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 or medical professional to an insurer, asking for payment or reimbursement for medical services. A claim may or may not be paid by the insurer.

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).