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Common Insurance Terms Defined

ACA Marketplace: The Affordable Care Act Health Insurance Marketplace, helps people without health coverage find and enroll in an insurance plan that fits your budget and meets your needs.

Balanced Billing - when a healthcare provider bills you for the difference between what your health insurance pays and what your provider charges.

Children's Health Insurance Program (CHIP) provides health coverage to children in families with incomes too high to qualify for Medicaid but can't afford private coverage. (877) KIDS-NOW / (877) 543-7669

COBRA: Allows an eligible employee who leaves a company to continue to be covered under the company’s health plan for a limited period of time for a higher premium.

Coinsurance: Amount you may still need to pay after meeting your deductible. Coinsurance is most often a percent (for example 20%).

Copayment (copay): Amount you may have to pay for healthcare or medications. A copay is often a fixed amount (for example $25).

Deductible: Amount you must pay for healthcare or medications before your insurance will pay.

Employer group health plan (EGHP): Coverage sponsored by an employer or union. If you either you, your spouse, or your parent (for children up to age 26) are working you may be eligible for insurance through your (their) employer. Employers with 50 full-time employees or more must offer insurance to their employees.

In-Network: Healthcare providers, practices, hospitals, etc. that are covered by your insurance plan. Choosing in-network providers is cheaper than out-of-network providers. To find a list of in-network providers contact your health insurance plan.

Indian Health Service is a Federal Health Program for American Indians and Alaska Natives.

Managed Care Plans – Some states are offering pilot programs enrolling people who are eligible for both Medicare and Medicaid.

Medicare Advantage – is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. People with ESRD are not eligible to apply for these plans, but some may already be enrolled in a Medicare Advantage plan before starting dialysis or needing a transplant.

Medicaid helps pay medical costs for people with low income and little savings. Medicaid can pay your Medicare premiums, deductibles, coinsurance and some costs Medicare doesn't cover

Medigap Plans – supplemental plans for Medicare recipients that helps cover what traditional Medicare does not, such as copayments, coinsurance, and deductibles. This includes the 20% not covered by Medicare Part B for outpatient services (i.e. dialysis) and immunosuppressant medication for transplant recipients. You can sign up for a Medigap plan in the six-month period after you enroll in Medicare.

Out of Network: Healthcare providers, practices, hospitals, etc. that are not as well covered by your insurance plan. It is cheaper to choose in-network providers instead of out-of-network providers. To find a list of in-network providers contact your health insurance plan.

Out of pocket maximum: The most you’ll have to pay during a period (usually a year). Once you reach the out of pocket maximum your plan pay 100% of covered services.

Premium: Amount to be paid monthly or quarterly to keep the health insurance plan active.

SHIP: State Health Insurance Assistance Program. Free help for people with Medicare coverage.

TRICARE serves Uniformed Service members, retirees and their families worldwide.

U.S. Department of Veterans Affairs (VA) Benefits: Apply for compensation, pension, education or vocational rehabilitation benefits on-line if you are a veteran. The VA can help pay for treatment or provide other benefits for veterans. Veterans should contact their local VA office for more information or call 1-800-827-1000 to reach the national office. The number for health care benefits at the VA is 1-877-222-8387. People who are retired from the military may also call the U.S. Department of Defense at 1-800-538-9552.

Last Reviewed: 11/01/2016
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