Glossary of Terms

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15th Deadline Rule

Signing up for coverage If you sign up for coverage before or on the 15th of the month, your coverage will start the 1st of the next month. If you sign up after the 15th of the month, your coverage will start the 1st of the following month. Canceling coverage If…
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Affordable Care Act (ACA)

The health care reform law passed in March 2010. The law was passed in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was changed by the Health Care and Education Reconciliation Act on March 30, 2010. The final version of…
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Alien Emergency Medical Program

Alien Emergency Medical is a program for people who are experiencing a qualifying medical emergency and who aren’t eligible for Medicaid due to citizenship status or Social Security number requirements. To qualify, a person must be: a parent with a dependent child an adult with a disability a blind adult…
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Allowed Amount

The highest dollar amount your health insurance plan will pay for covered health care services. This may also be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. Your provider can only charge more than…
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Annual Deductible Combined

The total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay. This usually refers to plans that are eligible for Health Savings Accounts (HSAs).
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Annual Limit

A cap on the benefits your insurance company will pay in a calendar 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…
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Anticipated Eligibility

Using the current information in your Washington Healthplanfinder account, anticipated eligibility is the the coverage you likely qualify for during the next coverage year. This could be a Qualified Health Plan with any cost-sharing reductions and health insurance premium tax credits, or it could be coverage through Washington Apple Health (Medicaid).
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Appeal

A request for your health insurer or plan to review a decision or a grievance.
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Attest/Attestation

When you apply for health coverage through Washington Healthplanfinder, you’re required to agree (or “attest”) to the truth of the information provided by signing the application.
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Authorized Representative (AREP)

Someone you choose to act on your behalf with Washington Healthplanfinder, such as a family member or other trusted person. An Authorized Representative may be any adult who is aware of your circumstances and can act on your behalf to apply for, or maintain your benefits, including your health insurance…
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Balance Billing

A balance billing is 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. An in-network provider may not “balance bill” you for covered services.
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Benefit Year

A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside Washington Healthplanfinder begins January 1 and ends December 31 of the same year. Your coverage ends December 31, even if your coverage started after January 1. Any changes to a…
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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.
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Brand Name (Drug)

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

A broker is a person or business who can help you enroll in a Qualified Health Plan through Washington Healthplanfinder. They can recommend which plan you should enroll in. They are also licensed and regulated by Washington state and typically get payments, or commissions, from health insurers for enrolling a…
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Bronze Health Plan

Plans in Washington Healthplanfinder are available in 4 categories – Bronze, Silver, Gold and Platinum. The category you choose impacts how much of the overall costs of services your insurer pays per year. On average, a Bronze plan pays 60% of the costs, a Silver plan pays 70%, a Gold…
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Care Coordination

The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.
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Carrier

A health insurance plan or organization.
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Catastrophic Health Plan

A catastrophic health plan meets all the requirements of other Qualified Health Plans (QHPs), but does not cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. Catastrophic health plans have lower monthly premiums but higher deductibles, co-payments, and co-insurance. You cannot use a…
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Certified Application Counselor

Similar to a Navigator, a Certified Application Counselor is an individual who is trained to help individuals and families apply for and enroll in coverage through the online application in Washington Healthplanfinder. These Counselors usually work in a hospital or other medical setting. Their role is to help people who…
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Children’s Health Insurance Program (CHIP)

A low-premium insurance program jointly funded by the state and federal government that provides health coverage to low-income children. In Washington State, CHIP is known as Children’s Washington Apple Health.
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Chronic Disease Management

An integrated care approach to managing illness that includes screenings, check-ups, monitoring and coordinating treatment, and patient education. If you have a chronic disease, it can improve your quality of life and reduce your health care costs by preventing or minimizing the effects of that disease.
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Claim

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

Your share of the costs of a covered health service. You start to pay co-insurance after you have paid your health plan’s deductible. Your plan pays the rest. Some health plan’s pharmacy benefits are set up so you pay co-insurance instead of a co-pay until your deductible is met.
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Co-Pay or Co-Payment

A fixed amount that you pay for a covered health care service, such as a regular doctor’s visit or prescription. Co-pays are paid at the time of service and do not apply toward your deductible costs.
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COBRA

A federal law that may allow you to temporarily keep health coverage in some situations: 1) after your employment ends; 2) if you lose coverage as a dependent of the covered employee; or 3) another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the…
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Community Rating

A method of setting premiums so that risk is spread evenly across the community, with all individuals in a community paying the same premium rate regardless of their health status and other factors such as age, gender, and other characteristics. A variation of community rating is adjusted community rating where…
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Complication 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 baby. Maternity and newborn care for women who have complications of pregnancy are now Essential Health Benefits. Morning sickness and non-emergency cesarean sections are not covered as…
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Conditional Eligibility

If you submit an application through Washington Healthplanfinder without necessary documentation, and you are otherwise eligible, you will be determined conditionally eligible. You have 90 days from submission to provide the required documentation.
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Coordination of Benefits

The process used to decide which plan pays first when 2 or more plans cover the same individual and are both responsible to pay for a portion of a claim.
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Cost Sharing

The share of costs for care covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, co-insurance, and co-payments, or similar charges. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. In Washington Apple, cost…
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Deductible

The amount you will spend on your health care before your health plan starts to pay some of your health care costs. You pay most of your health care costs until you reach the deductible amount.
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Dental Annual Maximum

Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay in a certain coverage year. You will pay for any dental care you get after you have met the annual maximum.
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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. Washington Healthplanfinder now offers new dental coverage. Dental plans can cover just adults, adults and children, or children only. Anyone who is eligible and enrolls in a Qualified…
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Dependent

A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction on their federal income tax return. Under the Affordable Care Act (ACA), individuals may be able to claim a premium tax credit to help cover the cost of coverage for…
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Dependent Coverage

Health insurance coverage for family members of the health plan policyholder, such as spouses, children, or partners.
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Drug List

A list of the prescription drugs covered by your health plan. Based on the design of your plan, you may pay a co-pay, co-insurance or the full cost of the drugs until your deductible is met. Also called a formulary.
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Durable Medical Equipment (DME)

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

Earned income includes all income and wages you receive from working or certain disability payments. Learn more about earned income.
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Eligible Immigration Status

An immigration status that is considered eligible for health coverage through Washington Healthplanfinder. The rules for eligible immigration status may differ in different insurance programs.
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Emergency Medical Condition

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

Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families. These plans are offered to people through their (or a spouse’s) former employer or employee organization. Many of these plans are not legally required to meet all provisions of the Affordable Care…
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Employer Shared Responsibility Payment (ESRP)

The Affordable Care Act (ACA) requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to their full-time employees (and their dependents) that meets minimum standards set by the Affordable Care Act, or to make a tax payment called the ESRP.
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Essential Health Benefits

A set of 10 health care services that all plans must cover. Some benefits are free. Some may have co-pays and co-insurance. Doctor visits and hospital stays Trips to the emergency room Care before and after your baby is born Mental health and substance use treatment services Prescription drugs Services…
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Excluded Services

Health care services that your health insurance plan does not pay for or cover.
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External Review

A review of a plan’s decision to deny coverage for, or payment of, a service by an independent third party. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process is not yet…
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Family and Medical Leave Act (FMLA)

A federal law that guarantees up to 12 weeks of job-protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage…
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Federal Poverty Level (FPL)

A measure of income level issued annually by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine your eligibility for certain programs and benefits, including Washington Apple Health (Medicaid), Health Insurance Premium Tax Credits, and cost-sharing reduction subsidies.
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Federally Qualified Health Centers (FQHC)

Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally Qualified Health Centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee, based on your ability to pay.
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Fee (Penalty)

If someone does not have a health insurance plan that qualifies as minimum essential coverage, he or she may have to pay a fee. The fee increases every year: from 1% of income (or $95 per adult, whichever is higher) in 2014 to 2.5% of income (or $695 per adult)…
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Fee For Service (FFS)

A method by which doctors and other health care providers are paid for each service performed. Examples of services include tests, office visits, or procedures. The fee for service method is often compared to the managed care model in which beneficiaries pay a set premium in return for care from…
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Flexible Benefits Plan

A benefit program that offers employees a choice of various benefits including cash, life insurance, health insurance, vacations, retirement plans, and child care. Although a common set of core benefits may be required, you can choose how your remaining benefit dollars are allocated to each type of benefit from the…
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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 co-payments 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…
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Formulary

A list of the prescription drugs your insurance plan will pay for, fully or partially. Depending on your plan, you may pay a co-pay for these drugs.
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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 generic drugs to be as safe and effective as brand-name drugs.
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Gold Health Plan

Plans in Washington Healthplanfinder are available in 4 categories – Bronze, Silver, Gold and Platinum. The category you choose impacts how much of the overall costs of services your insurer pays per year. On average, a Bronze plan pays 60% of the costs, a Silver plan pays 70%, a Gold…
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Grace Periods

Under the Affordable Care Act, there is a 90-day grace period to pay overdue premium payments for individuals who are enrolled in a Qualified Health Plan with tax credits. For individuals who are enrolled in a Qualified Health Plan without tax credits, the grace period to make overdue premium payments…
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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.
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Guaranteed Renewal

A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Guaranteed renewal does not prevent the issuer from raising premium rates at the time of renewal.
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Habilitative/Habilitation Services

Health care 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 therapy Other services for people with disabilities in a variety…
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Hardship Exemption

Under the Affordable Care Act, most people must pay a fee if they don’t have health coverage that qualifies as “minimum essential coverage.” One exception is based on showing that a “hardship” prevented them from becoming insured.
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Head of Household

If you are unmarried, you may file your taxes as a head of household. Please refer to www.irs.gov for more information.
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Health Care Authority (HCA)

The Washington State Health Care Authority is a government agency that oversees the state’s two top health care purchasers: Washington Apple Health (Medicaid) and the Public Employees Benefits Board (PEBB) Program, as well as other programs. For more information visit: hca.wa.gov or call 1-800-562-3022 for questions about Washington Apple Health.
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Health Insurance

A contract between an individual and a health insurance company or provider that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
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Health Insurance Marketplace (Washington Healthplanfinder)

A resource where individuals, families, and small businesses can: Learn about their health insurance plan options Compare plans based on costs, benefits, and other important features Choose a plan Enroll in coverage Washington Healthplanfinder also provides information on programs that help people with low-to-moderate incomes and resources pay for coverage.
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Health Insurance Premium Tax Credit (HIPTC)

Health insurance premium tax credits (also known as tax credits, premium tax credits, or advance premium tax credits) help lower the cost of your monthly health plan premium. The Affordable Care Act provides tax credits to help you afford coverage purchased through Washington Healthplanfinder. The amount of tax credits you’re…
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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 will not cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area in order to be…
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Health Plan Categories

Plans in Washington Healthplanfinder are available in 4 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…
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Health Reimbursement Arrangements (HRA)

Health Reimbursement Arrangements (HRAs) are employer-funded group health plans that reimburse employees 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.
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Health Savings Account

A type of medical savings account that allows consumers to save for medical expenses on a tax-free basis. To qualify, applicants must enroll in a high deductible health plan. A high deductible plan usually means higher out-of-pocket expenses, but a lower premium. The funds contributed to the account are not…
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High Deductible Health Plan

A plan that features higher deductibles than traditional insurance plans. You can combine a high deductible health plan with a health savings account or a health reimbursement account to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
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HIPAA Eligible Individual

This is your status once you have had 18 months of continuous creditable health coverage. To be HIPAA eligible, at least the last day of your creditable coverage must have been under an employer health plan. You also must: Have used up any COBRA or state continuation coverage Not be…
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Home and Community-Based Services

Services and support provided by most state Medicaid programs in your home or community that help with such daily tasks as bathing or dressing. This care is covered when provided by care workers or, if your state permits, by your family.
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Hospice Services

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

A situation where you were discharged from the hospital and then go 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…
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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.
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Household

A household includes: Yourself Your spouse, if you’re married Any children you are caring for who live with you Anyone else you include on your federal income tax return (even if they don’t live with you) Make sure to add all your household members, even if they aren’t seeking coverage.
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In-network Co-insurance

The percent of the doctor, clinic or other provider’s bill for covered services that you must pay when the provider is in your plan’s network, for example 20% of the bill amount. In-network co-insurance usually costs less than out-of-network co-insurance.
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In-network Co-payment

A fixed amount (for example, $15) you pay at each visit for covered health care services, from providers who contract with your health plan. Most plans will cover some cost from out-of-network providers. This coverage will be at a lower level than in-network.
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In-Network Provider

A doctor that is on a health plan’s approved list of health care providers. The health plan will cover approved services provided by this doctor.
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Individual Health Insurance Policy

Policies for people who are not connected to job-based coverage. Individual health insurance policies are regulated under state law.
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Individual Mandate

Under the Affordable Care Act, most people must purchase health insurance or pay a tax penalty. This is called the “individual mandate” or “individual responsibility”. However, the Affordable Care Act exempts several groups from the individual mandate, meaning that they do not have to get health coverage.
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Inpatient Care

Health care that you get when you are admitted as an inpatient to a health care facility, such as a hospital or skilled nursing facility.
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Insurance Co-op

A nonprofit entity in which the same people who own the company are insured by the company. Insurance cooperatives (co-ops) can be formed at a national, state, or local level. They can include doctors, hospitals, and businesses as member-owners.
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Lawful Permanent Resident or Legal Permanent Resident (LPR)

This is the status given to lawful residents with intent to reside. Legal permanent residents must meet 5-year requirements to be Medicaid eligible even if they are income eligible. LPRs are eligible for tax credits if they file taxes and enroll in a Qualified Health Plan.
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Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance company. The Affordable Care Act prohibits lifetime limits in any health plan or insurance policy.
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Long-term Care

Services that include medical and non-medical care for people who are unable to perform basic activities of daily living, such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living centers, or in nursing homes. Individuals may need long-term supports and…
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Medicaid

A state-administered health insurance program for low-income individuals and families, pregnant women, the elderly, and people with disabilities. 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 by state…
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Medical Loss Ratio (MLR)

A basic financial measurement used in the Affordable Care Act (ACA) 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…
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Medically Necessary

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

A federal health insurance program for people aged 65 or older and certain younger people with disabilities. Medicare also covers people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Individuals apply for Medicare through the Social Security Administration and not through Washington Healthplanfinder.
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Medicare Advantage (Medicare Part C)

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all of your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account…
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Medicare Part D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: 1) through a Medicare Prescription Drug Plan or 2) through a Medicare Advantage Plan that includes drug coverage.
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Metal Levels

Health plans through Washington Healthplanfinder come in four categories, called metal levels. They’re available in Bronze, Silver, Gold, and Platinum. The difference between the plans is what percentage of the cost of care they cover (for example, Bronze plans cover 60% of the costs, where Gold covers 80%).
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Minimum Essential Coverage

The type of coverage an individual must have to meet the individual responsibility requirement under the Affordable Care Act (ACA). This includes individual market policies, job-based coverage, Medicare, Washington Apple Health, TRICARE, and certain other coverage.
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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.
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Modified Adjusted Gross Income (MAGI)

The figure used to determine eligibility for lower costs in Washington Healthplanfinder and for Washington Apple Health. Generally, this MAGI figure is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. Washington Healthplanfinder calculates your modified adjusted gross income when you enter your application.
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Multi-State Plan

A multi-state plan is health insurance that covers you when you travel to different states. Coverage areas may vary according to your plan.
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Navigator (In-Person Assister)

An individual who is trained and able to help consumers look for health coverage options through Washington Healthplanfinder. They can help you complete eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
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Network

The facilities, providers, and suppliers with whom your health insurer or plan has contracted to provide health care services.
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Network Plan

A health plan that contracts with doctors, hospitals, pharmacies, and other health care providers to provide plan members with services and supplies at a discounted price.
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Non-Discrimination

A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also cannot be charged more because of your health status. Job-based plans can restrict coverage based on other factors, such as part-time employment, that are not related…
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Non-Formulary Prescription Drugs

A formulary is a list of preferred medications that a committee of pharmacists and doctors deems to be the safest, most effective and most economical. Drugs that are non-formulary are not on the health plan’s list.
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Open Enrollment Period

The period of time each year when eligible individuals can enroll in a Qualified Health Plan through Washington Healthplanfinder. Individuals may also qualify for special enrollment periods outside of open enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event.) You can apply for Washington…
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Out-of-Network Co-Insurance

The percent of the doctor, clinic or other provider’s bill for covered services that you must pay when the provider is not in your plan’s network, for example 40% of the bill amount. Out-of-network co-insurance usually costs more than in-network co-insurance.
Term

Out-of-Network Co-Payment

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

Out-of-Network Provider

A doctor that is not on the selected health plan’s approved list of health care providers. The health plan may not cover services provided by this doctor, and you may be required to pay for services out of pocket, at a higher charge than in-network services.
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Out-of-Pocket Costs

Your expenses for medical care that are not reimbursed or covered by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services, plus all costs for services that are not covered by your plan.  …
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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.
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Out-of-Pocket Maximum/Limit

The maximum amount you will pay in 1 calendar year for health services, not including premium payments or out-of-network costs. This limit must include deductibles, co-insurance, co-payments, or similar charges. It must include any other expenditure required of an individual that is a qualified medical expense for the essential health…
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Payment Bundling

A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each treatment, test, or procedure. This rewards providers for coordinating care, preventing complications and errors,…
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Plan

Plans in Washington Healthplanfinder are available in 4 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…
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Plan Year

A 12-month period of benefits coverage under an employer health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies, this 12-month period…
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Platinum Health Plan

Plans in Washington Healthplanfinder are available in 4 categories – Bronze, Silver, Gold and Platinum. The category you choose impacts how much of the overall costs of services your insurer pays per year. On average, a Bronze plan pays 60% of the costs, a Silver plan pays 70%, a Gold…
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Point of Service (POS) Plans

In these plans, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
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Policy Year

A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer. (Note: In employer health plans, this 12-month period…
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Pre-Existing Condition

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

A decision by your health insurance plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization…
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Preferred Provider

An in-network provider who has a contract with your health insurance plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers. Some health insurance or plans have “tiered” networks, and you must pay extra to see some providers. Your…
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Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
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Pregnancy Medical (Program)

Pregnant women are eligible for Pregnancy Medical (or Pregnancy Medicaid) if they meet certain income guidelines. Undocumented pregnant women qualify regardless of legal status. All medical care, including prenatal care, delivery and post-pregnancy follow up are included. Coverage lasts for 2 months after the birth of the child.
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Premium

The cost of your health insurance plan per month. You must pay this amount even when you do not get any medical care. Health plan premiums for individual and family customers must be paid directly to the insurance company.
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Premium Tax Credit

A premium tax credit reduces premium costs. Tax credits can be used when you make your premium payment. This help is also known as a health insurance premium tax credit (HIPTC) or advanced premium tax credit (APTC). The Affordable Care Act provides a new tax credit to help you afford…
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Prescription Drugs

Drugs and medications that, by law, require a prescription from a doctor.
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Prevention

Activities to prevent illness, such as routine check-ups, immunizations, patient counseling, and screenings.
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Preventive Services

Health care services, such as yearly health exams and flu shots, that are paid for by your health insurance plan at little or no cost to you. Some plans require the use of in-network providers for no-cost preventive services.
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Primary Applicant

An individual who creates an account on Washington Healthplanfinder and initiates one of three application types: 1) for myself; 2) for myself and others (household members); or 3) for other household members (but not myself).
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Primary Care

Health services that cover a range of prevention, wellness, and treatment services for common illnesses.
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Primary Care Provider (PCP)

The main doctor or nurse whom you choose to visit as part of your health plan. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you, give advice, and treat you on a range of health-related issues. They may also coordinate your…
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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. It is important to ask if prior authorization is required before you have a service or fill a prescription.
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Qualified Health Plan (QHP)

Under the Affordable Care Act, a Qualified Health Plan is an insurance plan that has been certified by Washington Healthplanfinder to offer quality insurance. It must provide essential health benefits, follow established limits on cost-sharing (such as deductibles, co-payments, and out-of-pocket maximum amounts), and meet other requirements.
Term

Qualifying Life Event

A change in your life that can make you eligible for a special enrollment period to enroll in health coverage outside a regular open enrollment period. Examples of qualifying life events are: moving to a new state; certain changes in your income; and changes in your family size (for…
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Referral

A written order from your primary care provider (PCP) for you to see a specialist or get certain medical services. If you do not get a referral first, your health insurance plan may not pay for the services.
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Rehabilitative/Rehabilitation Services

Health care 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 and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or…
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Secondary Insurance

Secondary insurance applies to people who have two insurance plans. One plan is the primary and the other is secondary. A secondary insurance payer only pays if there are costs the primary insurer did not cover. The secondary insurance payer may not pay all of the uncovered costs. Medicare is…
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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 is also generally the area where you can get routine (non-emergency) services. You may lose coverage if you move…
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Silver Health Plan

Plans in Washington Healthplanfinder are available in 4 categories – Bronze, Silver, Gold and Platinum. The category you choose impacts how much of the overall costs of services your insurer pays per year. On average, a Bronze plan pays 60% of the costs, a Silver plan pays 70%, a Gold…
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Skilled Nursing Care

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

A time outside of the open enrollment period when you and your family have a right to sign up for health coverage. In Washington Healthplanfinder, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage…
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Special Health Care Needs

The health care and related needs of children who have chronic physical, developmental, behavioral, or emotional conditions. These needs exceed the type or amount generally required by children.
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Specialist

A physician specialist is a doctor who focuses on a specific area of medicine or group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider, but not a doctor, who has additional training in a specific area of health…
Term

Specialist Referral Required

Some health plans ask you to get a referral from your primary care doctor before seeing a specialist in order for the plan to consider them qualified medical expenses. If you do not get a referral for these services, the plan will not cover them under the deductible, co-pay, and/or coinsurance.
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Subsidized Coverage

Health coverage that can be obtained through financial assistance programs to help people with low- and middle-incomes.
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Summary of Benefits and Coverage (SBC)

An easy-to-read summary that lets you compare the costs and coverage of health plans. You can compare plans based on price, benefits, and other features that may be important to you. You will get a Summary of Benefits and Coverage (SBC) when you shop for coverage on your own or…
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Tax Household

The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents.
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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 is sometimes used to determine the allowed amount.
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Unearned Income

Unearned income is all income that is not earned from work and comes from another source, such as dividends on an investment.
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Urgent Care

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

Vision coverage is a health benefit that at least partially covers vision care such as eye exams and glasses. All Qualified Health Plans (QHPs) sold on Washington Healthplanfinder include pediatric vision coverage. QHPs do not have to include adult vision coverage. If adult vision coverage is important to you, check…
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Washington Apple Health

See also Medicaid. A public health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and low-income 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…
Term

Washington Health Benefit Exchange

The Washington Health Benefit Exchange is a public-private partnership with the mission to redefine people’s experience with health care. The Exchange is responsible for Washington Healthplanfinder – an easily accessible, online marketplace for individuals, families, and small businesses to compare and enroll in coverage. The Exchange works in close coordination with…
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Washington Healthplanfinder

Washington Healthplanfinder is an online marketplace for individuals, families, and small businesses to find, compare, and enroll in Qualified Health and Dental Plans, as well as enroll in Washington Apple Health (Medicaid). Washington Healthplanfinder offers: Side-by-side comparisons of plans Tax credits or financial help to pay for co-pays and premiums…
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Well-Baby and Well-Child Visits

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