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.
Glossary
Affordable Care Act (ACA)
The comprehensive federal health care reform law enacted in March 2010. Also known as “Health Care Reform.”
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.
Copay (Copayment)
A specific dollar amount you pay for covered services — for example, a $10 copay for an office visit.
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.
Dependent
A spouse, child, or domestic/civil union partner who’s is covered under a policyholder or subscriber’s plan, depending on applicable law and the plan terms and conditions.
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
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.
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).
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 enact it.
Health care coverage (also known as “health 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.
Health Benefit Exchanges (also known as marketplaces)
Federally and state-run and regulated health benefit exchanges where you can shop, compare, and buy health care coverage. Link directly to your state’s exchange 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 |
Large employer
The definition of a “large employer” is an employer with 51 or more full-time-equivalent employees (101 or more in California and Colorado).
Marketplaces
A common nickname for the health benefit exchanges that are available in participating states or jurisdictions; also called “exchanges”.
Metal plans
These are ACA-compliant plans (that include essential health benefits) in your state's health benefit exchange, 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.
Open enrollment period
A period of time each year when you can purchase or change health care coverage.
Check with your health benefit exchange for open enrollment dates.
Out-of-pocket costs
Any amounts you pay for covered services, not including your monthly rate.
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, Evidence of Coverage and Disclosure Form (EOC) for your plan out-of-pocket maximum amount and to learn which services apply to your plan’s out-of-pocket maximum.
Pre-existing condition
A medical condition that a person has before being enrolled in a health plan.
Preventive services
Covered services that prevent or detect illness and do one 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
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.
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 one to 50 (one to 100 in California and Colorado) full-time-equivalent employees.
Special enrollment period
A period of time outside of the annual open enrollment when you can enroll in health care coverage. To be eligible for special enrollment, you must have experienced a situation known as a qualifying life event, which is defined by ACA regulations. Examples of qualifying life events include getting married, moving to a new Kaiser Permanente service area, and losing coverage because you lost your job. Even if your qualifying life event occurs during open enrollment, you’ll still have a special enrollment period and your coverage effective date may be different from open enrollment effective dates. Certain special enrollments will require prior coverage and/or payment of past-due premiums. Visit kp.org/specialenrollment for more information.
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 that includes:
- 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:
(TTY, call 711)
California
- English 1-800-464-4000
- Spanish 1-800-788-0616
- Chinese 1-800-757-7585
Colorado
- 1-800-632-9700
Georgia
- 1-888-865-5813
Hawaii
- 1-888-865-5813
Maryland, Virginia, District of Columbia
- 1-800-777-7902
Oregon
- 1-800-813-2000
Washington (Clark and Cowlitz counties)
- 1-800-813-2000
Washington (all other counties)
- 1-800-290-8900