Helpful Medical Terms To Help Understand The Affordable Care Act – ACA – Obamacare

The Affordable Care Act (more commonly known as “Obamacare” – one of the more helpful medical terms) is a sweeping health care reform law passed by Congress in 2010. Its intent was to improve the methods with which people can obtain and keep healthcare coverage. It set out to accomplish three main goals:

  • Increase access to health insurance.
  • Reduce health insurance costs.
  • Improve the ways that people can obtain health care.

Co-Insurance Percentage – A form of cost sharing that will lower your premium. It is usually a percentage of health care costs. A co-insurance percentage will include a “stop loss” amount. This will be the maximum cost you will incur.

Copay – A fixed amount you pay for a covered health expense, usually at the time of service.

Deductible – A deductible is tantamount you pay out of pocket before your health insurance benefits begin to pay. This amount will be calculated on a yearly basis. You will have a new deductible to have to be satisfied annually.

Not Subject to Deductible – It means just what it says. The health benefit is not subject to a deductible. This will sometimes apply to doctor’s office visit costs. An example would be, “doctor’s visit” copay $50 (not subject to deductible). Most “well care benefits” will not be subject to a deductible.

Network – Group of doctors, hospitals, and other health care facilities.

Preferred Physician Organization – PPO – Managed care organization consisting of a group of physicians, hospitals, and other health care facilities that contract with an insurance company to offer substantial health care discounts. Some are larger and offer a wide variety of doctors and hospitals. Other PPO’s are smaller and perhaps offer more substantial health care discounts which should result in lower insurance prices.

Health Maintenance Organization – HMO – A group of doctors, hospitals and other health care providers that contract with an insurance company to offer substantial health care discounts. Some of the characteristics of and HMO are; requiring the consumer to select a Primary Care Physician (who will be responsible to coordinate all medical care), the requirement to obtain a referral from the PCP to see a specialist, and a requirement to stay within the HMO network. Hopefully, these health care restrictions will result in a lower health insurance rates for the consumer.

Primary Care Physician – PCP – A physician, chosen by a health care consumer, who provides care to the patient at the time of the first (non-emergency) contact which usually occurs on an outpatient basis. Primary Care Physicians are usually general practitioners, a family practitioner and in some areas, a woman’s gynecologist may serve as the primary care physician. The PCP will make referrals to a specialist.

Specialist – Usually practices one branch of medicine. Some examples of specialists are:

  • Cardiologist
  • Dermatologist
  • Podiatrist
  • Ear, Nose, and Throat – ENT
  • Rheumatologist
  • Urologist

Pre-Existing Health Condition Clause – A pre-existing health condition is a medical condition that is usually excluded from health insurance coverage because the condition was believed to exist prior to the individual obtaining health insurance coverage. The Affordable Care Act eliminated pre-existing health conditions as a reason to deny coverage or reduce coverage for an individual applying for insurance. Good news for people that have pre-existing health conditions. Bad news for the healthy applicants because it has caused a dramatic increase in health insurance rates. (Pre-existing health conditions can still be declined by health insurers who are providing short-term health insurance policies.)

Stop Loss or Total Out of Pocket Expense – A convenient way to express your total out of pocket expense if you experience a serious accident or illness. It’s usually the entire amount of your annual deductible and the entire amount of your coinsurance percentage.

Well-Care Benefits – The Affordable Care Act stipulates that all eligible health plans offer preventive treatment without cost sharing. No Co-pay, deductible or co-insurance will apply to preventive care. Some examples of preventive care are; mammograms, screenings for cervical cancer, prenatal screenings, and colonoscopies. A good resource for learning more about preventive health benefits

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