Individuals & Families Glossary

Glossary of Terms

Learn the Language of Healthcare

Click on a letter below to begin searching for terms.

Affordable Coverage

Employer coverage is considered affordable – as it relates to the premium tax credit – if the employee’s share of the annual premium for the lowest priced self-only plan is no greater than 9.56% of annual household income. People offered employer-sponsored coverage that’s affordable and provides minimum value aren’t eligible for a premium tax credit.


Appeal

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


Annual limit

Many health insurance plans place dollar limits on the claims the insurer will pay over the course of a plan year. PPACA prohibits annual limits for essential benefits for plan years beginning after Sept. 23, 2010.


Allowed Amount

Maximum amount on which payment is based for covered healthcare services. This may be called an “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Brand Name Drugs

A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.


Blue Cross Blue Shield

A local health insurance company offering coverage through HealthSource RI.


Benefits

The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.


Benefit Year

A year of benefits coverage under an individual health insurance plan. The benefit year for individual and family plans bought inside or outside HealthSource RI begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year. The timeline for employer insurance can follow a different schedule, depending on when the business originally bought its health coverage.


Blue Cross Dental

A local health insurance company offering dental coverage through HealthSource RI.


Balance Billing

Refers to instances when a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

COBRA

A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee. You may also choose to enroll as an individual on HealthSource RI and may qualify for assistance.


Claim

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.


Complications of Pregnancy

Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.


Co-Insurance

Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.


Co-Payment

A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered health care service.

Drug List/Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.


Domestic Partnership

Two people who live together and share a domestic life, but aren’t married or joined by a civil union. In some states, domestic partners are guaranteed some legal rights, like hospital visitation.


Dependent Coverage

Insurance coverage for family members of the policyholder, such as spouses, children, or partners.


Dental Coverage

Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a “stand-alone” dental plan.


Delta Dental

A dental insurance provider offering coverage through HealthSource RI.


Durable Medical Equipment (DME)

Equipment and supplies ordered by a healthcare provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.


Deductible

The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 for covered services. Some plans pay for certain health care services before you’ve met your deductible.

Executive Office of Health and Human Services

Under state law, the Executive Office of Health and Human Services (EOHHS) serves as “the principal agency of the executive branch of state government” responsible for managing the departments of: Health (DOH); Human Services (DHS); Children, Youth and Families (DCYF); and Behavioral Healthcare, Developmental Disabilities and Hospitals (DBDDH).

The EOHHS is designated by state law as the Medicaid single state agency and, in this capacity, administers the State’s major publicly funded healthcare program. RI Medicaid, as the program is known, provides health coverage to low income uninsured adults, children, and elders and persons with disabilities and special needs that otherwise might not be able to afford or obtain the services and support they need to lead healthy, safe and independent lives.

Visit www.eohhs.ri.gov for more info.


Exclusive Provider Organization (EPO) Plan

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).


Essential Health Benefits

The Affordable Care Act requires that health plans on HealthSource RI 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.


Excluded Services

Healthcare services that your health insurance or plan doesn’t pay for or cover.


Emergency Services

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


Emergency Room Care

Emergency services you get in an emergency room.


Emergency Medical Transportation

Ambulance services for an emergency medical condition.


Emergency Medical Condition

An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Formulary/Drug list

A list of prescription drugs that a health plan covers that is organized into price tiers or categories.

Generic Drugs

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.


Guardian

Dental insurance provider


Grievance

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

Hybrid family deductible method

All deductibles paid count toward the family deductible amount, but, an individual will never pay more than their individual deductible.


High Deductible Health Plan (HDHP)

A plan that features higher deductibles than traditional insurance plans. High deductible health 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.


Health Savings Account (HSA)

A Health Savings Account-qualified plan allows customers to contribute to a separate tax-exempt account which can be used for qualified health care expenses. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses, such as deductibles and copayments. Unlike a Flexible Spending Account (FSA), funds roll over year-to-year if you don’t spend them.


Health Plan Metal Levels/Categories

Plans through HealthSource RI are primarily separated into 3 health plan categories — Bronze, Silver, and Gold,— 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’re likely to spend on your health benefits during the year. The percentages the plan will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This is not the same as co-insurance, in which you pay a specific percentage of the cost of a specific service.


Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.


Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.


Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.


Home Health Care

Healthcare services a person receives at home.


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.


Health Insurance

A contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium.


Habilitation Services

Healthcare services that help a person develop 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.

Inpatient Care

Health care that you get when you’re admitted as an inpatient to a health care facility, such as a hospital or skilled nursing facility.


In-Network Services

Services that are provided by doctors, hospitals, and other healthcare providers who have a contract with an insurer. These services are provided at negotiated rates that are typically less than what an individual would pay on their own.


In-Network Co-Payment

A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network co-payments are usually less than out-of-network co-payments.


In-Network Co-Insurance

The percent (for example, 20%) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

Minimum value

A health plan meets this standard if it is designed to pay at least 60% of the total cost of medical services for a standard population, and if its benefits include substantial coverage of inpatient hospital and physician services. Individuals offered job-based coverage that provides minimum value and is considered affordable aren’t eligible for a premium tax credit.


Minimum Essential Coverage (MEC)

The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.


Medically Necessary

Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms—and that meet accepted standards of medicine.


Medicaid/Medical Assistance

A joint federal-state health insurance program that is run at the state level and covers certain low-income children and adults and individuals with disabilities.


Maximum Out-of-Pocket Payments

The money you spend each year on your medical care (excluding your monthly premium) cannot exceed your health insurance plan’s maximum out-of-pocket cost. Once you reach your maximum, you are protected from additional costs like co-payments and co-insurance.


Managed Care

An organized way to manage the costs, use, and quality of the healthcare system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).


MAGI – Modified Adjusted Gross Income.

The figure used to determine whether you’re eligible for premium tax credits and other savings for HealthSource RI health insurance plans and for Medicaid.

MAGI is your adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.

For many people, MAGI is identical or very close to their adjusted gross income. MAGI doesn’t include Supplemental Security Income (SSI). MAGI does not appear as a line on your tax return.

Neighborhood Health Plan

A health insurance company offering coverage through HealthSource RI.


Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network that requires you to pay extra to see some providers.


Network

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

Out-of-Pocket Maximum/ Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or healthcare your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments, or other expenses toward this limit.


Out-of-Pocket Estimate

An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.


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.


Open Enrollment Period

A designated period of time during which customers can sign up for or renew their health insurance. For individuals and families, the open enrollment period happens once a year. For employer insurance, the open enrollment period happens before the renewal date or coverage start date. Eligible employees may choose plans, or make changes to their enrollment (for renewing employees). Changes include: Enrolling in new coverage, changing plans, changing plan coverage (enrolling or disenrolling dependents), enrolling in a dental plan and other changes.


Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or healthcare your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments, or other expenses toward this limit.


Out-of-Network Co-Payment

A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.


Out-of-Network Co-Insurance

The percent (for example, 40%) you pay of the allowed amount for covered healthcare services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Prior Authorization

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.


Primary Care Provider (PCP)

A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of healthcare services.


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.


Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Preventative services are offered at no cost to you.


Provider

A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), healthcare professional, or healthcare facility licensed, certified, or accredited as required by state law.


Primary Care Provider

A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of healthcare services.


Primary Care Physician

A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.


Prescription Drugs

Drugs and medications that legally require a prescription.


Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.


Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.


Preferred Provider Organization (PPO)

A network of healthcare providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Healthcare decisions generally remain with the patient as he or she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.


Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network that requires you to pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.


Pre-authorization

A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Pre-authorization isn’t a guarantee that your health insurance or plan will cover the cost.


Plan

A benefit your employer, union, or other group sponsor provides to you to pay for your healthcare services.


Physician Services

Healthcare services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Qualified Health Plan

Under the Affordable Care Act, an insurance plan that is certified by HealthSource RI provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.

Rhode Island Department of Human Services

The Department of Human Services offers a wide range of programs, services, and benefits to Rhode Islanders. Economic Supports include the Supplemental Nutrition Assistance Program (SNAP); Medicaid eligibility; RIWorks; the Child-Care Assistance Program (CCAP); Long-Term Care; the Low Income Home Energy Assistance Program (LIHEAP) and Weatherization Assistance Program (WAP); General Public Assistance; and Federal Community and Social Services Block Grants. The Office of Child Support Services establishes paternity, locates parents, and creates, changes, and enforces child support orders. The Office of Rehabilitation Services manages vocational rehabilitation, disability determination, and services for the blind and visually impaired.

Visit www.dhs.ri.gov for more info.


Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.


Rehabilitation Services

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


Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.

Summary of Benefits and Coverage (SBC)

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, renew or change coverage, or request an SBC from the health insurance company.


Stand-alone Dental Plan

A type of dental plan offered through HealthSource RI that’s not included as part of a health plan. You may want this if the health coverage you choose doesn’t include dental, or if you want different dental coverage.


Special Enrollment Period

A designated period of time during which Rhode Islanders can enroll in coverage outside of open enrollment. Individuals and families qualify for a special enrollment period if they’ve experienced a life changing event that affects their access to health insurance. For employer coverage, eligible employees and eligible household members may be added for coverage based on a qualifying event. Employers determine whether employees (or their dependents) qualify for a special enrollment period.


Service Area

A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan’s service area.


Specialist

A physician specialist who focuses on a specific area of medicine or a specific group of patients in order to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of healthcare.


Skilled Nursing Care

Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Total Cost Estimate (for health coverage)

The total amount you may have to pay for health plan coverage, which is estimated before you actually have the coverage and have health expenses under the coverage.


Tiered Network

An innovative or tiered network divides hospitals and doctors into groups, based on information about the quality of their care and the value of their prices. What you pay is based on the tier of the provider that you see. Patients pay less to go to providers in high-performing groups and pay more to see doctors with lower quality or value scores.


Third-Party Payer

Any payer of healthcare services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.

UCR (Usual, Customary, and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.


United Healthcare

A health insurance company that offers Medicaid coverage.


Urgent Care

Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Vision or Vision Coverage

Vision coverage is a health benefit that at least partially covers vision care, like eye exams and glasses. All Qualified Health Plans (QHPs) sold on HealthSource RI include pediatric vision coverage. QHPs don’t have to include adult vision coverage, however. If adult vision coverage is important to you, check the details of any plan you’re considering to see if it’s included.

If your QHP doesn’t include adult vision coverage, you can buy a “stand-alone” vision plan. Stand-alone vision plans aren’t offered through the Marketplace, and tax credits can’t be applied to them. Learn about available stand-alone vision plans by contacting your state’s Department of Insurance, or a local agent or broker.

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 preventative health screenings.

HealthSource RI connects you with health and dental insurance from these companies:

Individuals & Families: 1-855-840-4774
Employers & Employees: 1-855-683-6757