A
It's a person who contracts with an insurance company for benefits via direct pay.
Individual
It is a set dollar amount the member pays each month for health insurance coverage.
Premium
It's a plan that requires referrals and PCP selection but has the lowest out-of-pocket cost.
HMO
This is just another term for your family doctor, or the doctor you see for most of your health care needs.
Primary Care Physician (PCP)
Benefits that are normally not covered or only partially covered in regular medical plans.
Specialty Services
The unique number assigned to each subscriber for identification purposes.
Unique Member Identifier (UMI)
Is the scientific study of the emotions, behaviors and biology relating to a person’s mental well-being, their ability to function in everyday life and their concept of self.
Behavioral Health
Includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies.
Durable Medical Equipment (DME)
A third-party vendor who administers prescription drug benefits, provides a network of participating pharmacies, processes pharmacy claims, negotiates price discounts from pharmaceutical manufacturers, handles drug utilization and quality reviews, and facilitates all mail orders.
Pharmacy Benefits Manager (PBM)
Does having a health insurance card mean you’re currently covered?
Not necessarily — the card doesn’t prove active coverage. Eligibility must be verified.
Does a health insurance plan have to cover all FDA-approved drugs?
No. Plans can choose which drugs to include in their formulary based on cost and effectiveness.
Can someone be enrolled in both a Marketplace plan and Medicare at the same time?
No. Once enrolled in Medicare, you’re no longer eligible for premium tax credits through the Marketplace.