Glossary

A

actuarial value

The average share of covered medical costs a health plan pays. Metal tiers are based on actuarial value, so higher metal tiers usually mean the plan pays more of your costs and you pay less when you get care.

Advance Premium Tax Credit (APTC)

Financial help that can lower your monthly premium when you enroll in a Covered California plan, if you qualify.

Affordable Care Act

The federal health care law that created marketplaces like Covered California and expanded access to health insurance. Its full name is the Patient Protection and Affordable Care Act.

affordable insurance

Job-based health insurance is considered affordable if the employee’s share of the premium for self-only insurance stays under the current legal limit. This can affect whether someone qualifies for financial help through Covered California.

allowed amount

The amount a health plan and provider agree to use for a covered service.

ambulatory patient services

Medical care you get without being admitted to a hospital or other facility.

annual household income

The total income counted for your household for the year, based on the income used for tax purposes.

annual limit

A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services, such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.

B

Bronze plan

A metal-tier plan with lower monthly premiums and higher out-of-pocket costs when you use care, compared with higher metal tiers.

benefit

A health care product or service your plan covers.

C

carrier

A company that provides health insurance plans.

COBRA

A federal law that may let you temporarily keep health coverage after certain events like losing your job or other coverage.

Coinsurance

Your share of the cost of a covered service, shown as a percentage of the allowed amount.

Copay

A set amount you pay for a covered service, usually when you get care or are billed.

Cost-sharing

The share of covered health care costs you pay yourself, such as deductibles, copays and coinsurance.

Covered California

California’s health insurance marketplace, where people can compare plans, enroll in coverage, and find out whether they qualify for financial help.

Covered California for Small Business (CCSB)

Covered California’s small-business program for employers and employees. Keep SHOP as an alias that points here.

D

Deductible

The amount you may have to pay for covered services before your plan starts paying for some services. The deductible does not apply to every service.

Dependent

A child or other person who may be included in a tax household or covered under another person’s plan, depending on the program and rules that apply.

Dependent coverage

Health coverage for eligible family members, such as a spouse or children.

E

eligible immigration status

An immigration status that can make someone eligible to enroll in health coverage through Covered California. For more details, view our Information for Immigrants page.

emergency services

Care to evaluate and treat an emergency medical condition so it does not get worse.

Enhanced Silver plan

A Silver plan with extra out-of-pocket savings for eligible people based on income.

enrollment counselor

A trained assister who can help consumers apply for insurance and enroll, but cannot recommend which plan is best for them.

essential health benefits

Core categories of care that marketplace plans must cover, such as emergency care, hospital care, prescription drugs, preventive care and more.

exchange

Another term for health insurance marketplace.

exclusive provider organization (EPO)

A type of plan or network that usually covers care only from providers in its network, except for emergencies or approved out-of-network care.

F

federal poverty level (FPL)

A federal income measure used to help determine eligibility for programs and financial help. See the FPL chart for income ranges.

formulary

A health plan’s list of covered prescription drugs. Also called a drug list.

G

Gold plan

A metal-tier plan with higher monthly premiums than Bronze or Silver, but lower out-of-pocket costs when you use care.

H

habilitative services

Health care services that help a person keep, learn or improve skills for daily living.

health care service plan (HCSP)

A type of health care network that offers covered benefits through one network of providers.

health insurance marketplace

A place where individuals and families can compare health plans, learn about financial help, and enroll in coverage. In California, that marketplace is Covered California.

health maintenance organization (HMO)

A type of health plan that usually covers care only from doctors and hospitals in its network, except in emergencies.

hospitalization

Care in a hospital that requires you to be admitted as an inpatient.

I

in-network

A term used to describe services that are covered through your plan’s network of contracted doctors, hospitals, and other providers.

independent practice association (IPA)

A physician organization that negotiates with health insurance companies on behalf of doctors in private practice.

inpatient care

Health care you receive after being admitted to a hospital or other facility.

L

legal resident of California

A person who is lawfully present is determined in accordance with federal law. Learn more about residency requirements on our Eligibility page.

M

marketplace

Another term for health insurance marketplace. See health insurance marketplace.

Medi-Cal

California’s Medicaid program, which provides health insurance for people who qualify based on current rules.

Medi-Cal Access Program (MCAP)

A California program that provides low-cost health coverage for eligible pregnant people who do not qualify for Medi-Cal.

minimum coverage plan

Also called a catastrophic plan. It is designed mainly to protect against very high medical costs and is available only to certain people who meet age or hardship rules.

minimum essential coverage (MEC)

A health insurance plan that meets the Affordable Care Act’s requirement for having health insurance.

minimum value

A health plan through a job provides minimum value if it is expected to pay at least 60 percent of covered medical costs.

N

Navigator

A Covered California assister who provides culturally and linguistically appropriate enrollment help and information.

network

The doctors, hospitals, pharmacies and other providers a health plan has contracted with to provide care.

O

open enrollment

The yearly time period when people can enroll in a health plan or make changes to their plan. Outside that window, people usually need a qualifying life event to enroll, while Medi-Cal is available year-round.

out-of-pocket costs

Health care costs you pay yourself and are not reimbursed for.

out-of-pocket limit

The most you pay for covered services during a plan year before your plan pays 100 percent of covered costs. Premiums and some other charges do not count toward this limit.

P

Platinum plan

A metal-tier plan with the highest monthly premiums and the lowest out-of-pocket costs when you use care.

preferred provider

A provider who has agreed to discounted rates with your health plan.

preferred provider organization (PPO)

A type of health plan that lets you use providers outside the network, usually at a higher cost.

premium

The amount you pay to keep your health plan active, usually every month.

premium assistance

A type of financial help that lowers monthly premium costs. See Advance Premium Tax Credit.

Premium tax credit

A tax credit that helps eligible individuals and families afford health coverage purchased through a marketplace such as Covered California.

preventive care

Routine care such as screenings, checkups and counseling that helps prevent illness or find problems early.

pricing region

One of California’s health insurance pricing areas. Available plans and prices vary by region, and users can find their region through Shop and Compare.

primary care provider

The doctor or other qualified clinician who provides routine care, coordinates care and helps patients access other services.

Q

qualified health plan (QHP)

A marketplace-certified health plan that covers essential health benefits, follows cost-sharing rules, and meets other legal requirements.

qualifying life event (QLE)

A life change that can make someone eligible for special enrollment, such as getting married, having a baby or losing other insurance.