Health Insurance Defined

October 27, 2017

The 2018 Open Enrollment period is almost here! This is the time each year when anyone can sign up for a health insurance plan, swich plans or renew their current plan. It runs November 1 through December 15.

To help you evaluate your options, we put together a benefits glossary.

Basic Care Dental

Services that don’t involve a significant laboratory expense for the dentist. These may include fillings and extractions.

Catastrophic Health Plan

This type of plan offers a very low monthly payment per month, but offer less coverage in the event of a healthcare service. The annual deductible is $6,350 (double for families).

Example: Under my catastrophic plan, if I incur a $4,000 bill for qualified health services, and I haven’t yet met my deductible, I am responsible to pay the full bill out of my pocket.


A fixed amount (for example, $15) a plan requires you to pay for a covered healthcare service. This payment is typically due when you receive a service.

Example: My plan has a $20 co-pay for a doctor visit. When I visit my doctor for a qualified service, I only pay the $20 co-payment when I check in.


Usually represented as a percentage, this reflects the costs of a covered healthcare service that you’re responsible for, after you’ve met your deductible.

Example: I met my plan’s $1,500 deductible. My plan has a 20% co-insurance so I must pay 20% of the cost of my next qualified health care service. The health insurance plan will pay the remaining 80%.

Contact Lens Exam

The contact lens exam is a special exam in addition to your routine eye exam. This special contact lens exam ensures proper fit of your contacts and evaluates your vision with the contacts. Depending on your needs, a doctor will provide training and education based on the type of services and eyewear provided.


This is the dollar amount you must pay out-of-pocket for healthcare services before your health insurance plan kicks in.

Example: My health insurance plan has a deductible of $1,500. If I haven’t yet paid $1,500 towards my deductible, I must continue paying out of my pocket until I do. It’s good to know which things apply toward my deductible, and which ones don’t.

Diagnostic/Preventive Care Dental

Routine services performed to keep teeth healthy. These may include exams, cleanings, x-rays, fluoride treatments and sealants.

Embedded Deductible

If you are on a family medical plan with an embedded deductible, the plan will track both an individual deductible and a family deductible. Each member of the family has the opportunity to meet their individual deductible and have their medical bills covered before the entire family deductible is met.


Surgery treating cracked teeth and dental trauma. Most common procedure is root canal.

Essential Health Benefits

An important component of the Affordable Care Act is a requirement for health insurance plans to provide adequate coverage for “Essential Health Benefits”-broad categories of important health services.

Essential health benefits must include items and services within at least the following ten categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.

Eye Exam

Routine eye exams are an important preventive measure for maintaining your overall health and wellness. During an eye exam, your doctor can look for vision problems and signs of serious medical conditions such as glaucoma, cataracts, diabetes, and even cancer.

Government Tax Credit

Sometimes called a “subsidy,” the government is providing tax credits to help some individuals pay for the cost of health insurance coverage on the Public Exchange. If you are eligible for a tax credit, the government will apply the credit to the cost of your health insurance coverage.


An HMO (Health Maintenance Organization) is a type of health plan that has a large network of doctors who agree to provide care to the HMO’s members. If you choose an HMO plan, you’re required to select a Primary Care Doctor, and then are required to visit this doctor whenever you need care. To visit a specialist, you will need to get a referral from your Primary Care Doctor. There are many types of HMOs, but typically members will have lower out-of-pocket healthcare expenses if they select an HMO plan.

Health Savings Account (HSA)

A Health Savings Account (HSA) allows you to put pre-tax money into a savings account to use towards qualified medical expenses. An HSA can only be used with a High Deductible Health Plan.

High Deductible Health Plan (HDHP)

High deductible health plans (HDHP) typically have a low monthly cost, but cost more when you receive a service. They get their name because the deductible (how much you pay out of your pocket) is higher.


Health insurance companies connect with certain providers and/or healthcare facilities to provide lower rates than out-of-network providers.

Example: I am changing health insurance coverage – it’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise it may cost me more to see that doctor.

Lifetime Limit

Health insurance companies set a cap on the amount they will pay over the course of your lifetime and/or for specific benefits.

Example: My health insurance coverage has a $1 million lifetime cap and a $250,000 cap on organ transplants. In the event I incur more than $250,000 in costs for a transplant, the health insurance company would only pay $250,000.

Major Care Dental

Procedures and treatments that are complex in nature and involve a dental laboratory expense. These may include crowns, inlays/onlays, bridgework, and implants.

Maximums for Dental

This is the maximum dollar amount the insurance company will pay towards the cost of dental care within a certain time frame (usually January through December). The consumer is responsible for paying any costs above the maximum.

Non-Embedded Deductible

If you are on a family medical plan with a non-embedded deductible, the entire family deductible must be met before any family member’s medical bills will be covered. The family deductible can be met by one member of the family or a combination of family members.

Oral Surgery

Surgery to treat many diseases, injuries and defects in the hard and soft tissues of the oral (mouth).

Orthodontia Dental

Services to prevent and correct misaligned teeth and jaws.


Providers and/or healthcare facilities that are considered “Out-of-Network” are not connected to the health insurance company and typically cost more than those that are considered “In-Network”

Example: I am changing health insurance coverage. It’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise it may cost me more to see that doctor.

Out-of-Pocket Costs

A medical expense is considered out-of-pocket if your health insurance company will not cover it and it’s above your monthly payment (premium). For example, payments towards deductibles, coinsurance, and copayments are all considered out-of-pocket expenses.

Out-of-Pocket Max

Also known as “OOP Maximum” or “Out-of-Pocket Maximum,” this is the most you would pay during the coverage time (typically a year) before your eligible costs are paid 100%. Keep in mind that this does not include premiums, which you have to pay each month.

Example: My health insurance coverage out-of-pocket max is $5,000. My out-of-pocket expenses include my annual deductible of $1,500, my copayments for doctors and prescriptions, and the coinsurance on eligible healthcare services. If I spend over $5,000 on qualified health services in these areas, my health insurance company will begin paying 100%.


Treatment for the structure of teeth and surrounding tissue.

Plan Tier

Part of the Affordable Care Act is a rating system that has been implemented for health plans available on the Public Exchange. Plans are ranked as Platinum, Gold, Silver, Bronze, and Catastrophic.

Think of the tiers as a type of ranking-from the most amount of coverage for health services (Platinum) to the least amount of coverage for health services (Catastrophic). Keep in mind that “most coverage” does not necessarily mean “better” as Platinum plans also come with the highest monthly cost per month.

Example: I only want health insurance coverage for major health events. A Platinum plan is going to cost the most per month and provide more coverage than I am looking for. A Catastrophic Plan will cost the least per month and provide only minimal coverage.

Preferred Provider Organization

A Preferred Provider Organization (PPO) is a type of health plan that has a network of doctors that the PPO’s members can visit for reduced rates. These doctors are considered “in-network.” If you visit an “out-of-network” doctor, you will likely have to pay more for your care. You can see a specialist without getting a referral.


Your premium is the amount you pay for your health insurance coverage, typically each month. It’s sometimes referred to as your monthly payment.

Prescription Drugs

Prescription drugs are one of many Essential Health Benefits. Gravie wants to learn more about your specific needs so we can find a plan with adequate coverage.

Brand Name: Medications sold under a trademarked name, like Nexium or Advair. Only the company that has the patent can produce and sell these specific medications.

Generic: Generic prescription drugs are not a familiar brand name, but are made of the same active ingredients and must meet the same quality and safety standards. They are the lowest cost tier of drugs.

Specialty: These prescriptions are typically extremely costly and are used to treat severe and chronic conditions. Sometimes they require unique handling and storage.

Preventive Care

Preventive care services are one of the best ways to keep you and your family healthy. These services, which typically include yearly checkups, screenings and immunizations, can help you stay healthy and avoid or delay health problems.


A doctor or health care professional.

Term Life Insurance

Term life insurance is a straightforward way to protect those who are financially dependent on you. The policy pays a benefit to your beneficiaries if you pass during the term the coverage is active. Your premiums never increase and there is no medical exam required.

We hope this glossary was helpful! For additional help evaluating your options for 2018, contact the Gravie advisors. Our licensed, expert advisors help members choose the best benefits for their needs and budget. With Gravie, you’re always a phone call, email or chat away from someone who’s on your side, willing to go the extra mile.

If you’re interested in becoming a Gravie member and getting year-round benefits support from the Gravie advisors, register here or call us at 800.501.2920. If you’re an employer interested in getting Gravie for your company, fill out a contact form

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