Insurance Translator

Confused by health insurance lingo? Let us translate.

No more jargon—just clear, simple explanations so you can make informed decisions.

Glossary of Common Terms

Advance Directive

A legal document that explains your healthcare preferences if you’re unable to speak for yourself.
Example: You can choose who makes medical decisions for you in case of an emergency.

Advance Premium Tax Credit (Subsidy)

A government discount that lowers your monthly Marketplace premium based on income.
Example: If you qualify, you might pay $100/month instead of $500.

AHCA

Agency for Health Care Administration—oversees Medicaid and health facilities in Florida.
Example: AHCA helps administer state Medicaid benefits and policies.

Annual Notice of Change (ANOC)

A letter you get each fall that explains any changes to your Medicare Advantage or Part D plan.
Example: Your copays or coverage might be different next year—this letter tells you.

Appeal

A formal request to ask your insurance company to review and change a decision you disagree with.
Example: If your claim was denied, you can file an appeal to ask for a second look.

Calendar Year

January 1 through December 31—the standard year used for most deductibles and tax-related benefits.
Example: Even if your plan starts in July, your deductible may reset on the calendar year.

Census

A list of employees and their basic info—like age, zip code, and number of dependents—used to get group insurance quotes.
Example: To see your group plan options and pricing, we’ll ask you to fill out a simple census form about your team.

CMS

Centers for Medicare & Medicaid Services—the federal agency that runs Medicare.
Example: CMS sets the rules and guidelines for Medicare coverage.

COBRA

A federal law that lets employees keep their group health insurance for a limited time after leaving a job.
Example: COBRA lets you keep the same plan for up to 18 months—but you pay the full premium.

Coinsurance

The percentage you pay for services after meeting your deductible.
Example: If your coinsurance is 20%, you pay 20% of the cost and your plan pays 80%.

Contribution Requirement

The minimum amount an employer must pay toward their employees’ premiums.
Example: Most small group plans require employers to cover at least 50% of the employee’s premium.

Copayment (Copay)

A set fee you pay for certain services, like doctor visits or prescriptions.
Example: A $25 copay means you pay $25 when you visit the doctor.

DCF

Department of Children and Families—handles Medicaid and other benefit applications in Florida.
Example: You apply for Medicaid in Florida through DCF.

Deductible

The amount you must pay out-of-pocket for covered healthcare services before your insurance starts to pay.
Example: If your deductible is $2,000, you’ll pay that much before insurance begins to help.

Dependent Eligibility

Rules that define who qualifies to be added to an employee's group plan (like spouse or children).
Example: Some plans allow adult children up to age 26 to stay on the policy.

Drug Tiers

Drugs are grouped into tiers by your insurance plan, usually based on cost. Lower tiers cost less; higher tiers cost more.
Example: A Tier 1 drug may cost $5, while a Tier 4 specialty drug could cost hundreds.

Dual Eligible

Someone who qualifies for both Medicare and Medicaid.
Example: You may get extra help with premiums, prescriptions, and more.

EOB (Explanation of Benefits)

A summary you get after care that shows what was billed and what your plan paid.
Example: This is not a bill—it shows what your provider charged and what you might owe.

Employer Coverage

Health insurance offered through a job or union, which may cover the employee and their dependents.
Example: If your job offers coverage that's considered affordable and meets basic standards, you may not qualify for a subsidy on the Marketplace.

EPO (Exclusive Provider Organization)

A plan that covers services only if you use providers in the network—except in an emergency. No referrals needed.
Example: You don’t need a referral, but if you go out-of-network, the plan won’t pay anything unless it’s an emergency.

ERISA

A federal law that sets standards for most private employer-sponsored benefit plans.
Example: ERISA requires employers to provide plan information and protect employee benefits.

Essential Health Benefits

Ten categories of services all Marketplace plans must cover.
Example: These include maternity care, prescriptions, and mental health treatment.

FL KidCare

Florida’s low-cost health insurance program for children.
Example: Depending on income, coverage may cost $0–$20/month per child.

Formulary

A list of prescription drugs that your insurance plan covers.
Example: You’ll want to check if your medications are on the plan’s formulary.

Formulary Exception

A request to your insurance company to cover a drug that isn’t normally on their list (formulary).
Example: If your doctor says a non-covered medication is medically necessary, you can ask for a formulary exception so your plan may cover it.

FSA (Flexible Spending Account)

A tax-free account you can use for medical or dependent care costs. Funds usually expire at the end of the year.
Example: You might set aside $1,000 to pay for copays or prescriptions, but you have to use it by December.

Group Benefits

Health insurance and other perks (like dental, vision, or life insurance) offered to a group—usually employees of a company.
Example: Your job may offer group benefits that include medical, dental, and even disability insurance, often at a lower cost than buying on your own.

Guaranteed Issue

A rule that says insurance must accept you regardless of your health.
Example: Medigap plans are guaranteed issue when you first enroll in Medicare.

HMO (Health Maintenance Organization)

A plan that only covers care from in-network providers and usually requires a referral to see a specialist.
Example: You’ll need to choose a primary doctor and get a referral before seeing a cardiologist.

HSA (Health Savings Account)

A tax-advantaged savings account you own, used with high-deductible health plans. Funds roll over and never expire.
Example: You can save money tax-free for medical expenses now or in the future—even into retirement.

HRA (Health Reimbursement Arrangement)

An account funded by your employer to help pay for medical expenses or insurance premiums.
Example: Your employer might offer $2,000 a year to help you pay for out-of-pocket costs.

ICHRA (Individual Coverage Health Reimbursement Arrangement)

A benefit that lets employers reimburse employees tax-free for individual health insurance premiums and medical expenses.
Example: Instead of offering a traditional group plan, your employer may give you a set monthly amount to shop for your own plan.

Income (Modified Adjusted Gross Income)

Your estimated household income used to determine Marketplace subsidy eligibility.
Example: It's based on your tax return, and helps decide if you qualify for savings.

In-Network

Healthcare providers who have a contract with your insurance company.
Example: Using in-network providers usually saves you money.

Lifetime Maximum

A limit on how much a plan will pay over your lifetime—rare in modern plans.
Example: Older plans may have capped coverage at $1 million total.

Medicaid

A state and federal program offering free or low-cost health coverage to eligible individuals.
Example: You may qualify for Medicaid based on income, disability, or family status.

Medicare Advantage (Part C)

A type of Medicare plan offered by private companies that includes Part A, B, and usually D.
Example: Instead of Original Medicare, you get your coverage through a private plan.

Medicare Supplement (Medigap)

Extra coverage that helps pay costs not covered by Original Medicare, like deductibles and coinsurance.
Example: It helps cover the ‘gaps’ left by Medicare.

Minimum Essential Coverage (MEC)

The type of health insurance that meets the government's basic standards under the Affordable Care Act.
Example: Having MEC keeps you in compliance with federal rules and may affect your eligibility for subsidies or other programs.

Network

The group of doctors, hospitals, and providers your insurance has agreements with.
Example: Staying in-network usually means lower costs for you.

Open Enrollment Period (OEP)

The yearly window when anyone can enroll in or change a health plan.
Example: Marketplace Open Enrollment typically runs from Nov 1 to Jan 15.

Out-of-Network

Providers who don’t contract with your insurance—may cost more.
Example: Some PPO plans still help pay for out-of-network care, but HMO plans may not.

Out-of-Pocket Maximum

The most you’ll pay in a year for covered services. After that, your plan pays 100%.
Example: Once you reach your $7,000 max, your insurance covers everything else.

Participation Requirement

A rule that says a certain percentage of eligible employees must enroll in the group plan.
Example: A carrier may require 70% of eligible staff to join in order to offer a group policy.

Plan Year

The 12-month period your group insurance plan is active—often not the same as a calendar year.
Example: Your plan might run July 1–June 30 even though your deductible resets in January.

POS (Point of Service)

A mix between an HMO and a PPO—you’ll need a referral to go out-of-network, and those visits cost more.
Example: You can go out-of-network, but only if your doctor refers you—and expect higher costs when you do.

PPO (Preferred Provider Organization)

A plan that lets you see any provider, but costs less if you use in-network doctors. Referrals are not required.
Example: You can go to any specialist without a referral—even out-of-network—but you’ll pay less if they’re in-network.

Premium

The monthly amount you pay to keep your health insurance active.
Example: Think of this as your membership fee to stay enrolled in the plan.

Preventive Care

Routine health services meant to prevent illness, often covered at no cost.
Example: Annual checkups and screenings usually count as preventive.

Prior Authorization

Approval required from your plan before getting certain services or medications.
Example: Some MRIs or brand-name drugs need approval first.

QSEHRA (Qualified Small Employer Health Reimbursement Arrangement)

A simplified version of ICHRA for employers with fewer than 50 full-time employees who don’t offer group coverage.
Example: Your small business might give you $300/month through a QSEHRA to help pay for Marketplace insurance.

Quantity Limit

A rule that limits how much of a medication you can get at one time, based on safety or cost.
Example: You might only be allowed 30 pills per month, even if your doctor prescribed more.

Referral

An order from your primary care doctor to see a specialist.
Example: Many HMO plans require a referral before you can see a dermatologist.

Reimbursement

When your plan pays you back for services you paid out-of-pocket.
Example: You might pay for a visit upfront and submit the bill for reimbursement.

Section 125 Plan (Cafeteria Plan)

A tax-saving plan that lets employees pay premiums and benefits using pre-tax dollars.
Example: These plans can reduce your taxable income when paying for things like insurance premiums or childcare.

Special Enrollment Period (SEP)

A time outside of Open Enrollment when you can sign up for coverage due to life events.
Example: Losing your job or having a baby could qualify you for a SEP.

Standalone Drug Plan

A separate Medicare plan that only covers prescription drugs (Part D).
Example: You can pair this with Original Medicare and a Medigap plan.

Step Therapy

A rule that requires you to try a lower-cost drug first before your plan covers a more expensive one.
Example: You may have to try a generic drug first—even if your doctor prescribed a brand-name—unless you get approval to skip that step.

Tax Household

Everyone you include on your federal tax return, which determines subsidy eligibility.
Example: Even if your adult child has other insurance, they must be listed if you claim them.

Underwriting

A review process that looks at your health to decide if and how you can get a plan.
Example: Outside of your first Medicare enrollment window, you might face underwriting.

Voluntary Benefits

Extra coverage like life, dental, vision, accident, or critical illness that employees can choose to buy.
Example: Employees pay the full cost, but they get group pricing and payroll deductions.

Waiting Period

The amount of time an employee must work before their group health benefits begin.
Example: Your job might have a 60-day waiting period before you're eligible for coverage.

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Frequently Asked Questions

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What should I do if I think something was denied in error?

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