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TERMS TO KNOW

The insurance landscape includes language that can be COPAYMENT

confusing. These common terms are important to know:
A fixed amount (for example, $15) you pay for a
covered health care service, usually when you get the
ACCUMULATOR ADJUSTER PROGRAM
service. The amount can vary by the type of covered
Accumulator adjuster programs are strategies that health care service.**
pharmacy benefit managers implement, often, but
not only, in connection with large group employer COPAY ASSISTANCE

health plans. AAPs apply to patients who use drug Copay assistance (sometimes called “copay cards”
copay cards and other forms of manufacturer copay or “coupons”) is money that helps patients afford
assistance. Under an AAP, a pharmacy benefit out-of-pocket costs for their medications. Patients
manager accepts copay assistance for out-of-pocket with chronic conditions such as bleeding disorders
costs associated with a prescribed drug, but then need specialty medications to manage their disease.
doesn’t credit that amount toward the patient’s Copay assistance is often the only way that they can
overall deductible or out-of-pocket maximum. This afford the out-of-pocket costs for their life-saving
means that the PBM will draw down the full value medications.
of the copay card and still require the patient to
pay copays (for additional medication fills, doctor’s COST SHARING

visits, etc.) up to the yearly out-of-pocket maximum. The share of costs covered by your insurance that
The manufacturer assistance will not apply toward you pay out of your own pocket. This term generally
satisfying the yearly maximum. includes deductibles, coinsurance, and copayments,
or similar charges, but it doesn’t include premiums,
AFFORDABLE CARE ACT
balance billing amounts for non-network providers or
The ACA is a comprehensive health care reform the cost of non-covered services.**
law enacted in March 2010. Often referred to as
“Obamacare,” the ACA’s reforms affect nearly every DEDUCTIBLE

American in some way. The law creates paths to The amount you owe for health care services covered
coverage for people who do not get insurance by your health insurance or plan before your health
through their jobs; protects the ability of people with insurance or plan begins to pay. For example, if your
preexisting conditions to obtain insurance on a non- deductible is $1,000, your plan won’t pay anything
discriminatory basis; requires Marketplace plans to until you’ve met your $1,000 deductible for covered
cover essential health benefits, including prescription health care services subject to the deductible. The
drugs; eliminates lifetime and annual caps on health deductible may not apply to all services.**
benefits; limits yearly out-of-pocket exposure for
patients; and more. OUT-OF-POCKET LIMIT

CLAIM The maximum amount you will be required to pay
for covered services in a year before the plan covers
A request for payment that you or your health care 100 percent of all costs. Generally, this includes the
provider submits to your health insurer after you deductible, coinsurance and copayments (varies
receive covered items or services.* from plan to plan), but not premiums. Plans can set

different out-of-pocket limits for different services,
COINSURANCE
and some plans do not have out-of-pocket limits.*
Your share of the costs of a covered health care
service, calculated as a percentage (for example, 20 PREMIUM

percent) of the allowed amount for the service. You A monthly or annual payment you make to your
pay coinsurance plus any deductibles you owe. For insurer to get and keep insurance coverage. Premiums
example, if the health insurance or plan’s allowed can be paid by employers, unions, employees or
amount for an office visit is $100 and you’ve met your individuals or shared among different payers.*
deductible, your coinsurance payment of 20 percent
would be $20. The health insurance or plan pays the * Resource: National Hemophilia Foundation Glossary
of Commonly Used Health Care Terms
rest of the allowed amount.** ** Resource: Healthcare.gov Glossary
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