Accountable Care Organization (ACO)

A group of medical professionals (hospitals, physicians, and suppliers) responsible for serving a specific patient population. Subject to quality standards. An ACO may keep a percentage of cost savings if it saves money on care.

Actuarially Fair Premium

One component of the overall premium set by an insurance provider based solely on predicted medical costs for enrollees.

Adverse Tiering

A generally prohibited practice in which all drugs used to treat the same condition (angina, bipolar disorder, multiple sclerosis, etc) are placed in a high (expensive) formulary tier, even generic drugs. The Affordable Care Act views this practice as discrimination.

Allowed Amount Maximum

Amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

When a medical professional bills you for the difference between their charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance-bill you for covered services.

Benefit Design

Differences in how individual plans meet Benefit Mandates. For example, Plan A requires a $30 co-payment for a primary care appointment with a lower premium, while Plan B provides a free primary care appointment with a higher premium. Both plans meet the mandate for primary care but share costs with their patients in different ways.

Benefit Mandate

A legal requirement that health insurance plans cover certain services or products provided by hospitals or physicians. Self-funded plans are exempt from state benefit mandates, but fully-insured plans must comply with both state and federal mandates.

Broker

A licensed person or organization you pay to look for insurance on your behalf.

Bundled Payment

A payment model in which an insurer pays a healthcare facility for one entire episode of care. For example, for a knee surgery, a bundled payment would cover all presurgical tests, the surgery itself, hospital stay, and follow-up care. Also called a Case Rate.

Cancellation

The termination of insurance coverage during the policy period. Flat cancellation is the cancellation of a policy as of its effective date, without any premium charge.

Capitation

A fixed fee paid by an insurance plan to a health care professional for services, per patient per month. This is the "budget" for each enrollee. Utilized by HMO plans.

Catastrophic Coverage

A health insurance plan with a low premium (low regular payments made per month) and a high deductible (high cost that must be met before insurance will cover part of the bill). Similar to high-deductible health insurance (HDHI). Only offers protection for enrollees against high, unpredictable medical costs such as emergency room visits or hospital stays.

Children's Health Insurance Program (CHIP)

A program offering coverage to children from families that may not qualify for Medicaid but cannot afford private insurance. May be applied for at any time. Coverage varies from state to state.

Claim

A notice submitted by a patient to an insurer that under the terms of a policy, a loss maybe covered. Submitting a claim does not guarantee payment.

Claimant

A person or organization submitting a claim in hopes of receiving financial compensation.

Closed Formulary

A formulary in which medical drugs not listed will not be covered by the insurance plan under any circumstances.

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. For example, if the health insurance or plan’s allowed amount for an office visit is $100, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount if your deductible is met.

Co-payment

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

Community Rating

A premium set based on healthcare costs in a geographic area (for example, the average cost across Chicago or New York City)

Complications of Pregnancy

Conditions due to pregnancy, labor, and/or delivery that require medical care to prevent serious harm to the health of the mother or her baby.

Consumer Cost Sharing

The cost of insurance that a patient must pay to receive care. Often used interchangeably with Out of Pocket Costs.

Cost-sharing Reduction

A health insurance marketplace subsidy to reduce out-of-pocket costs for health care services. Patients are eligible if they qualify for a Premium Tax Credit, have a household income between 100% and 250% of the federal poverty level, and enroll in a Silver plan.

Coverage Exclusions

A treatment, procedure, or product that is always excluded from coverage by an insurance plan. Varies by individual plan, but common exclusions include cosmetic surgery, eye exams, dental care, home health care, and experimental procedures. Patients must pay for these services out of pocket (unless they have supplemental dental or vision insurance, in those cases).

Coverage Limitations

Limits in what healthcare services or providers are covered under a specific plan. The more limitations on coverage, the lower the cost to the patient (generally).

Decline

A company's refusal to accept the request for insurance coverage.

Deductible

The amount you owe for health care services before your health insurance plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve paid your $1000 deductible for covered health care services. The deductible may not apply to all services.

Diagnosis-Related Group (DRG)

Groups of related diagnoses grouped together by Medicare to determine hospital payment. More intensive DRGs (surgery) correspond to increased payments from Medicare to the hospital, while less intensive DRGs (fever) correspond to decreased payments. Called Ambulatory Payment Classifications (APCs) in the non-hospital (clinic) setting.

Discharge Planning

A service provided by a hospital to help patients continue their medical care once they have left the hospital (in the outpatient setting). This may involve coordinating between a primary care physician, a specialty physician, physical/occupational therapy, nursing services, and the like.

Disease Management Program

A program coordinating patient care between multiple medical professionals in which patients are often on strict and closely monitored medication regimens.

Dual-eligible Beneficiary

A person who is eligible for both Medicare (by age or disability) and Medicaid (by income).

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, blood testing strips for diabetics, and more.

Emergency Medical Treatment and Labor Act (EMTALA)

An act that requires hospitals to stabilize or transfer patients if they present with a true emergency, regardless of ability to pay. Services may still be billed after the patient is stabilized. Patients can seek to negotiate prices or apply for Medicaid (if they qualify).

Emergent Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergent Medical Transportation

Ambulance services for an emergency medical condition.

Emergent Services

Evaluation of an emergent medical condition and treatment to keep the condition from getting worse.

Essential Health Benefits

Minimum coverage standards established by the Affordable Care Act for individual and small group plans. There are ten essential health benefit categories, including ambulatory care, emergency services, maternity care, mental health and substance use disorder treatment, prescription drugs, rehab services, lab services, preventative care, and pediatric care.

Evidence of Coverage (EOC)

An insurance document listing the terms of a certain insurance plan akin to a contract. Varies by plan. Insurers reference the EOC to determine if a benefit is covered or denied by a specific plan. Also called a certificate of coverage (COC).

Exclusive Provider Organization (EPO)

A plan that restricts the professionals a patient can see in exchange for a lower deductible. Out of network costs are generally not covered. Similar to HMOs, but a primary care referral for specialty services is often not required.

Experience Rating

A premium set based on healthcare costs for an individual or a group of related people (for example, all people with diabetes or high blood pressure)

Expiration Date

The date on which a policy ends

Facility Fee

Fee paid by an insurer to a healthcare facility for a patient's use of the grounds. Often uses the Per Diem payment model. For example, if you stay in the hospital three days for surgery, your insurer will pay a per diem facility fee for your three days of "hospital rent."

Fee Schedule

A list of prices for a medical service, either negotiated by private insurers or administered by public insurers. Used in the Fee-For-Service payment model.

Fee for Service

A negotiated rate paid from insurance providers to healthcare professionals after care has been provided. Not prepaid. Utilized by PPOs. For example, if you see your doctor for a flu shot, your insurance company pays separate fees to the doctor for their consultation and the shot itself.

Formulary

A list of medications covered by a specific insurance plan. Often composed of tiers, with lower tiers containing drugs that are less expensive. A classic four-tiered formulary offers the lowest copayments for generic drugs (tier one), higher copayments for preferred/discounted brand drugs (tier two), higher copayments for non-preferred brand drugs (tier three), and the highest payments for expensive drugs such as biologics (tier four). Some have fifth or sixth tiers depending on the drugs covered. Formularies can be found online or within a Summary of Benefits and Coverage for a particular plan.

Fully Insured Plan

An insurance plan in which smaller employers and individuals contract with a state-licensed insurer to administer benefits and take on financial risk. Regulated by state-specific requirements and often do not cross state lines for this reason.

Gap Coverage

Limited medical insurance with a specific purpose. Common gap plans include critical illness insurance (for specific diseases), disability income protection, accident-only insurance, and fixed-benefit indemnity medical insurance (which assists with out-of-pocket costs). Is commonly purchased by a patient in addition to their Major Medical Insurance.

Grace Period

A specified period immediately following the premium due date during which a payment can be made to continue a policy without interruption. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.

Grandfathered Plan

An insurance plan in place before the passage of the Affordable Care Act (ACA) in 2010 which has not undergone substantial changes. These plans are exempt from most ACA requirements.

Group Insurance

A type of insurance in which more than one individual pays a premium to a health insurance provider or employer. These premiums are pooled together and used to pay out coverage for medical expenses.

Group Market

An insurance marketplace that sells insurance plans to employers.

Guaranteed Issue

A requirement under the Affordable Care Act that insurers must offer insurance coverage to anyone who applies.

Guaranteed Renewability

A requirement under the Affordable Care Act that insurers must offer to renew a health insurance policy each year to anyone who continues to pay their premiums.

Health Insurance

A policy that pays a medical bill in part or in whole in exchange for smaller payments over time.

Health Insurance Literacy (HIL)

The knowledge, ability, and confidence to effectively choose and use health insurance

Health Maintenance Organization (HMO)

A type of insurance plan where patients are encouraged to use hospitals and see practitioners that are owned by or directly contract within the network. Out of network services are partially covered or not covered at all. Generally allow patients to see a restrictive range of providers at a lower cost than a PPO. Ex: Kaiser Permanente.

Health Savings Account (HSA)

An account which allows individuals to pay for current expenses while saving for future qualified medical expenses. HSAs are nontaxable accounts and are owned by the patient (so if a person changes jobs, their HSA follows them from one job to another).

High Deductible Health Plan (HDHP)

Health plan product that combines a health savings account (HSA) with traditional medical coverage. Typically include higher annual deductibles and out-of-pocket maximums, but preventative care services are fully covered and enrollees are often charged a lower monthly premium.

In Network

Facilities, providers, and suppliers like doctors, hospitals, and pharmacies that your health insurance company contracts with to provide health care at a discounted rate.

Incontestable Clause

A policy provision in which the company agrees not to contest the validity of the contract after it has been in force for a certain period of time, usually two years.

Indemnity

A payment to an insurance plan enrollee, generally a fixed amount per hospital day. Common to insurance plans in the 1900s.

Indian Health Service (IHS)

A federal agency under the Department of Health and Human Services (HHS) established to provide healthcare to federally recognized American Indians, Alaska Natives, and their descendants. Like the VHA, it is not a health insurance plan.

Individual Mandate

A policy under the Affordable Care Act requiring most Americans to have health insurance or to pay a penalty. The penalty is capped at the cost of a bronze plan (see Precious Metal Categories).

Individual Market

An insurance marketplace that sells plans to individuals and their families outside of the employment market.

Individual Marketplace

A health insurance marketplace where individual patients and their families can compare plans, apply for subsidies, determine eligibility for government-sponsored plans, and potentially enroll in those plans. Coverage must be purchased during the Open Enrollment period. Also called a health insurance exchange.

Insurance

A financial guarantee against an unforseen event. Generally small payments are provided over time, and an insurance provider pays a large sum to the covered person in the event of disaster or disability

Insured

The policyholder; the person(s) protected in case of a loss or claim.

Insurer

The insurance provider

List Price

The "menu price" of a healthcare service, medication, or item as reported by a hospital or physician, that a patient would pay in full if not covered by insurance. List prices can often be negotiated down by those without insurance.

Loading Charge

One component of the premium set by an insurance provider. The cost of administering a claim and part of the profit margin collected by an insurer.

Major Medical Insurance (MMI)

Comprehensive insurance that covers a wide range of medical benefits. Retaining MMI satisfies the Affordable Care Act's requirement for US adults to have health insurance. May be supplemented with Gap Coverage.

Managed Care

A set of tools used by managed care plans (such as HMOs, PPOs, EPOs, and POSs) to reduce healthcare spending and improve quality of care. Tools include out-of-pocket costs, contracting with low-cost professionals, and limiting coverage on certain procedures.

Marketplace Plan

An insurance plan operated through the federal government, where people can shop and apply for health insurance. You will need your income, household information, and employer information to see if you qualify. Unless you meet the requirements of a qualifying event, there are only certain times during the year you can shop for insurance plans.

Medicaid

A state-administered health insurance plan designed for low-income or other "medically needy" people with chronic illness or disability. Low-income individuals are qualified based on their income in comparison to the Federal Poverty Level (FPL).

Medical Loss Ratio (MLR)

The percentage of the premium paid back to the patient in benefits. Under the Affordable Care Act, the minimum MLR is 85% for large group plans and 80% for individual and small groups plans. For instance, if your monthly premium is $100, then $80 must be spent on your medical care or quality improvement. Otherwise, the insurance company will owe you a rebate.

Medical Necessity

A determination made by an insurance company as to the value of a medical treatment, procedure, or product. Medically unnecessary treatments will not be covered. If your doctor and insurer disagree about medical necessity, you can challenge the insurer through an internal (to the insurer) or external (to a third party) review process.

Medicare

A program funded by the federal government providing insurance for US citizens older than 65 years of age. Part A covers hospital expenses; Part B covers office visits, imaging, and lab services; Part C (Medicare Advantage) is a private alternative with expanded benefits in place of A and B; and Part D covers prescriptions drugs. Traditional Medicare does not cover long-term care, assisted living, dental, vision, or hearing aids.

Medigap

A supplemental insurance to Medicare to cover deductibles, coinsurance, and copayments and expand benefits for individuals needing more assistance.

Moral Hazard

The tendency of people to live more recklessly with regards to their health because they have health insurance. This tendency is minimized through out-of-pocket payments, annual limits on insurance payouts, and prior authorization.

Narrow Network

A restricted network of medical professionals who contract with an insurance company to take their enrollees. Narrow networks have smaller numbers of covered physicians in exchange for lower premiums and out of pocket costs.

Open Enrollment

The designated time each year when you can purchase, apply for, and make changes to an insurance plan for the upcoming year. It is typically November 15th through December 1st, unless modified by an employer or if you have a qualifying life event that has occurred.

Open Formulary

A formulary of medications where drugs that are not listed might be covered at a higher cost.

Out of Network

Facilities, providers, and suppliers like doctors, hospitals, and pharmacies that your health insurance company does not contract with. Going to an out of network facility is typically associated with a higher rate or is not covered at all by insurance.

Out of Pocket Costs

Healthcare costs not covered by an insurance plan or included in a plan's premium. Generally includes copayments (fixed cost per service), coinsurance (fixed percentage per service), and an annual deductible (cost that patient must pay per year before insurance will pay for services). Total health insurance costs thus include BOTH the premium AND the out-of-pocket costs.

Out of Pocket Maximum

A limit in the amount of money paid for covered health care services in a plan year. If met, your health plan will pay 100% of all covered health care costs for the rest of the year. For example, if your out-of-pocket maximum is $5,000 and you have spend that by October, your insurance plan will pay 100% of covered services in November and December of that year.

Over-the-Counter (OTC) Drug

A medication that can be purchased by a patient without a physician prescription but are usually not covered by insurance. Some plans will cover OTC drugs if they are prescribed by a doctor, and employers can offer a Flexible Spending Arrangement (FSA) or Health Reimbursement Arrangement (HRA), which is an employer-managed account of pre-taxed dollars set aside specifically for OTC drugs or other healthcare purchases.

Panel

A group of patients that regularly see one doctor. For example, if you are established with Dr. Jones for primary care, you are in his panel of patients.

Pay or Play Mandate

A provision of the Affordable Care Act requiring employers with 50 or more full-time employees to offer health insurance ("playing") or paying a penalty ("paying"). Part-time and seasonal employees are excluded from the mandate.

Per Diem

Payments made to a hospital or healthcare facility "by the day" regardless of services provided during that day. For instance, if you stay in the hospital for three days, each day has a flat per diem rate regardless of the treatments you get each day.

Pharmacy Benefit Manager (PBM)

A third party that administers pharmaceutical benefits on behalf of an insurance company. Manages formularies, processes and pays pharmaceutical claims to a patient, and draws up contracts with local pharmacies and drug manufacturers.

Pharmacy and Therapeutics (P&T) Committee

A committee of physicians, pharmacists, and other health professionals that develop and update insurance plan formularies.

Point of Service (POS)

A plan that is less restrictive than a HMO (and allows patients more choice in choosing a practitioner) but is more restrictive and less expensive than a PPO, generally.

Policy

The written contract of insurance detailing what is covered (or paid for) by an insurance plan and what is not.

Policy Limit

The maximum amount a policy will pay. Policies often have annual or lifetime limits.

Pre-existing Conditions

Health conditions (such as diabetes, high blood pressure, high cholesterol, etc) that were present before the current term of insurance. Under the ACA, insurers may not exclude or limit coverage of pre-existing conditions.

Precious Metal Categories

A category system used in health insurance to understand the value of a plan across different insurance providers. Categories include bronze, silver, gold, and platinum. Bronze plans cover 60% of health care costs, silver plans cover 70%, gold plans cover 80%, and platinum cover 90%. All precious metal plans are estimated to have the same Actuarial Value, but actual costs may vary by year. See Actuarially Fair Premium.

Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers to create a network of participating providers. Costs are lower within the network and higher outside of the network. Generally allow patients to see a wider range of providers for a higher cost than an HMO.

Premium

A fixed amount of money an insurance company charges for basic coverage, usually billed monthly. Similar to a gym membership or cable subscription. Composed of two parts: the actuarially fair premium and the loading charge. Paid regardless of whether the patient uses healthcare or not. Larger groups of people and healthier groups of people tend to pay lower premiums (since they will likely use less healthcare and be less expensive for an insurance company).

Premium Tax Credit

A health insurance marketplace subsidy to reduce monthly premium costs for individuals who meet criteria. Individuals are eligible if their annual household income is between 100% and 400% of the federal poverty level, if this individual does not qualify for public coverage, and if no employment coverage is available. The credit can be claimed in advance (and you pay only the reduced amount to the insurer per month) or receive a tax credit on the full cost of the premium the following year.

Prior Authorization

Requirement by an insurance plan that a patient seeks specific approval for a procedure to determine if it will be covered by insurance. Facilitated by a physician's office. Abbreviated "prior auth."

Private Health Insurance

A state-licensed health insurer or self-funded employee health benefit plan that takes on financial risk, administers benefits, and pays claims as associated with healthcare costs for individuals and their families.

Private Health Insurers

Insurers that offer plans without the assistance of state or federal governments. There are generally three types: commercial (for-profit) health insurers, non-profit (Blue Cross Blue Shield) health insurers, and HMOs.

Professional Fee

Fee paid by an insurer to a clinician performing services. For example, if you stay in the hospital for three days to have gallbladder surgery, your insurer will pay a professional fee to the surgeon for performing the surgery and consulting with you pre- and post-operatively.

Provider Directory

A list of medical professionals that will be covered or considered in-network by a specific insurance plan. The directory is available online or in a patient's Summary of Benefits and Care document. Since directories are not always up-to-date, always confirm if a professional takes your insurance by calling their office directly.

Provider Network

Hospitals, physicians, imaging facilities, laboratory facilities, and other healthcare facilities that are covered by a particular plan. This means that they will offer a discounted rate on their services to those who are members of the plan, and offer full list price to those who are not.

Public Health Insurance

A branch of the state or federal government that takes on financial risk, administers benefits, and pays claims as relates to healthcare for individuals and their families.

Qualified Health Plan (QHP)

A health insurance plan offered on a marketplace that meets Affordable Care Act guidelines and is pre-approved by the state hosting the marketplace. Most comply to the Precious Metal categories (so a Silver plan purchased in California offers similar financial protection as a Silver plan purchased in New York, as an example).

Qualifying Life Event

Any change in a personal situation (loss of coverage, changes in household, changes in residence, or other similar events) that make you eligible for a Special Enrollment period outside yearly Open Enrollment.

Quote

An estimate of the cost of insurance, based on information supplied to the insurance provider by the applicant.

Referral

A physician officially directs a patient to see a specialty physician. Some plans require that a referral is placed between physicians before the patient's visit to the specialist is covered.

Reinstatement

The restoring of a lapsed policy to full force and effect. The reinstatement may be effective after the cancellation date, creating a lapse of coverage. Some companies require evidence of insurability and payment of past due premiums plus interest.

Reverse Deductible

An insurance policy in which the insurer pays an initial amount for covered care and the patient pays any additional costs above a certain value. Also called reference pricing. For example, if the insurer says they will pay $1,200 for a colonoscopy (the reference price), and your hospital charges $1,600 for the procedure, you would pay the $400 difference. If you went to a different hospital that only charged $900, your insurance would completely cover the procedure (but you would NOT be eligible for a $300 payment).

Risk Adjustment

Adjustment of payment to healthcare professionals based on the riskiness of their patients. Insurers will pay more for patients expected to cost more (ie riskier patients) and less for patients expected to cost less (ie less risky patients). Often used in a HMO insurance system.

Risk Amenable

Term used to define the preference of the minority of people who prefer not to pay any money at all in the short term and gamble that they will not experience a catastrophic bill in the future. This preference may lead people to avoid health insurance.

Risk Averse

Term used to define the preference of most people to pay a small amount monthly (a known and predictable quantity) to avoid a potentially catastrophic surprise bill (an unknown and uncertain quantity). This preference may lead people to over-insure themselves.

Selection

The tendency of sicker people to join plans with less restrictive benefits and higher premiums and healthier people to join plans with more restrictive benefits and lower premiums. This is of benefit to both patients (who pay only for the benefits they need) and insurers (who don't under- or over-pay for medical care).

Self Funded Plan

An insurance plan in which large employers take on risk by collecting premiums and paying out claims within their company. These plans are exempt from state-specific regulations and allow large companies to offer the same benefits to their employees across state lines. Under the ACA, these plans are exempt from offering essential health benefits packages or meeting the minimum MLR.

Service Benefits

Payment directly to healthcare personnel for services and supplies.

Small Business Health Options (SHOP) Marketplace

A health insurance marketplace for small businesses (at least 2 but no more than 50 full-time employees) that offers employees of businesses who opt in to select from any Precious Metal coverage in their geographic area. SHOP coverage may begin for a given business at any time of the year. State or federally supported depending on the state.

State Children's Health Insurance Program (SCHIP)

A health insurance program to cover children otherwise not insured under Medicaid. Like Medicaid, it is administered by each state and coverage is based off of family income relative to the Federal Poverty Level (FPL). Also abbreviated CHIP.

Step Therapy

A medication policy within a health insurance plan that a patient must try a less expensive medication before "stepping up" to a more expensive one. If a patient goes out of order, the more expensive drug may not be covered by insurance.

Summary of Benefits and Coverage (SBC)

A standardized form that insurers or employers must provide to their enrollees containing the details of a plan. Often includes covered benefits, costs paid by the enrollee, coverage limits, and exceptions.

Surprise Medical Bill

A bill received unexpectedly by a patient from an out-of-network (not covered) medical professional. Examples include an in-network (covered) doctor ordering a lab test at an out-of-network lab facility, or an in-network ambulance taking a patient to an out-of-network hospital. Patients have the right to negotiate surprise medical bills with the out-of-network medical professional and their insurance company.

Tiered Network

A network of medical professionals in which a patient pays less to see low-cost or high-performing doctors, nurses, physical therapists, and the like. Similar to a narrow network but often offers more practitioner choice for the patient.

Transitional Insurance

A plan to cover healthcare costs for individuals who are between permanent plans. Ex: Consolidated Omnibus Budget Reconciliation Act (COBRA) plans.

Tricare

A health insurance program covering service members, service dependents, retirees, and retiree dependents. Covers current or former members of the Army, Navy, Marine Corp, Air Force, Coast Guard, Public Health Service, National Oceanic and Atmospheric Administration, National Guard, and Reservists. "Tri" refers to three benefit plans offered to enrollees. Formerly known as CHAMPUS.

Underinsurance

The state of having an insurance plan that does not meet the patient's needs. This can be due to frequently switching plans and having coverage gaps or having insurance that is unaffordable and not used.

Veterans Health Administration (VHA)

A division within the Veterans Administration (VA) established to provide medical service to United States veterans. Not a health insurance plan.

Walk-in Clinic

A retail clinic (inside a pharmacy or grocery store) or an urgent care clinic that offers extended hours and does not require an appointment for care. A retail clinic is often less expensive than an urgent care clinic, which itself is less expensive than a trip to the hospital. Can often provide care for urgent issues (urinary tract infections, respiratory infections, sexual health services, etc) but may or may not be covered under an insurance plan.