Exclusions

Services or treatments that are not covered by a health insurance plan. Exclusions vary by plan, and they may include specific treatments, procedures, or prescription drugs that are not considered medically necessary.

Exchange Plan

A health insurance plan purchased through the ACA Marketplace (also known as the exchange). These plans must meet ACA standards and cover Essential Health Benefits. Exchange plans come in different levels, including Bronze, Silver, Gold, and Platinum.

End-Stage Renal Disease (ESRD)

A medical condition in which a person’s kidneys stop functioning permanently, requiring dialysis or a kidney transplant. Individuals with ESRD are eligible for Medicare regardless of age.

Enrollee

An individual who is covered by a health insurance plan, such as those offered through Medicare, Medicaid, CHIP, or the ACA Marketplace.

Enrollment Period

The designated time frame during which individuals can sign up for or make changes to their health insurance coverage. Medicare has an Annual Enrollment Period, and the ACA Marketplace has an Open Enrollment Period.

Federal Poverty Level (FPL)

A measure of income issued annually by the Department of Health and Human Services (HHS) to determine eligibility for various government assistance programs, including Medicaid, CHIP, and ACA subsidies. The FPL varies based on household size and geographic location.

Formulary

A list of prescription medications that are covered by a health insurance plan, such as Medicare Part D or CHIP. Drugs listed on a formulary are usually divided into tiers, with different levels of cost-sharing based on the type of drug (generic, brand-name, or specialty).

Federally Qualified Health Center (FQHC)

A community-based health clinic that provides comprehensive primary and preventive care services, including dental, mental health, and substance use services. Medicaid, Medicare, and CHIP typically cover services received at FQHCs, which serve low-income, uninsured, and underserved populations.

Fee-for-Service (FFS)

A traditional healthcare payment model in which healthcare providers are paid separately for each service provided to a patient, such as doctor visits, tests, or procedures. Medicare and Medicaid offer FFS options, although many states are moving towards managed care models.

Formulary Tiers

Categories within a drug formulary that determine the level of coverage and cost-sharing for medications. Typically, Tier 1 includes generic drugs with the lowest copays, while higher tiers include brand-name and specialty drugs with higher costs.

Full Medicaid Benefits

Comprehensive healthcare services provided to individuals who qualify for Medicaid based on income, age, disability, or other criteria. Full Medicaid benefits include hospital care, doctor visits, preventive services, prescription drugs, and long-term care, among others.

Financial Assistance (ACA)

Subsidies provided through the ACA Marketplace to help eligible individuals and families pay for health insurance premiums and out-of-pocket costs. There are two main types of financial assistance: premium tax credits and cost-sharing reductions.

Flexible Spending Account (FSA)

A tax-advantaged account that allows individuals to set aside pre-tax dollars to pay for eligible healthcare expenses, such as medical, dental, and vision care. FSAs are commonly offered by employers as part of health benefit plans, and the funds must be used within a specified period.

Family Coverage

A health insurance plan that covers an entire family, including the policyholder, spouse, and dependents. Under the ACA, parents can keep their children on their health plan until age 26, even if the children are not financially dependent or living with the parents.

Federal Medical Assistance Percentage (FMAP)

The federal government’s share of the costs of providing Medicaid and CHIP services to eligible individuals. The FMAP varies by state and is based on the state’s per capita income, with lower-income states receiving a higher federal match.

Generic Drugs

Medications that contain the same active ingredients as brand-name drugs but are sold at lower prices. Medicare Part D, Medicaid, and CHIP often cover generic drugs to reduce costs for beneficiaries.

Gold Plan (ACA)

A health insurance plan offered through the ACA Marketplace that covers approximately 80% of healthcare costs, with the remaining 20% paid by the enrollee. Gold plans have higher premiums but lower out-of-pocket costs compared to Bronze and Silver plans.

Grace Period

The extra time given to policyholders to pay their health insurance premiums after the due date. During the grace period, coverage continues, but failure to pay by the end of the grace period may result in termination of coverage. This applies to ACA, Medicare, and Medicaid plans.

Guaranteed Issue

A requirement under the ACA that insurance companies must offer health insurance to any applicant regardless of health status, age, or gender, and cannot deny coverage based on pre-existing conditions.

Gap Coverage

Insurance coverage that fills the gaps in a primary health insurance policy. Medicare Supplement (Medigap) plans are a common form of gap coverage, helping pay for out-of-pocket costs not covered by Original Medicare (such as copayments, coinsurance, and deductibles).