Glossary

Terms you should know

Health care is full of industry-speak. Without knowing the basics, it’s hard to understand how things work. Here are some key terms you should know as you navigate the world of health care.

Affordable Care Act (ACA)

The comprehensive federal health care reform law enacted in March 2010. Also known as “Obamacare” or “Health Care Reform.”

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Coinsurance

A percentage of the charges that you must pay for covered services. For example, a 20% coinsurance for a $200 procedure means you pay $40.

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Copay (Copayment)

A specific dollar amount you pay for covered services — for example, a $10 copay for an office visit.

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Cost share

The portion of charges for a service or prescription that you’re responsible for paying, such as a copay, coinsurance, or deductible payment.

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Deductible

The amount you pay for covered services each year before the health plan issuer starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.

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Dependent

A spouse, child, or domestic partner who’s is covered under a policyholder or subscriber’s plan, depending on applicable law and the plan terms and conditions.

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Essential health benefits

Each state or jurisdiction defines its own specific essential health benefits, but they must include items and services from 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
  • Pediatric services, up to age 19, including oral and vision care

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Grandfathered plan

A health plan you were enrolled in when the Affordable Care Act (ACA) became law on March 23, 2010. The health plan must have been in existence on or before that date and meet certain requirements. Grandfathered plans are exempt from many of the changes required under the ACA.

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Health care

The prevention, treatment, and management of diseases and injuries, as well as the preservation of mental and physical health, through services offered by trained and licensed professionals (like doctors, psychologists and dentists).

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Health Care Reform

A general term for the major health policy changes put in place by the federal Affordable Care Act and any state laws passed to put it in place.

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Health care coverage (also referred to as “insurance” or “plan”)

A contract that requires your health care coverage issuer to pay some or all of your health care costs in exchange for a premium you pay.

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Health insurance marketplaces (also known as exchanges)

Federally and state-run and regulated markets where you can shop, compare, and buy health care coverage. Link directly to your state’s marketplace here.

State or jurisdiction URL
California coveredca.com
Colorado connectforhealthco.com
District of Columbia dchealthlink.com
Georgia healthcare.gov
Hawaii healthcare.gov
Maryland marylandhealthconnection.gov
Oregon healthcare.gov
Virginia healthcare.gov
Washington state wahealthplanfinder.org

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Large employer

The definition of a “large employer” is an employer with 51 (101 or more in California and Colorado) or more full-time-equivalent employees.

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Marketplaces

A common nickname for the health insurance marketplaces that are available in participating states or jurisdictions, also called “exchanges”.

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Metal plans

These are ACA compliant plans (which include essential health benefits) in the health insurance marketplaces, presented in 4 “metal” levels: Bronze, Silver, Gold, and Platinum. The metal plans are not based on the quality of care but how you and your plan split the costs of your health care.

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Open enrollment period

A period of time each year when you can purchase or change health care coverage.

Check with your marketplace for open enrollment dates.

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Out-of-pocket costs

Any amounts you pay for covered services, not including your monthly premiums.

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Plan out-of-pocket maximum

The total amount of cost sharing you’ll pay for certain covered services in a plan year or policy year. Please refer to your Evidence of Coverage or Combined Membership Agreement, Disclosure Form, and Evidence of Coverage for your plan out-of-pocket maximum amount and to learn which services apply to your plan’s out-of-pocket maximum.

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Pre-existing condition

A medical condition that a person has before being enrolled in a health plan.

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Premium

Periodic membership charges paid by or on behalf of each member in exchange for the provision or arrangement of all medically necessary covered Services. Premiums are in addition to any cost share.

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Preventive services

Covered services that prevent or detect illness and do 1 or more of the following:

  • Protect against disease and disability or further progression of a disease
  • Find disease in its earliest stages before noticeable symptoms develop

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Provider

A physician, health care professional, or health care facility that’s licensed, certified, or accredited as required by state law to provide health care services and supplies.

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Small employer

An employer is considered a “small employer” eligible to purchase coverage in the Small Business Health Options Program (SHOP) or, in the state of California, Covered California for Small Business if the small business employer has 1 to 50 (1 to 100 in California and Colorado) full-time-equivalent employees.

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Special enrollment period

A period of time outside of the annual open enrollment when you can enroll or change health care coverage. To be eligible for special enrollment, you must have experienced a situation known as a “triggering event (qualifying life event),” which is defined by ACA regulations. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you’ll still have a special enrollment period and your coverage effective date may differ from open enrollment effective dates. Certain special enrollments will require prior coverage and/or payment of past due premiums.

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Summary of Benefits and Coverage (SBC)

A plain-language summary of your benefits and coverage. In compliance with the Affordable Care Act (ACA), every issuer must supply this document and a uniform glossary of common health terms to members and prospective members during open enrollment or upon request.

The SBC provides a brief summary of information like:

  • Cost sharing for some common medical services such as office visits or lab tests
  • Deductibles and out-of-pocket limits
  • Services not covered by the plan

Kaiser Permanente members, you can request copies or more information from your region:

California

Call our Member Service Contact Center:

  • 1-800-464-4000 English
  • TTY users, call 711

Colorado

Call Member Services:

  • 303-338-3800 Denver metro area
  • 1-844-837-6884 Mountain Colorado
  • 1-844-201-5824 Northern Colorado
  • 1-888-681-7878 Southern Colorado
  • TTY users, call 711

Georgia

Call Member Services:

  • 404-261-2590 Atlanta metro area
  • 1-888-865-5813 other areas
  • TTY users, call 1-800-255-0056

Hawaii

Call our Customer Service Center:

  • 808-432-5955 (Oahu)
  • 1-800-966-5955 (Neighbor Islands)
  • TTY users, call 1-877-447-5990

Maryland, Virginia, District of Columbia

Call Member Services:

  • 301-468-6000 D.C. metro area
  • 1-800-777-7902 other areas
  • TTY users, call 301-879-6380

Oregon and Washington

Call Membership Services:

  • 503-813-2000 Portland area
  • 1-800-813-2000 other areas
  • TTY users in Oregon, call 1-800-735-2900
  • TTY users in Washington, call 1-800-833-6388

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