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Get Covered Illinois Glossary
A
Advanced Premium Tax Credit (APTC)
The APTC is financial help that can lower your monthly health insurance premium. The amount you qualify for is based on factors such as your household size and estimated annual income. If you receive APTC, you'll compare the amount you received with the amount you were eligible for when you file your federal taxes. Any difference may affect your tax refund or taxes owed. Learn more about tax reconciliation and financial help through Get Covered Illinois.
Affordable Care Act
Passed in March 2010, the Patient Protection and Affordable Care Act (Affordable Care Act) is a federal law that makes health coverage more accessible and affordable for individuals and families. It includes protections for customers and helps expand access to health care services.
Adjusted Gross Income
Your total taxable income minus certain eligible deductions or adjustments.
All Kids
Illinois’ health insurance program for children, providing comprehensive, low-cost or free coverage regardless of immigration status or pre-existing health conditions. The program includes Illinois’ implementation of the federal Children’s Health Insurance Program (CHIP), as well as Medicaid coverage for eligible children.
American Indian or Alaska Native
Individuals who are members of a federally recognized American Indian or Alaska Native tribe. Federally Recognized tribal members are eligible for additional opportunities, such as a monthly enrollment opportunity and enhanced Cost Sharing Reductions.
Annual Household Income
The total amount of income for a family in a calendar year.
Appeal
A request for your health insurance company or marketplace to review a decision that denies a benefit or payment.
Assisters
Certified professionals who provide free, in-person, or virtual help to residents applying for health insurance through the Get Covered Illinois marketplace. This includes navigators and certified application counselors.
B
Benefit
The health care items or services covered under a health insurance plan.
Broker
A trained and licensed professional who provides free, in-person help and advice for selecting private insurance plans.
Bronze Plan
A health insurance plan in the Bronze metal tier, where the plan generally covers about 60 percent of health care costs and you pay about 40 percent, typically with lower premiums and higher out-of-pocket costs.
C
Catastrophic Health Plan
A health insurance plan with a low monthly premium and very high annual deductible designed to protect customers from worst-case situations like a serious injury or illness. They are NOT comprehensive health coverage. They are generally available to people under age 30 or those who file a hardship or affordability exemption. Customers can apply for exemptions through HealthCare.gov, then provide Get Covered Illinois with the hardship exemption certification number.
Chronic Disease Management
An integrated care approach to managing illness that includes screenings, checkups, monitoring, coordinating treatment and patient education to improve quality of life and reduce costs for people with chronic disease. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Claim
A request for payment that you or your health care provider submits to your health insurer after you receive items or services you think are covered.
COBRA
A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee or another qualifying event. If you elect COBRA coverage, you generally pay 100 percent of the premiums plus a small administrative fee.
Coinsurance
Your share of the costs of a covered service, usually shown as a percentage, usually after you have met your deductible and until you reach your out-of-pocket maximum.
Copayment (Copay)
A fixed amount you pay for a covered health care service or prescription, usually at the time you receive the service.
Cost-Sharing
The share of costs covered by your insurance that you pay out of pocket, generally including deductibles, coinsurance and copayments, but not premiums or the cost of non-covered services.
Cost-Sharing Reductions (CSR)
Subsidies that lower the amount you pay when you get care by reducing out-of-pocket costs (like deductibles, copays and coinsurance) for eligible people enrolled in Silver plans.
Eligibility is based on the projected household income you report; it may apply if your income is between 100% and 250% of the federal poverty level (FPL) and you otherwise qualify for coverage through Get Covered Illinois. Federally recognized tribe members or Alaska Native Claims Settlement Act (ANCSA) shareholders may qualify for additional CSR.
Customer
An Illinois resident who is shopping for, comparing or enrolling in individual health insurance coverage through the state’s official marketplace.
Customer Service Representative
A trained employee who works in a customer service or call center and helps customers understand their health insurance options, eligibility and enrollment.
D
Deductible
The amount you owe for health care services your health insurance plan covers before your plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you have met your deductible for covered health care services. Some services are covered before the deductible, such as annual check-ups and preventative care.
Dental Coverage
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays and fillings. Some dental coverage may be embedded in a health plan. However, most health plans will only cover major dental care resulting from an accident or injury and will not cover preventative or basic dental services. Stand-Alone Dental Plans are more likely to cover these services.
Dependent
A child or other individual for whom a parent, relative or other person may claim a personal exemption tax deduction. Under the Patient Protection and Affordable Care Act (ACA), individuals may be able to get premium assistance to help cover the cost of coverage for themselves and their dependents.
Dependent Coverage
Insurance coverage for family members of the policyholder, such as spouses, children or partners.
Disability
A limit in a range of major life activities; this can include limits on activities such as seeing, hearing and walking and on tasks such as thinking and working.
E
Eligible Immigration Status
An immigration status recognized by the marketplace as eligible for coverage. Certain individuals who are considered lawfully present have an eligible immigration status and may qualify for financial assistance.
Emergency Services
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Essential Health Benefits
Health care service categories that must be covered by certain health plans, including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care.
F
Federal Poverty Level (FPL)
A measure of income level issued annually by the U.S. Department of Health and Human Services and used to determine eligibility for certain programs and benefits. Find your FPL.
Fee-for-Service
A method in which doctors and other health care providers are paid for each service performed, such as tests or office visits.
Federally Recognized Tribe
An American Indian or Alaska Native tribe, band, nation, pueblo, village or community that the U.S. Department of the Interior acknowledges to exist as an American Indian tribe.
Members of federally recognized tribes may qualify for additional cost-saving benefits.
Formulary
A list of prescription drugs covered by your health plan; the covered drugs and your costs for them can vary by plan.
G
Get Covered Illinois
The state’s official health insurance marketplace.
Gold Plan
A health insurance plan in the Gold metal tier, where the plan generally covers about 80 percent of health care costs and you pay about 20 percent.
Grievance
A stated dissatisfaction or complaint about a health plan or insurer that is not the same as an appeal of a coverage or payment decision.
H
Health Coverage
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment or a government program such as Medicare, Medicaid or All Kids.
Health Insurance
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Insurance Marketplace
A resource where individuals, families and small businesses can learn about their health coverage options, compare health insurance plans based on costs, benefits and other features, choose a plan and enroll in coverage, often with access to financial assistance. Get Covered Illinois is our state’s official health insurance marketplace. This is also referred to as “marketplace.”
Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors and hospitals that work for or contract with the HMO, often requires you to live or work in its service area, and frequently focuses on prevention and wellness; most HMOs do not cover out-of-network care except in emergencies.
Health Savings Account (HSA)
A personal savings account you can use to pay for certain qualified medical expenses with pretax dollars, available only if you are enrolled in an HSA-qualified plan such as a high-deductible health plan, catastrophic plan or Bronze plan.
Home Health Care
Health care services a person receives at home.
Hospice Services
Services that provide comfort and support for persons in the last stages of a terminal illness and for their families.
Hospital Outpatient Care
Care in a hospital that usually does not require an overnight stay.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually involves an overnight stay; an overnight stay for observation may still be considered outpatient care. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Household
The taxpayer or taxpayers filing jointly and any individuals claimed as dependents on a single federal income tax return. The household size is the number of people included in your household.
Household Income
The total income of all members of your household whose income is required to be reported on a federal tax return. Household income is used to determine eligibility for financial help.
I
In-Network
The facilities, providers and suppliers such as doctors, hospitals and pharmacies your health insurance company or plan has contracted with to provide health care services; also called a provider network or preferred providers. Most health plans cover in-network providers at lower costs compared to out-of-network providers; some health plans will not cover out-of-network providers at all.
Insurer
A company that provides health insurance plans. Also called a carrier.
J
Job-Based Health Plan
Coverage that is offered to an employee, and often the employee’s family, by an employer.
K
L
Laboratory Services
An essential health benefit, covered by all health plans sold through Get Covered Illinois.
Lawfully Present
Individuals who are lawfully present in the United States and meet applicable eligibility requirements may qualify for marketplace coverage and financial assistance. This includes many non-citizens, such as lawful permanent residents (green card holders), refugees, asylees, certain visa holders, and others with qualifying immigration statuses. Eligibility rules may change, so customers should consult current marketplace guidance for the most up-to-date information.
Long-Term Care
Services that include medical and nonmedical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing; long-term services can be provided at home, in the community, in assisted living facilities or in nursing homes, and may be needed at any age.
M
Managed Care
An organized way to manage costs, use and quality of the health care system; major types of managed care plans include Health Maintenance Organizations (HMOs), Point-of-Service (POS) plans and Preferred Provider Organizations (PPOs).
Maternity and Newborn Care
An essential health benefit, covered by all health plans sold through Get Covered Illinois. You are eligible for these benefits, regardless of whether your pregnancy began before your coverage started. Plans include a Summary of Benefits and Coverage describing childbirth costs.
Medicaid
A state administered health insurance program for certain low-income people, including families and children, pregnant women, the elderly and people with disabilities. The federal government provides part of the funding and sets guidelines, while states design and operate their programs.
Medicare
A federal health insurance program for people age 65 and older and certain younger people with disabilities. It also covers people with end stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Mental Health and Substance Use Disorder Services
Get Covered Illinois plans cover mental health and substance use disorder services as essential health benefits, including psychotherapy and counseling (behavioral health treatment), mental/behavioral health inpatient services and substance use disorder treatment. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Metal Tiers
Categories of health plans (Bronze, Silver, Gold and Platinum) based on how you and your plan share costs.
Minimum Essential Coverage
Health coverage that meets the Affordable Care Act’s coverage requirements, including marketplace plans, job-based coverage, Medicare, Medicaid, and certain other types of coverage. Individuals who have an offer of certain other minimum essential coverage may not qualify for advanced premium tax credits (APTC) through the marketplace.
Modified Adjusted Gross Income (MAGI)
Your Adjusted Gross Income (AGI) with certain amounts (untaxed foreign income, nontaxable Social Security benefits, etc.) added back in; used to determine if you qualify for certain government programs or tax benefits such as premium tax credits and Medicaid.
N
Navigator
Trained staff or organizations, often from local community groups, that provide free help with filling out applications and enrolling in coverage. Find a navigator near you.
Navigator Grantee
A Get Covered Illinois Certified Enrollment Entity that has been awarded grants to participate in the navigator program and provide outreach, education and enrollment assistance.
Navigator Program
A program established by federal law in which marketplaces award grants to entities that provide fair, impartial information, outreach, education and enrollment assistance to customers.
Network
The facilities, providers and suppliers such as doctors, hospitals and pharmacies your health insurer or plan has contracted with to provide health care services; also called a provider network or preferred providers.
Non-Preferred Provider
A provider who does not have a contract with your health insurer or plan to provide services to you; you generally pay more to see a nonpreferred provider.
O
Open Enrollment
The designated period each year when individuals can compare, enroll in, or make changes to health insurance plans through a marketplace such as Get Covered Illinois. Individuals with certain qualifying life events may qualify for a special enrollment period outside of this time.
Out-of-Network
Any facilities, providers and suppliers such as doctors, hospitals and pharmacies that are not part of your health insurance company or plan’s provider network. Most plans will not pay or will pay less if you go out-of-network.
Out-of-Pocket Costs
Your expenses for medical care that are not reimbursed by insurance, including deductibles, coinsurance and copayments for covered services plus costs for services that are not covered; this does not include your premium.
Out-of-Pocket Maximum
The most you pay during a policy period (usually a year) for covered health services; after you reach this amount with deductibles, copays and coinsurance, your health plan pays 100 percent of the allowed amount for covered benefits, although not all expenses count toward this limit.
P
Pediatric Services
Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening and oral health risk assessments. This is an essential health benefit, which is a part of every health plan sold on the marketplace
Physician Services
Health care services a licensed medical physician (M.D. or D.O.) provides or coordinates.
Plan
A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Plans may be offered through an employer, union, government program, or Get Covered Illinois.
Plan-Based Enrollers
Representatives who work directly for a health insurance company that offers individual coverage through the marketplace, who are trained and authorized to provide enrollment assistance and may accept premium payments on behalf of the company they work for.
Plan Year (Policy Year)
The 12-month period in which a health plan provides coverage; often the same as the calendar year, January through December.
Policy
The contract (agreement) between the person buying health insurance and the company providing it, describing covered health care services, coverage limitations and required out-of-pocket costs.
Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary; sometimes called prior authorization, prior approval or precertification, and often required before you receive certain services except in an emergency.
Pre-Existing Medical Condition
Any illness or condition a patient has before obtaining insurance. Under the Affordable Care Act, insurers cannot deny coverage or charge higher premiums because of a pre-existing condition.
Preferred Provider
A medical provider who has a contract with your health insurer or plan to provide services to you at a discount; some plans use tiered networks that may require you to pay more to see certain preferred providers.
Preferred Provider Organization (PPO)
A type of health insurance plan that contracts with a network of participating doctors and hospitals; you pay less if you use providers in the network but can use out-of-network providers at a higher cost.
Premium
The amount you pay for your health insurance plan, usually each month; you must pay it on time even if you do not use health care services that month.
Premium Tax Credit
Type of assistance that helps customers pay for health insurance purchased through the marketplace. The credit may be claimed when filing federal taxes or received in advance as an advanced premium tax credit to reduce monthly premiums.
Prescription Drug Coverage
Health insurance or a health plan benefit that helps pay for prescription drugs and medications. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Prescription Drugs
Drugs and medications that require a prescription by law.
Preventive Care (Preventive Services)
Routine health care that includes screenings, checkups, vaccinations and patient counseling to prevent illnesses, disease or other health problems, often covered without cost sharing when provided by in-network providers.
Primary Care
Health services that cover a range of prevention, wellness and treatment for common illnesses; primary care providers include doctors, nurses, nurse practitioners and physician assistants who often maintain long-term relationships with patients and coordinate their care.
Primary Care Physician
A doctor (M.D. or D.O.) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A doctor (M.D. or D.O.), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider
A doctor (M.D. or D.O.), other health care professional or health care facility licensed, certified or accredited as required by state law.
Provider Network
A list of health care providers and facilities that an insurance plan contracts with to provide care to its members, typically referred to as in-network providers.
Q
Qualifying Life Event
An event that makes an individual eligible to enroll in or change health insurance coverage outside of the open enrollment period, such as moving, getting married or having a baby; a life change event opens a special enrollment period.
R
Rehabilitation Services (Rehabilitative Services)
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled; these services may include physical and occupational therapy, speech language pathology and psychiatric rehabilitation in a variety of inpatient and/or outpatient settings. This is an essential health benefit, which is a part of every health plan sold on the marketplace.
Rescission
The retroactive cancellation of a health insurance policy; under federal law, rescission is generally illegal except in cases of fraud or intentional misrepresentation of material facts.
Rider (Exclusionary Rider)
An amendment to an insurance policy that can add coverage or, in some individual policies, permanently exclude coverage for a specific health condition, body part or body system; certain exclusionary riders are not permitted under current federal law.
S
Silver Plan
A health insurance plan in the Silver metal tier, where the plan generally covers about 70 percent of health care costs and you pay about 30 percent.
Small Business Employers
Employers that generally have fewer than a specified number of fulltime employees or equivalents. Some health reform provisions apply only to small employers.
Small Business Health Options Program (SHOP)
A marketplace program that offers health insurance choices to small businesses and their employees, allowing employers to offer a variety of plans and contribution options. Get Covered Illinois does not offer SHOP at this time.
Small Business Tax Credit
A federal tax credit for eligible small businesses that have a limited number of employees, pay average annual wages below a set threshold and pay at least half of employee health insurance premiums when coverage is purchased through a marketplace.
Special Enrollment Period
A period of time outside of open enrollment when you and your family can enroll in or change health coverage if you experience a qualifying life event, such as marriage, the birth of a child, or loss of other coverage.
Specialist
A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions, or a nonphysician provider with advanced training in a specific area of health care.
Stand-Alone Dental Plan
A marketplace insurance plan that covers most preventative and basic dental care such as regular cleanings, exams, x-rays, fillings, etc. A Stand-Alone Dental Plan does not include coverage for any non-dental health care and is a separate product from a health insurance plan.
Standardized Plans
Health insurance plans that use a common cost sharing and benefit structure so that customers can more easily compare options across different companies.
Subsidy
Financial assistance, such as premium assistance and cost sharing reductions, that lowers the cost of premiums and out-of-pocket expenses for qualifying individuals and families who purchase coverage through a marketplace.
Summary of Benefits and Coverage (SBC)
A standard, easy to understand document that summarizes the benefits, coverage, costs and key features of a health plan so customers can compare plans side by side.
T
Tax Credit
A tax benefit that can reduce the amount of tax owed or increase a refund. In the Marketplace, this term most commonly refers to the premium tax credit and advanced premium tax credit, which help customers pay for health insurance coverage.
Telehealth (Telemedicine)
The use of telecommunications and information technology, such as two-way video, email, smartphones and other tools, to allow medical providers to evaluate, diagnose and treat patients at a distance in real time.
Third Party Payer
Any payer of health care services other than you, such as an insurance company, an HMO, a PPO or a government program.
U
Urgent Care
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away but not so severe as to require emergency room care.
V
Verification (Data Matching)
The process used by the marketplace to compare information provided on an application with trusted federal, state or other data sources to confirm eligibility for health coverage and financial help.
W
Waiting Period
The time that must pass before coverage can become effective for an employee or dependent, who is otherwise eligible for coverage under a job-based health plan. Marketplace health plans do not have employment-based waiting periods. Coverage generally begins on the plan's effective date after enrollment.
Well-Baby and Well-Child Visits
Routine preventive checkups for infants, children and adolescents. These visits may include physical exams, growth and development assessments, vaccinations, vision and hearing screenings, and oral health risk assessments.
X
Y
Z
Zero Cost Sharing Plan
A marketplace health plan available to eligible American Indian and Alaska Native customers that has no deductibles, copays or coinsurance for covered services.
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