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Insurance Definitions


An event that is sudden, unexpected, and unintended, and over which the insured person has no control.

Affordable Care Act Compliant

Affordable Care Act compliant means all plans include:

  • Essential Health Benefits (see definition of Essential Health Benefits)
  • No Annual Dollar Limits on Essential Health Benefits
  • Unlimited plan maximum
  • No Pre-existing Condition Exclusions
  • Dependent Coverage to Age 26
  • Limits on Cost-Sharing

*The exception to this is the Grandfathered plans.


Licensed salespersons who represent one or more health insurance companies and present their products to consumers.

Allowed amount

Maximum amount on which payment is based for covered health care services. This may be called eligible expense or negotiated rate.


If a physician wants to perform a surgery, order a medical supply, or refer the patient to a specialist an authorization and approval by the health plan is required.


Licensed insurance salesperson who obtains quotes and plan information from multiple sources for clients.


The insurance company offering a health plan.

Certificate of insurance

The certificate of insurance is a printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. It discloses what is covered, what is not, and dollar limits.


A request for payment by a provider for a given service or item.


In health insurance, coinsurance is sometimes used synonymously with copayment, but is defined differently – a copay is typically fixed while the coinsurance is a percentage that the insurer pays after the insurance policy’s deductible is met.


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

Contracted provider

A medical provider that has an agreement with a health plan to accept their patient at a previously agreed upon rate for payment.

Covered expense

A medical procedure or item that is deemed payable by the insurance plan.


A set dollar amount which must be satisfied within a specific time frame before the health plan begins making payments on claims

Essential Health Benefits

Essential Health Benefits are treatments and services required by ACA to be covered under most insurance plans. Additionally, specific Preventive/Wellness services must be covered in-network at 100%. These benefits are outlined in your plan brochure. Please visit U.S. Department of Health & Human Services – Healthcare for additional information.

These core services include the following categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health/behavioral health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care


Those items or medical services that are not covered by the health plan.

Explanation of benefits

A summary of the payment made by your health plan to the medical provider.

Grandfathered Plans

Grandfathered plans are plans that were purchased before March 23, 2010. These plans have a grandfathered status and don’t have to follow the same rules and regulations or offer the same benefits, rights and protections as new plans. This means that on many old plans you can still be dropped from coverage for reasons other than fraud, be denied treatment for preexisting conditions, face annual and lifetime dollar limits and more. 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). If a plan loses grandfathered status participants may have to upgrade to a new plan that meets the requirements of the Affordable Care Act.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care.


Health Maintenance Organization. These plans generally provide the highest level of coverage, meaning the lowest out of pocket for you, but a higher premium. HMOs use doctors, hospitals and specialists that are in the network. If you seek care outside the network, your care may not be covered at all.


A facility which provides diagnosis, treatment, and care of a person who needs acute inpatient hospital care under the supervision of doctors.


Refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

Individual health insurance

Health insurance coverage on an individual, not group, basis. Individual health insurance policies are regulated under state law.


Bodily injury due to a sudden, unforeseeable, external event which is solely, directly, and independent of disease, bodily infirmity, or any other causes.

Insured person

An eligible student or eligible dependent who has been accepted for coverage and who has paid the required premium.

Involuntary loss of coverage

Prior coverage has been involuntarily terminated due to no fault of the insured person, which includes coverage that terminates due to a loss of employment by the student or the student’s spouse or parent.

Managed care

A method by which cost containment features are applied to a health plan whether by limiting the reimbursement levels paid to providers or by reducing utilization.

Maximum Benefit

The Affordable Care Act states-no annual dollar limits are allowed on most covered benefits beginning January 1, 2014.

Some Important Details

  • Be aware that plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered “essential.”
  • If the new rules apply to your plan, they will affect you as soon as you begin a new plan year or policy year on or after September 23, 2010. (For example, if your policy has a calendar plan year, the new rules would apply to your coverage beginning January 1, 2011).
  • If you have a “grandfathered” individual health insurance policy, your health plan is not required to follow the new rules on annual limits. (A grandfathered individual health insurance policy is a plan that you bought for yourself or your family; that you did not receive through your employer; and that was issued on or before March 23, 2010.) If you’re not sure whether your plan is grandfathered, ask your insurance company.
  • The ban on lifetime dollar limits for most covered benefits applies to every health plan — whether you buy coverage for yourself or your family, or you receive coverage through your employer.
  • Some plans may be eligible for a waiver from the rules concerning annual dollar limits, if complying with the limit would mean a significant decrease in your benefits coverage or a significant increase in your premiums.

Maximum out-of-pocket expense

The maximum dollar amount a member is required to pay out of pocket during a year. Until this maximum is met, the plan and member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.

Maximum plan dollar limit

The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan.

Medical necessity

A medical procedure or service must be performed only for the treatment of an accident, injury, or illness and cannot be considered experimental, investigational, or cosmetic.


Groups of physicians, hospitals, and other health care providers working with the health plan to offer care at negotiated rates.

Out of network

Usually refers to physicians, hospitals, or other health care providers who are considered nonparticipants in an insurance plan. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered, or covered only in part by an individual’s insurance company.

Out-of-pocket expense

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.

Participating provider

A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan. They are deemed to be “in-network.”


Primary Care Physician. A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Policy year maximum benefit

The maximum payment the company will make under the policy for each insured person for covered charges.


Preferred Provider Organization. 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.


A medical condition diagnosed prior to the effective date of the health plan.

Preferred allowance

The amount a network provider has agreed to accept as payment in full for covered charges.


The payment for an insurance policy.

Short Term Health Insurance

In the U.S., short term health insurance refers to health insurance plans with a limited duration, typically several months. Short term health insurance plans are typically less expensive than traditional plans, but do not cover pre-existing conditions and other essential benefits. Short term plans are also not considered “adequate coverage” under the Affordable Care Act so enrollees may be subject to the tax penalties of being uninsured. These plans are not renewable by the same company, in Idaho. This can cause problems for people who acquire a longer term illness, since the short term plan is completely terminated at the end of the coverage period.

State mandated benefits

When a state passes laws requiring that health insurance plans include specific benefits.

Travel insurance plan

This is insurance that covers medical expenses and other losses while temporarily traveling outside of one’s own country of permanent residence. You are required to have a passport or Visa to be eligible for coverage. There is limited or no coverage in your home country or country of permanent residence.


The company that assumes responsibility for the risk, issues insurance policies, and receives premiums.

Usual & customary

A reduction in the payment of benefits on a claim which is justified by the insurance company as “the going rate” to be paid in that geographical area.