Insurance Glossary

A federal subsidy that reduces your monthly health insurance premium. Based on your income and the cost of plans in your area.

The maximum amount your insurance will pay for a covered service. Also called "eligible expense" or "negotiated rate."

When an out-of-network provider bills you for the difference between their charge and the allowed amount. Banned in many states.

The second-lowest cost Silver plan (SLCSP) in your area. Used to calculate your premium tax credit.

A low-premium, high-deductible plan available to people under 30 or those with a hardship exemption. Not subsidy-eligible.

Your percentage share of costs after meeting your deductible. For example, 20% coinsurance means you pay 20% of covered services.

A fixed amount you pay for a covered service at the time of service. For example, $30 for a doctor visit.

Extra savings on out-of-pocket costs (lower deductibles, copays) for people with incomes below 250% FPL who choose Silver plans.

The amount you pay out-of-pocket before your insurance starts covering costs. Resets each year.

A plan that only covers in-network care (except emergencies) but doesn't require referrals to see specialists.

The 10 categories of services ACA plans must cover: ambulatory, emergency, hospitalization, maternity, mental health, prescription drugs, rehab, lab services, preventive care, and pediatric services.

A statement from your insurance showing what was billed, what they paid, and what you owe. Not a bill.

Income thresholds set by the government, used to determine eligibility for subsidies and Medicaid. Updated annually.

Your plan's list of covered prescription drugs, organized into tiers with different costs.

A medication with the same active ingredient as a brand-name drug but typically much cheaper.

A plan requiring you to choose a primary care physician (PCP) and get referrals to see specialists. Usually lower cost.

Doctors, hospitals, and other providers that have contracts with your insurance to provide care at negotiated rates.

The income figure used to determine subsidy eligibility. For most people, it's close to your Adjusted Gross Income (AGI).

The online platform (HealthCare.gov or state exchanges) where you shop for and enroll in ACA health insurance plans.

Plan categories (Bronze, Silver, Gold, Platinum) that indicate how costs are shared. Higher metals = higher premiums but lower out-of-pocket costs.

The annual period (usually Nov 1 - Jan 15) when you can sign up for or change Marketplace coverage without a qualifying event.

Providers who don't have a contract with your insurance. You'll pay more (or everything) for their services.

The most you'll pay for covered services in a year. After reaching this, insurance pays 100%. Includes deductibles, copays, and coinsurance.

A hybrid plan combining HMO and PPO features. You have a PCP and need referrals, but can go out-of-network at higher cost.

A flexible plan that lets you see any provider without referrals. In-network care costs less than out-of-network.

Approval from your insurance required before certain services are covered. Also called "prior authorization."

The monthly amount you pay for health insurance coverage, regardless of whether you use healthcare services.

Services like checkups, vaccines, and screenings that prevent illness. Covered 100% with no cost-sharing under ACA.

Your main doctor who manages your overall care and provides referrals to specialists when needed (in HMO/POS plans).

A life change (marriage, baby, job loss, moving) that lets you enroll in coverage outside Open Enrollment.

A geographic region used to determine your premium rates. Usually based on county or ZIP code.

A recommendation from your PCP to see a specialist, required by HMO and POS plans before insurance covers the visit.

The benchmark used to calculate your premium tax credit. Your subsidy is based on this plan's premium.

A time outside Open Enrollment when you can enroll due to a qualifying life event. Usually lasts 60 days.

High-cost medications used to treat complex conditions. Often require special handling and have highest copays.

A standardized document that explains what a plan covers, what it costs, and what's not covered. Required for all plans.