COBRA: A federal law (Consolidated Omnibus Budget Reconciliation Act of 1985) that requires group medical plans with twenty or more employees to offer continued healthcare coverage for 18–36 months after a job loss or cancellation of coverage.
EPO (Exclusive Provider Organization): A type of health plan that does not require choosing a primary care physician or referrals for specialists but only covers in-network providers, except for emergencies.
HMO (Health Maintenance Organization): A health plan that requires selecting a primary care physician (PCP) to coordinate care, referrals for specialists, and use of in-network providers only (except in emergencies), typically with lower premiums but less flexibility.
PPO (Preferred Provider Organization): A health plan that does not require a primary care physician or referrals, covers both in- and out-of-network providers, and typically has higher premiums with greater flexibility.
Small Business Health Insurance: A type of coverage available to businesses with 2–50 employees, offering discounted premiums for staff, tax advantages for owners, and generally guaranteed availability.
ACA (Affordable Care Act) Reporting: Employer reporting requirements under the Affordable Care Act, including providing Forms 1094-C and 1095-C to the IRS and employees to demonstrate compliance with coverage mandates.
Applicable Large Employer (ALE): A designation under the Affordable Care Act for employers with 50 or more full-time equivalent employees; ALEs must offer health coverage that meets minimum standards or face penalties.
ERISA (Employee Retirement Income Security Act): A federal law that sets minimum standards for most employer-sponsored benefit plans, requiring disclosure, reporting, and fiduciary responsibilities to protect employees.
Medicaid: A joint federal and state program that provides health coverage to low-income individuals and families, children, pregnant women, elderly adults, and people with disabilities; each state administers its own program under federal guidelines.
Medicare: A federally funded healthcare program that provides hospital and medical coverage primarily for people aged 65 and older.
Open Enrollment: The annual period when you can enroll in, change, or cancel your health insurance plan.
Special Enrollment Period (SEP): A time outside of open enrollment when you may qualify to change coverage due to life events such as marriage, birth, or loss of other coverage.
Summary Plan Description (SPD): A detailed guide provided by your employer or insurer that outlines your health plan’s benefits, rights, and obligations.
Coinsurance: The percentage of medical costs you pay after meeting your deductible; unlike a fixed copayment, coinsurance is expressed as a percentage (e.g., 20%) until you reach your out-of-pocket maximum.
Copayment (Copay): A fixed-dollar amount you pay for certain healthcare services (e.g., $25 for a doctor visit), typically due at the time of service.
Deductible: The amount a group must pay out of pocket for medical expenses before insurance begins covering costs; the deductible level directly affects the premium amount.
Maximum Out-of-Pocket (OOP): The highest total amount you are required to pay for covered healthcare expenses in a plan year, including deductibles, copays, and coinsurance; once reached, your insurance pays 100% of covered services for the rest of the year.
Premium: The monthly payment required to keep your health insurance policy active; premium amounts are determined by multiple factors such as plan type, coverage level, and participant demographics.
Flexible Spending Account (FSA): A tax-advantaged account that lets you set aside pre-tax dollars for eligible medical expenses, but typically does not roll over from year to year.
Health Savings Account (HSA): A tax-advantaged savings account available to those with high-deductible health plans, allowing contributions, growth, and withdrawals for qualified medical expenses to be tax-free; funds roll over annually and remain with you even if you change jobs.
In-Network: Healthcare providers or facilities that have a contract with your insurance company to deliver services at discounted rates.
Network: The group of doctors, hospitals, and facilities contracted with your health plan to provide services at negotiated rates.
Out-of-Network: Healthcare providers or facilities not contracted with your health plan; using them usually results in higher costs or full responsibility for charges.
Primary Care Physician (PCP): A family doctor, pediatrician, or internist required by most HMOs and POS plans to manage your care, treat most conditions, and provide specialist referrals.
