer. This coverage takes the places of Medicare Parts A and B (hospital and medical services), and may cover Medicare Part D prescription drugs as well. Generally, you must use plan providers except in emergency or urgent care situations.

Member ID Card

A card you get from your insurance company, listing your name and insurance ID number, as well as other plan-specific details, such as the copayment or coinsurance for office visits, prescription drugs, etc.

Minimum Essential Coverage

Coverage under an employer-sponsored plan, plans in the individual market, grandfathered plans, or a government program such as Medicare or Medicaid. Specialized coverage, such as coverage only for vision or dental care, workers' compensation, disability policies, or coverage only for a specific disease, is not included.

Minimum Value

A health plan meets this standard if it’s designed to pay at least 60 percent of the estimated total cost of medical services for a standard population. 



The facilities, providers, and suppliers your health insurer or plan has contracted with to provide healthcare services.


Any drugs that are not on an insurer’s formulary list, and are not usually covered by the plan.



Services provided by doctors, hospitals, and other healthcare providers who have not contracted with the insurance company. These services may have different copayments or coinsurance than in-network services, or they may not be covered at all (meaning that the member is responsible for the full cost of the services).

Out-of-pocket Costs

Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

Out-of-Pocket Maximum

The maximum amount, per year, you are required to pay out of your own pocket for covered healthcare services after paying any deductible and/or coinsurance requirements. Not all services apply toward the out-of-pocket maximum. Ask your insurer if you aren’t sure whether a service applies.


Part-time Employee

An employee who works less than 30 hours per week.

Patient-Centered Medical Home

A primary care practice that offers efficient coordination of care through a personalized care team. Primary care physicians, along with a local, on-site registered nurse or health coach, tap into specialists, hospital services, behavioral health professional, pharmacies, nutritionist, etc. as needed to ensure each patient gets the right care.

Point of Service (POS)

POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all (you may be responsible for the full cost).

Pre-existing Condition

A health problem you had before the date that new health coverage starts.


Approval in advance. Insurers may recommend that you or your doctor get preapproval for some services, such as surgery or a hospital stay, before you actually receive the service.


See “preauthorization.”

Preferred Provider Organization (PPO)

A type of health plan with a preferred network of doctors and other healthcare providers. Members usually do not have to get referrals for specialty or out-of-network care, but they may have higher out-of-pocket costs for out-of-network care.


The monthly or annual charge for your insurance policy. It is based on the insurer’s prediction of how much it will cost, on average, to pay for each plan member’s healthcare.

Premium Tax Credit

A new tax credit provided by the Affordable Care Act to help you afford health coverage purchased through HealthSource RI. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you're due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

Preventive Health Services

Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary Care

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

Primary Care Physician (PCP)

The doctor you choose to be your primary source for medical care. Your PCP provides your basic care and coordinates any other medical care you may need, including from specialists and hospitals. Not all health plans require you to have a PCP, but it is recommended for everyone.

Prior Authorization

See “preauthorization.”

Provider - Healthcare Words Category P

A term commonly used for healthcare professionals and medical facilities, such as doctors, nurses, hospitals and clinics.


Qualified Health Plan

Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the health insurance marketplace provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each health insurance marketplace in which it is sold. (The health insurance marketplace in Rhode Island is HealthSource RI.)

Qualifying Event

A life event that allows you to make a change to your health plan. For example, getting married would be a qualifying event that would allow you to switch from an individual plan to a family plan, so your new spouse can be covered.


Rate Review

A process that allows state insurance departments to review rate increases before insurance companies can apply them to you.


A written or verbal authorization from your primary care physician (PCP) to receive care from another doctor, specialist, or medical facility. This applies to HMO and point of service (POS) coverage. Examples of common referral services include care from a specialist or tests from a laboratory.

Rehabilitative (Rehabilitation Services)

Healthcare services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical, occupational, and speech therapy services in a variety of inpatient and/or outpatient settings.

Reinsurance Fee

A fee that employer-sponsored group health plans and self-insured plans will be subject to. It will be used to fund the transitional reinsurance program for individual plans. Reinsurance is a reimbursement system that protects insurers from very high claims. It is a way to stabilize an insurance market and make coverage more available and affordable.


The retroactive cancellation of a health insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.


Self-insured Plan

Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.

Small Business Health Options Program (SHOP)

A program that small employers can take advantage of through HealthSource RI. With the SHOP, small employers establish a defined annual premium contribution for their employees, allowing each employee to select the insurer, benefit plan, and premium level of their choice. In 2016, employers with less than 100 employees in 2016 will be considered “small employers” and SHOP-eligible. In 2017, states will have the ability to approve large employers (100+ employees) to buy plans through the SHOP program.


A healthcare professional whose practice is limited to a certain branch of medicine, such as specific procedures, age categories of patients, specific body systems, or certain types of diseases. For example a cardiologist treats heart issues, and a pediatrician treats children.

Specialty Drugs

High-cost drugs that are prescribed to treat chronic or long-term conditions, such as infertility, HIV, cancer, multiple sclerosis, and others. These drugs may require special monitoring by a doctor to reduce health risks and watch for side effects.


The right of your primary insurer to get payment from a third party, such as another insurer, when that third party is legally responsible to pay. For example, if you were in a car accident and it was the other driver’s fault, that person’s auto insurance may be responsible to pay your medical claims related to the accident.

Summary of Benefits and Coverage

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, or renew or change coverage. You can request an SBC from your employer or the health insurance company.



A healthcare program for active duty and retired uniformed services members and their families.


Waiting Period

The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage.

Well-baby and Well-child Visits

Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

Wellness Programs

A program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight-loss programs, and preventive health screenings.