Health insurance glossary + terms to know

If you are offered health insurance from your employer, it is considered "affordable" if your annual contribution (what comes out of your paycheck for the year) does not exceed (go over) 9.5% of your total gross annual household income.

If your employer offers affordable health insurance that meets minimum essential coverage requirements, you may not be eligible for certain subsidized health plan options.

Your annual medical deductible is an amount you may need to pay each benefit year before we will pay for covered services.

• You may need to pay part or all of your medical bill(s) until you reach your total annual medical deductible.
• If you have a family plan, your family annual medical deductible combines the annual medical deductibles paid by covered family members.

Note: A plan with a lower annual deductible will often have a higher monthly premium (and vice versa).

Your annual medical out-of-pocket maximum is a limit on the amount you need to pay for covered medical services within a benefit year.

• Your annual deductibles (if applicable), medical co-insurance, and medical co-payments all contribute to this maximum amount.
• Once you reach your full annual medical out-of-pocket maximum, we will pay for covered services for the remainder of the benefit year and you no longer need to pay co-payments or co-insurance for covered services. 

Keep in mind, once you reach your full annual medical out-of-pocket maximum, you are still responsible for your monthly premiums, co-payments, and co-insurance for prescription drugs.

Your annual pharmacy deductible is an amount you may need to pay each benefit year specifically for prescription drugs before we will pay for covered pharmacy costs.

Your annual pharmacy out-of-pocket maximum is a limit on the amount you need to pay specifically for covered prescriptions within a benefit year.

Once you reach your pharmacy out-of-pocket maximum, we will pay for covered prescriptions in full through the remainder of the benefit year. If you have a family plan, and a pharmacy out-of-pocket maximum, you need to reach your total family pharmacy out-of-pocket maximum before we will pay for covered prescriptions in full for all members enrolled under a family plan. However, once an individual in your family reaches their individual annual pharmacy out-of-pocket maximum, we will pay for covered pharmacy services in full for that individual.

A benefit year is the consecutive 12-month period during which health plan benefits are purchased and administered; deductibles, co-insurance, and the out-of-pocket maximums are calculated; and most benefit limits apply.

Note: In some cases, your first benefit year will not be a full 12 months.

An adult caretaker relative is a person who is:

• Living with children under age 19 to whom they are related by blood, adoption, or marriage, or
• A spouse or former spouse of one of those relatives, AND
• The primary caretaker of these children when neither parent is living in the home.

• Pregnant
• A parent or adult caregiver
• Disabled according to standards set by federal law
• HIV-positive
• In treatment for breast or cervical cancer

For more information about these categories of eligibility, please call MassHealth at 800-841-2900 (TTY: 800-497-4648).

A citizen national is a person who, though not a citizen of the United States, owes permanent allegiance to the United States. Please call the U.S. Citizenship and Immigration Services National Customer Service Center at 800-375-5283 (TTY: 800-767-1833) for more information, or visit www.uscis.gov

A health insurance plan that allows an employee who leaves a company to continue paying for coverage through their work for a certain amount of time.

Coinsurance is an amount, stated as a percentage, that you will pay for certain covered services, depending on your plan level. For example, if you have 20% co-insurance for a $100 covered medical service, then you will owe $20 at the time of the service.

ConnectorCare plans are affordable health insurance plans offered through the Massachusetts Health Connector. They have low monthly premiums and low out-of-pocket costs, with no deductibles.

A copayment is a fixed amount you may have to pay for a covered pharmacy or medical service at the time of service.

Cost sharing means you will pay for a portion of your health care costs not covered by Tufts Health Plan. The amount or percentage you pay will depend on your plan level.

A covered health service is care you need to get that we will pay for (cover).

Covered medications are drugs your doctor can prescribe that we will pay for (cover).

Your current household income is the combined income of all tax household members from all sources, including wages, commissions, bonuses, Social Security and other retirement benefits, unemployment compensation, disability, interest, and dividends.

Tip: Use the household income which you would report on your taxes for each person in your household.

A deductible is the amount that you must pay toward covered health care services before Tufts Health Plan will begin paying.

A person is considered disabled if they have a physical or mental condition that prevents or limits their ability to work for at least 12 months, and they:

• Get or can get Department of Mental Health services
• Get Emergency Aid to Elders, Disabled, and Children (EAEDC) benefits

An eligible resident is a person living in the United States who is eligible to apply for adjustment to permanent resident status. Please call the U.S. Citizenship and Immigration Services National Customer Service Center at 800-375-5283 (TTY: 800-767-1833) for more information, or visit www.uscis.gov

In deciding family size, MassHealth counts parents (natural, step, and adoptive) and their children under the age of 19 who live with them.

• If you’re pregnant, MassHealth counts your unborn child (or children) as a member of your family.
• If neither parent lives at home, a family can be children under the age of 19 and the relative(s) living at home and taking care of them.

If you are married and have no children under age 19, MassHealth and Commonwealth Care count you and your spouse.

Your household size is based on the number of personal exemptions which you would claim on your tax return during the specified year of health care coverage — regardless of how many people in your family or household will be covered under your health plan. Your household size would include yourself (or the income of the taxpayer), your spouse (if applicable), and any child or person who you claim as a tax dependent (this includes the income of any person who must report their income on a separate return but you still claim as a dependent on your tax return).

For example, if you would claim yourself, a spouse, and two children as dependents/exemptions on your tax return, your household size is four.

Generally, this describes coverage for care that POS and PPO members receive from participating providers in the Tufts Health Plan network. In-network coverage typically costs less than out-of-network coverage. In most cases, if you have a POS plan, you need to have a referral from your primary care provider (PCP) to another participating provider in order for in-network cost-sharing to apply. 

Inpatient medical care includes hospital or clinic treatment that requires at least one overnight stay.

Some examples may be if you are having a baby, or if you need to have surgery that requires you to stay overnight.

An integrated annual deductible is when your payments for either medical or pharmacy services both apply toward your deductible.

For example, if you have a $500 integrated annual deductible, and spend $400 on medical costs and $100 on pharmacy costs, you have met your $500 integrated annual deductible. Once you've met your integrated annual deductible, you only have to pay pharmacy or medical co-insurance or co-payments until you reach your total integrated out-of-pocket maximum.

An integrated annual out-of-pocket maximum is the maximum amount you may pay in a benefit year for both medical and pharmacy covered services. Once you reach your annual out-of-pocket maximum, you no longer need to pay co-payments or co-insurance for covered medical services. We will pay for covered medical services for the remainder of the benefit year. However, you will still need to pay your monthly premiums. Your monthly premiums do not contribute toward this maximum amount.

Check your plan to get more information about your covered services and costs. If your plan does not have an integrated annual out-of-pocket maximum, then your plan may have an annual medical out-of-pocket maximum and a separate annual pharmacy out-of-pocket maximum.

An integrated deductible is when your out-of-pocket expenses for both medical and pharmacy expenses are applied toward the same deductible total.

A lawfully present immigrant is:

• An immigrant or noncitizen who has been admitted to the U.S. and has not overstayed the period of time for which he or she was admitted.
• An immigrant who has current permission from the U.S. Citizenship and Immigration Services to stay or live in the U.S.

Learn more about U.S. citizenship and immigration terms.

A written document stating the medical care a person wants or does not want in the event the person becomes unable to speak his or her wishes.

MassHealth is the Medicaid program in Massachusetts that pays part or all of health care insurance costs for people who qualify.

Not sure? Check your MassHealth or health plan member ID card.

Medically necessary services, supplies, or drugs are those that prevent, diagnose, stop the worsening of, improve, correct, cure, or treat a medical condition that endangers your life, causes suffering or pain, causes physical deformity or malfunction, may cause or worsen a disability, or could result in making you very sick.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

For information about Medicare eligibility, visit  www.medicare.gov/MedicareEligibility  or call Social Security at 800-772-1213.

Minimum essential coverage is the type of coverage you need to have to meet the individual responsibility requirement under the Affordable Care Act, or you may face a penalty when you file your taxes for the year. This is defined as:

• Coverage under certain government-sponsored plans
• Employer-sponsored plans, with respect to any employee
• Plans in the individual market
• Grandfathered health plans
• Any other health benefits coverage, such as a state health benefits risk pool, as recognized by the Department of Health and Human Services.

Minimum essential coverage does not include health insurance coverage consisting of excepted benefits, such as dental-only coverage.

If your employer offers affordable health insurance that meets minimum essential coverage requirements, you may not be eligible for certain subsidized health plan options.

Not sure if your employer-sponsored plan meets minimum essential coverage requirements? Ask your employer.

In an effort to ensure the new-to-market prescriptions that we cover are safe, effective and affordable, we delay coverage of many new drugs until a physician specialist reviews them. If your doctor feels you need a new medication, they can contact us to request coverage.

Medications that are not currently covered by us. If your provider feels you require this medication, your provider should contact us. They may submit a request for coverage to Tufts Health Plan. We will cover the medication if it meets our coverage guidelines. If the request is approved, you will be covered for your prescription.

Out-of-network coverage applies only to POS and PPO plans. Tufts Health Plan will cover care that POS and PPO members receive from non-participating providers, but it usually costs more than in-network coverage. In addition, if you have a POS plan, you will — in most cases — have out-of-network coverage when you receive care for covered services from participating providers without your primary care provider’s referral.

An out-of-pocket maximum is a limit on the amount you need to pay for covered services within a benefit year.

Outpatient medical care includes hospital or clinic treatment that does not require an overnight stay. This means you are given care and discharged on the same day.

Part D is a program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage.

If you would like us to help you apply for MassHealth, this form will let us help you with the enrollment process. We may be able to give you status updates and help you if questions come up.

Your annual deductible is an amount you may need to pay each benefit year before we will pay for covered services.

The Power of Attorney is a written document in which one person gives another person the control to act for them in certain situations and functions.

Your premium is your monthly contribution to pay for your health plan coverage. The amount you pay may be based on your age, where you live in Massachusetts, your income, your plan and plan level, and your type of coverage. You’ll learn your exact premium when you apply and enroll. A plan with a lower premium will often have higher out-of-pocket costs (copayments and coinsurance) when you receive covered services.

Preventive care is health care that focuses on preventing disease and keeping you healthy. It includes early detection of disease, discovery and identification if you may be at risk for specific problems, counseling, and other necessary interventions to detect and avoid a potential health issue.

Common examples include screening tests, health education, and immunizations.

Your primary care provider is the doctor or other provider you see first for most health problems. They make sure you get the care you need to stay healthy. They also may talk with other doctors and health care providers about your care and refer you to them.

Prior authorization, also called “prior permission,” is the approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. Covered services that need prior authorization are marked in the Member Handbook. Some drugs are covered only if you get prior authorization from us. Covered drugs that need prior authorization are marked in the List of Covered Drugs or Preferred Drug List.

Your projected household income is your estimate for next year of the combined income of all tax household members from all sources, including wages, commissions, bonuses, Social Security and other retirement benefits, unemployment compensation, disability, interest, and dividends.

Tip: Use the household income which you would report on your taxes for next year for each person in your household.

Qualified immigrants are immigrants who have been given the right to reside permanently in the U.S., and to work in the U.S. without restriction.

Learn more about U.S. citizenship and immigration terms

Outside of the open enrollment period, all members can change health plan enrollment or coverage type (individual to family) for the following reasons (called “qualifying events”):

• Marriage
• Divorce, legal separation, or annulment
• Birth, adoption, or placement for adoption of a child
• Dependent spouse required to cover a child by court order
• Death of a spouse or dependent
• Covered dependent reaches the age limit for coverage, making them ineligible for coverage.
• You, your spouse, or eligible dependent move outside of your health plan’s service area.
• You, your spouse, or eligible dependent begins or returns from an unpaid leave of absence.
• You, your spouse, or eligible dependent has a change in job status (for example: change from full-time to part-time employment or leaving employment) that affects eligibility for benefit coverage under the employer’s plan or a plan of your spouse's or eligible dependent's employer.
• You, your spouse, or eligible dependent becomes a citizen, national, or lawfully present individual.
• You, your spouse, or eligible dependent are an American Indian, as defined by section 4 of the Indian Self-Determination and Education Assistance Act. See Indian Self-Determination and Education Assistance Act, 25 U.S.C. §450b(d). Such individual may enroll in or change from one plan to another one time per month.
• You, your spouse, or eligible dependent are newly determined eligible for a Federal Premium Tax Credit or there is a change in eligibility for a ConnectorCareplan.
• You lose minimal essential coverage.
• You are enrolled in an employee-sponsored plan that is not affordable.
• You are enrolled in a qualified health plan which substantially violates rules of your contract.
• You move to an area where you are newly eligible.
• You were erroneously enrolled in a qualified health plan by the Connector or the Department of Health and Human Services (HHS).
• Other special circumstances 

The qualifying event must be reported to the Health Connector within 60 days of the event. Changes to health plan enrollment or coverage type will be effective as of the qualifying event date.

Outside of the open enrollment period, all members can change health plan enrollment or coverage type (individual to family) for the following reasons (called "qualifying events"):

• Moved or will move within Massachusetts and left or will leave the service area of their health plan
• Became or will become ineligible for their employer’s health insurance benefits
• Became or will become ineligible for coverage offered by their school
• Used up or declined to participate in a former employer's COBRA or mini-COBRA benefits
• Lost or will lose coverage due to a divorce, legal separation, or end of a domestic partnership
• Lost or will lose eligibility as a dependent on a parent or guardian’s plan
• Lost coverage due to the death of a subscriber
• Lost or will lose government-subsidized coverage
• Lost or will lose coverage because their insurer will not renew their plan
• Received a waiver from the Department of Public Health’s Office of Patient Protection

The Commonwealth of Massachusetts, not Tufts Health Plan, determines eligibility. To learn more about your health plan options, including Tufts Health Plan, call the Health Connector at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

The quantity limit for a medication that can be purchased at any one time. A common QL is a 30-day supply, which is the maximum number of units needed for 30 days based on the prescribed daily/weekly dose. You’re covered for up to the quantity posted in our covered drug list. If your doctor believes you need to take more than that quantity, the doctor may submit a request for authorization.

A referral is authorization (permission) before you can use other providers in the plan’s network.

A lawfully present immigrant is a legal immigrant who has lived in the United States for less than five years.

Please call the U.S. Citizenship and Immigration Services National Customer Service Center at 800-375-5283 (TTY: 800-767-1833) for more information about residents with special status, or visit www.uscis.gov.

A specialist is a doctor who provides health care services for a specific disease or part of the body.

If you enroll in a new plan through the Health Connector, you may be eligible for certain state and federal subsidies to help you pay for your health insurance premiums and other costs. The level of help you can get is based on the federal poverty level applicable to you (determined by your income and family size).

Medical plans often place providers and hospitals in different categories, or tiers, with different cost-sharing amounts. Typically, you’ll save money when you see Tier 1 providers.

Your type of coverage describes how you set up your plan and who in your household will be covered. Types of coverage include:

• Individual (just yourself)
• Individual and spouse
• Individual and a child or children
• Family (you, a spouse, and a child or children)

Depending on which type of coverage you select, you will need to provide ages for each covered individual.

U.S. citizens are generally one of the following:

• An individual born in the United States
• An individual whose parent is a U.S. citizen
• A former alien who has been naturalized as a U.S. citizen
• An individual born in Puerto Rico
• An individual born in Guam
• An individual born in the U.S. Virgin Islands Learn more about U.S. citizenship and immigration terms.  

U.S. nationals are individuals who:

• Owe permanent allegiance to the U.S. and may enter and work in the U.S. without restriction, and
• Were born in American Samoa or the Commonwealth of the Northern Mariana Islands.

Learn more about U.S. citizenship and immigration terms.