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.