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 Coding

The process of defining a medical visit by standardized ICD-10 and CPT codes. Physicians may "upcode" a patient visit (calling it more long and complex than it was) or "undercode" a patient visit (calling it shorter and less complex than it was). Medical coding defines payment from insurers to medical professionals.

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.