Every term from the videos, defined in plain language. Each one comes with a short video so you can see how it works.
89 terms
A
Actuarial valueUnderstanding your plan
The percentage of total average costs for covered benefits that a health plan pays. For example, a plan with an 80% actuarial value (a Gold plan: A Marketplace health plan category where the plan pays about 80% of covered costs and you pay about 20%. Gold plans have higher monthly premiums than Bronze or Silver, but lower deductibles. They're best if you expect to use a lot of health care — the higher premium is offset by lower costs each time you get care. See entry) is expected to pay 80% of covered costs for a standard population — you'd pay the remaining 20% on average through Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry.
ExampleA Bronze plan: A Marketplace health plan category where the plan pays about 60% of covered health care costs, and you pay about 40%. Bronze plans typically have the lowest monthly premiums but the highest deductibles and out-of-pocket costs. Starting in 2026, Bronze plans are compatible with Health Savings Accounts (HSAs). See entry has ~60% actuarial value: the plan pays 60% of covered costs on average, you pay 40%. A Platinum plan: A Marketplace health plan category where the plan pays about 90% of covered costs and you pay about 10%. Platinum plans have the highest monthly premiums but the lowest out-of-pocket costs when you get care. Best suited to people who use health care very frequently. See entry has ~90% actuarial value — you pay only 10% on average.
Licensed insurance professionals who can help you choose and enroll in a plan. Agents may work for one insurance company; brokers typically represent several insurance companies. You don't pay extra to use one, but they're usually paid a commission by the insurer. To get Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry savings, they must enroll you through the Marketplace.
ExampleA broker compares plans from three insurers for you at no charge.
The maximum amount a plan will pay for a covered health care service. Also called eligible expense, payment allowance, or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference (called Balance billing: When a health care provider bills you for the difference between their charge and the amount your insurance pays. This most commonly happens with out-of-network providers. In-network providers have agreed to accept negotiated rates — out-of-network ones have not. See entry) if you're out of Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry.
ExampleYour plan's allowed amount for an MRI is $800. If your Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry provider charges $1,200, your insurance may only cover its share of the $800 — you could owe the rest.
Asking your insurance company, or the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry, to take another look at a decision to deny a benefit or payment. If your plan refuses to pay a Claim: A request for payment that you or your health care provider submits to your health insurer after you receive care. The insurer reviews the claim and pays its portion according to your plan terms, then notifies you of any remaining balance you owe. See entry or ends your coverage, you have the right to appeal.
ExampleYour plan denies an MRI, so you file an appeal with your doctor's notes.
When a health care provider bills you for the difference between their charge and the amount your insurance pays. This most commonly happens with Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry providers. In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry providers have agreed to accept negotiated rates — out-of-network ones have not.
ExampleAn Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry surgeon charges $5,000. Your insurer's Allowed amount: The maximum amount a plan will pay for a covered health care service. Also called eligible expense, payment allowance, or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference (called balance billing) if you're out of network. See entry is $3,000 and pays 70% of that ($2,100). You may owe not just your 30% share ($900) but also the $2,000 difference — totaling $2,900.
Prescription drugs sold under a manufacturer's trademark name. Brand-name drugs are typically more expensive than generics and placed in higher tiers on your plan's Formulary: A list of prescription drugs covered by your insurance plan, sometimes called a drug list. Drugs on the formulary are typically divided into tiers — generic drugs in lower tiers with lower copays, brand-name drugs in higher tiers with higher costs. Drugs not on the formulary may not be covered at all. See entry, meaning higher Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry or Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry for you. Always ask your doctor or pharmacist whether a generic equivalent is available.
ExampleYour doctor prescribes Lipitor (brand name) for cholesterol. Your plan places it in Tier 3 at $75/month. The generic atorvastatin is Tier 1 at $10/month — same active ingredient.
A Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health plan category where the plan pays about 60% of covered health care costs, and you pay about 40%. Bronze plans typically have the lowest monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry but the highest Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry and Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry. Starting in 2026, Bronze plans are compatible with Health Savings Accounts (HSAs).
ExampleYou're young and healthy. You choose a Bronze plan with a $450/month Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry and a $6,000 Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry. You pay for most routine visits yourself, but you're covered if something catastrophic happens.
A low-cost Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health plan available to people under 30, or people over 30 who qualify for a hardship or affordability exemption. Catastrophic plans have very low monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry but very high Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry — they mainly protect you from worst-case scenarios. They cover 3 primary care visits per year before you meet the deductible.
ExampleYou're 26 and rarely need medical care. A Catastrophic plan costs $95/month. You pay for most care out of pocket (Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry is over $9,000), but you're protected if you're in an accident or get seriously ill.
CHIP — Children's Health Insurance ProgramGovernment programs
A federal-state program that provides low-cost health coverage to children in families that earn too much to qualify for Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry but can't afford private insurance. In some states, CHIP also covers pregnant women. Like Medicaid, you can apply year-round.
ExampleYour household income is above the Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry limit but below what private insurance is affordable. Your children qualify for CHIP — they get dental, vision, doctor visits, and hospital care at very low or no cost.
A request for payment that you or your health care provider submits to your health insurer after you receive care. The insurer reviews the claim and pays its portion according to your plan terms, then notifies you of any remaining balance you owe.
ExampleAfter your hospital stay, the hospital files a claim with your insurance. Your insurer processes it, pays the covered portion, and sends you an EOB showing what's left for you to pay.
A federal law that gives workers (and their families) the right to continue employer-sponsored group health insurance coverage for a limited period after losing job-based coverage — typically 18 months. COBRA continuation coverage is often expensive because you pay the full Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry (employer + employee share) plus a small administrative fee.
ExampleYou leave your job in April. COBRA lets you stay on your employer's health plan for up to 18 months. The catch: you pay the full $650/month Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry yourself (your employer no longer contributes).
The percentage of costs of a covered health care service you pay after you've paid your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry generally have higher coinsurance.
ExampleYou've met your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry. A Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry visit has an allowed cost of $500. Your coinsurance is 20% — you pay $100, your insurance pays $400.
A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the Allowed amount: The maximum amount a plan will pay for a covered health care service. Also called eligible expense, payment allowance, or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference (called balance billing) if you're out of network. See entry.
ExampleYour plan charges a $30 copay for primary care visits. Every time you see your doctor, you pay $30 — whether the appointment cost $100 or $300.
A discount that lowers the amount you have to pay for Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry on a Silver Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plan. You qualify based on your income. Cost-sharing reductions are only available with Silver plan: A Marketplace health plan category where the plan pays about 70% of covered costs and you pay about 30%. Silver plans are the only tier where you can get cost-sharing reductions if your income qualifies — which can dramatically lower your deductible, copays, and coinsurance. If you qualify for extra savings, Silver is almost always the best value. See entry — you must enroll in Silver to get the extra savings.
ExampleYou qualify for cost-sharing reductions. On a standard Silver plan: A Marketplace health plan category where the plan pays about 70% of covered costs and you pay about 30%. Silver plans are the only tier where you can get cost-sharing reductions if your income qualifies — which can dramatically lower your deductible, copays, and coinsurance. If you qualify for extra savings, Silver is almost always the best value. See entry your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry might be $4,000. With your CSR applied, it drops to $800 — significantly lowering your Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry for the year.
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry or Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry for covered services — your insurance company pays the rest. Plans with lower monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry generally have higher deductibles.
ExampleYour deductible is $1,500. You visit a Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry who charges $400. You pay the full $400 — it counts toward your deductible. After you've paid $1,500 total across the year, your insurance starts sharing costs.
Durable medical equipment (DME)Coverage & benefits
Equipment and supplies a provider orders for everyday or long-term use, like oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetes.
A statement from your insurance company sent after you receive care. It explains what was billed, what the insurance paid, what adjustments were made, and what you owe. An EOB is not a bill — it's an informational statement. A separate bill from the provider will arrive if you owe any amount.
ExampleYou have a lab test. Your EOB arrives first: lab billed $400, insurance paid $280, you owe $120. A few days later, the lab sends you a bill for $120.
A managed care plan where services are covered only if you use doctors, Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry, or hospitals in the plan's Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry — except in an emergency. Unlike PPOs, EPOs don't cover any Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry care, but unlike HMOs, they usually don't require Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry to see specialists.
ExampleYou have an EPO. You can see any In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entrySpecialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry without a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry. But if you see an Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry provider for a non-emergency, your plan pays nothing — you owe the full amount.
EPSDT (Early and Periodic Screening, Diagnostic, and Treatment)Government programs
The name for the full set of benefits Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry covers for children.
ExampleYour child's Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry well-child visits and follow-up care fall under EPSDT.
A set of 10 categories of services that all Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry and Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry plans must cover. They include: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use services, prescription drugs, Rehabilitative services: Care that helps you get back, keep, or improve skills you lost because you were sick, hurt, or disabled. It can include physical, occupational, and speech therapy. See entry, lab services, preventive care, and pediatric services including dental and vision for children.
ExampleYour plan must cover mental health visits, prescription drugs, and maternity care as essential health benefits — insurers cannot refuse to cover these or impose annual or lifetime limits on them.
A review of your plan's denial by an independent third party with no ties to the plan. You can usually ask for one after your plan turns down your Appeal: Asking your insurance company, or the Marketplace, to take another look at a decision to deny a benefit or payment. If your plan refuses to pay a claim or ends your coverage, you have the right to appeal. See entry, and sooner in urgent cases.
ExampleAfter your plan rejects your Appeal: Asking your insurance company, or the Marketplace, to take another look at a decision to deny a benefit or payment. If your plan refuses to pay a claim or ends your coverage, you have the right to appeal. See entry, an outside reviewer decides the MRI should be covered.
An income measure the U.S. Department of Health and Human Services updates every year. Programs use it to decide who qualifies for Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry savings, Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry, and CHIP (the Children's Health Insurance Program).
ExampleThe Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry compares your household income to the FPL to see what savings you qualify for.
A list of prescription drugs covered by your insurance plan, sometimes called a drug list. Drugs on the formulary are typically divided into tiers — Generic drugs: Prescription drugs sold under their chemical name rather than a brand name. Generic drugs are FDA-approved to be as safe and effective as brand-name equivalents but are typically much cheaper. They have the same active ingredient, strength, and dosage form as the brand-name version. See entry in lower tiers with lower Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, Brand-name drugs: Prescription drugs sold under a manufacturer's trademark name. Brand-name drugs are typically more expensive than generics and placed in higher tiers on your plan's formulary, meaning higher copays or coinsurance for you. Always ask your doctor or pharmacist whether a generic equivalent is available. See entry in higher tiers with higher costs. Drugs not on the formulary may not be covered at all.
ExampleYour plan's formulary lists your blood pressure medication as a Tier 1 generic — $10 Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry. A newer brand-name alternative is Tier 3 — $60 copay. Same drug class, very different cost.
A special account you put money into to pay for certain out-of-pocket health care costs on a pre-tax basis, lowering your taxable income. Unlike HSAs, FSAs are usually use-it-or-lose-it — unused funds typically don't roll over. FSAs are available with most types of employer plans, not just HDHPs.
ExampleYour employer offers an FSA. You contribute $1,800 for the year pre-tax. You use those funds to pay for glasses, dental work, and prescription Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry throughout the year — all tax-free.
General Enrollment Period (Medicare)Government programs
January 1 to March 31 each year. If you missed your first chance to sign up and don't qualify for a Special Enrollment Period (SEP): A time outside the yearly Open Enrollment Period when you can sign up for or change health insurance. You qualify if you have certain life events — losing health coverage, moving to a new area, getting married, having a baby, or adopting a child. You typically have 60 days before or after the event to enroll. See entry, this is when you can sign up for Medicare Part B: Medicare's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many preventive services like screenings and vaccines. See entry (Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry's medical insurance).
ExampleYou missed your window at 65, so you sign up in February and coverage starts the next month.
Prescription drugs sold under their chemical name rather than a brand name. Generic drugs are FDA-approved to be as safe and effective as brand-name equivalents but are typically much cheaper. They have the same active ingredient, strength, and dosage form as the brand-name version.
ExampleYour doctor prescribes lisinopril — the generic version of Zestril. Both treat high blood pressure identically, but the generic costs $10/month while the brand name might cost $80+.
A Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health plan category where the plan pays about 80% of covered costs and you pay about 20%. Gold plans have higher monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry than Bronze or Silver, but lower Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry. They're best if you expect to use a lot of health care — the higher premium is offset by lower costs each time you get care.
ExampleYou have a chronic condition and see doctors frequently. A Gold plan's higher Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry is worth it because your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry is low — you hit it quickly and pay much less per visit throughout the year.
Extra time after a missed Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry payment before your coverage ends. If you use the Premium tax credit: A tax credit you can use to lower your monthly health insurance payment (your premium) when you enroll through the Health Insurance Marketplace. The amount depends on your household income and family size. You can apply it in advance to reduce each monthly payment, or claim it all when you file your tax return. See entry and have paid at least one full month, it's usually 3 months. Pay everything you owe before it ends to keep your coverage.
ExampleYou miss March's payment, then catch up in April to keep your plan.
An individual plan bought on or before March 23, 2010, outside the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry. It may not include some Affordable Care Act protections, and it can lose grandfathered status if it cuts benefits or raises costs in certain ways.
ExampleYour plan letter says it's grandfathered, so you check which newer protections it lacks.
Care that helps you (or a covered family member) keep, learn, or improve skills for daily living, like therapy for a child who isn't walking or talking at the expected age. It can include physical, occupational, and speech therapy.
A health plan with a higher Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry than traditional insurance plans. The minimum deductible amounts are set by the IRS each year. HDHPs are the only plans compatible with a Health Savings Account (HSA). They often have lower monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry but require you to pay more out of pocket before coverage kicks in.
ExampleYour HDHP has a $1,600 Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry. You pay for most routine care yourself until you hit that amount. But your monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry is lower than a Gold plan: A Marketplace health plan category where the plan pays about 80% of covered costs and you pay about 20%. Gold plans have higher monthly premiums than Bronze or Silver, but lower deductibles. They're best if you expect to use a lot of health care — the higher premium is offset by lower costs each time you get care. See entry — and you can use an HSA to set aside pre-tax money to cover those costs.
The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange."
ExampleYou lose your job-based plan and shop for a new one on HealthCare.gov.
A type of health insurance plan that limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry care except in an emergency. HMOs usually require you to choose a Primary care physician (PCP): A doctor who provides and coordinates your basic health care. In HMO and POS plans, your PCP is your first point of contact for most health issues — and the person who refers you to specialists. In PPO and EPO plans, a PCP isn't always required. See entry (PCP) who coordinates your care and provides Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry to see Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry.
ExampleYou have an HMO. To see a dermatologist, you first visit your primary care doctor, who writes you a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry. If you see a dermatologist without a referral, or see one outside the Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry, your plan likely won't pay.
Home and community-based services (HCBS)Government programs
Help with daily tasks like bathing or dressing, given at home or in the community instead of in a facility. Most state Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry programs offer it, and some states let family members be paid caregivers.
ExampleMedicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry pays an aide to help your grandfather get ready each morning so he can stay in his own home.
HRA — Health Reimbursement ArrangementSaving & tax accounts
An employer-funded account that reimburses employees for qualified out-of-pocket medical expenses, and in some cases, individual health insurance Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry. Unlike HSAs, HRAs are funded entirely by the employer — you cannot contribute your own money. Unused funds may roll over depending on your employer's plan design.
ExampleYour employer puts $1,000 into your HRA each year. When you have medical expenses, you submit receipts and get reimbursed from that fund — tax-free.
A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses such as Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry, and some other costs. HSAs are only available if you have an HSA-eligible (High Deductible) health plan. Funds roll over year to year and can even be invested.
ExampleYou contribute $2,000 pre-tax to your HSA. Your $1,500 Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry hits from a hospital stay — you pay it from your HSA tax-free. The leftover $500 rolls into next year, earning interest.
Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry compared to going Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry.
ExampleYour in-network cardiologist costs a $60 Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry. The same visit out of Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry could cost $600 or more with no insurance discount applied.
Initial Enrollment Period (Medicare)Government programs
Your first chance to sign up for Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry: a 7-month period that starts 3 months before the month you turn 65 and ends 3 months after it.
ExampleYou turn 65 in August, so your window runs from May through November.
Care you get after being formally admitted to a hospital or other facility, like a Skilled nursing facility care: Daily skilled nursing and rehab care in a skilled nursing facility, like physical therapy or IV medicine that only a nurse or doctor can give. See entry.
ExampleStaying overnight after being admitted for pneumonia is inpatient care.
Late enrollment penalty (Medicare)Government programs
An extra amount added to your monthly Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entryPremium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry if you sign up for Medicare Part B: Medicare's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many preventive services like screenings and vaccines. See entry (Medicare's medical insurance) or Medicare Part D: Medicare's prescription drug coverage. You get it through a separate drug plan added to Original Medicare, or through a Medicare Advantage plan that includes drugs. Private companies run these plans under Medicare's rules. See entry (Medicare's prescription drug coverage) later than you should have. It grows the longer you wait, and the Part B penalty can last as long as you have Part B.
ExampleYou delayed Medicare Part B: Medicare's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many preventive services like screenings and vaccines. See entry without job-based coverage, so your Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry now includes a penalty every month.
A term for immigrants who have an eligible immigration status, like certain visas, humanitarian statuses such as asylum, or legal status under other laws. Being lawfully present is one requirement for Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry coverage.
ExampleA green card holder is lawfully present and can buy a Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plan.
A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period.
ExampleYour income drops significantly. You apply for Medicaid and qualify. Your coverage starts almost immediately — no waiting for Open Enrollment — and your monthly cost is $0 or very low.
Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry.
ExampleYour mom turns 65 in June. She can get Medicare instead of buying her own plan.
A Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry plan from a private insurance company approved by Medicare. It covers everything Medicare Part A: Medicare's hospital insurance. It helps pay for inpatient hospital stays, care in a skilled nursing facility, hospice, and some home health care. See entry (Medicare's hospital insurance) and Medicare Part B: Medicare's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many preventive services like screenings and vaccines. See entry (Medicare's medical insurance) cover, and most plans include drug coverage. You may need to use the plan's Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry.
ExampleYour neighbor picked a Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry Advantage plan that bundles hospital, doctor, and drug coverage in one card.
Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry's hospital insurance. It helps pay for inpatient hospital stays, care in a Skilled nursing facility care: Daily skilled nursing and rehab care in a skilled nursing facility, like physical therapy or IV medicine that only a nurse or doctor can give. See entry, Hospice services: Care focused on comfort and support for people in the last stages of a terminal illness, and for their families. See entry, and some home health care.
ExampleA three-night hospital stay after surgery is billed under Part A.
Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many Preventive services: Health care services recommended to prevent illness or detect problems early, before symptoms appear. Under the Affordable Care Act, Marketplace plans must cover a set of preventive services at no cost to you — no copay or deductible — as long as you use an in-network provider. See entry like screenings and vaccines.
ExampleYour yearly checkup and a flu shot fall under Part B.
Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry's prescription drug coverage. You get it through a separate drug plan added to Original Medicare: Medicare run directly by the federal government: Part A (Medicare's hospital insurance) plus Part B (Medicare's medical insurance). After you meet the deductible, Medicare pays its share of the approved amount and you pay your share. You can see any doctor or hospital that takes Medicare. See entry, or through a Medicare Advantage (Part C): A Medicare plan from a private insurance company approved by Medicare. It covers everything Part A (Medicare's hospital insurance) and Part B (Medicare's medical insurance) cover, and most plans include drug coverage. You may need to use the plan's network. See entry plan that includes drugs. Private companies run these plans under Medicare's rules.
ExampleYou add a Part D plan so your blood pressure medicine is covered.
Extra insurance you buy from a private company to help pay your share of costs in Original Medicare: Medicare run directly by the federal government: Part A (Medicare's hospital insurance) plus Part B (Medicare's medical insurance). After you meet the deductible, Medicare pays its share of the approved amount and you pay your share. You can see any doctor or hospital that takes Medicare. See entry, like Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry. Plans are standardized and named by letters, so the same lettered plan has the same benefits whichever company sells it.
ExampleA Medigap plan helps pay the Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry left after Original Medicare: Medicare run directly by the federal government: Part A (Medicare's hospital insurance) plus Part B (Medicare's medical insurance). After you meet the deductible, Medicare pays its share of the approved amount and you pay your share. You can see any doctor or hospital that takes Medicare. See entry pays for an outpatient procedure.
Any plan that counts as having health coverage under the Affordable Care Act, like Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plans, job-based plans, Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry, Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry, and CHIP.
ExampleYour job-based plan counts as minimum essential coverage.
The income figure used to decide whether you qualify for Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry savings, Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry, or CHIP (the Children's Health Insurance Program). It starts with the adjusted gross income on your tax return and adds a few things, like untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest. For many people it's the same or close to their adjusted gross income.
ExampleYou don't find MAGI as a line on your tax return; you figure it from your adjusted gross income.
A trained person or group who helps people and small businesses find coverage and fill out Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry forms. Navigators must be unbiased, and their help is free.
ExampleA local navigator walks you through your application at the library.
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry providers typically means lower costs for you than going out of network.
ExampleYour plan's network includes Dr. Smith at City Medical but not Dr. Jones at Regional Hospital. Seeing Dr. Smith means lower Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry and your costs count toward your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry.
The yearly period — November 1 through January 15 — when people can enroll in or change a Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health insurance plan. Coverage starting January 1 requires enrollment by December 15. Outside of Open Enrollment, you can only enroll if you qualify for a Special Enrollment Period (SEP): A time outside the yearly Open Enrollment Period when you can sign up for or change health insurance. You qualify if you have certain life events — losing health coverage, moving to a new area, getting married, having a baby, or adopting a child. You typically have 60 days before or after the event to enroll. See entry.
ExampleOpen Enrollment runs November 1 – January 15. If you miss it and don't have a Qualifying life event (QLE): A change in your situation that makes you eligible for a Special Enrollment Period to sign up for or change health insurance outside of Open Enrollment. Examples include losing health coverage, getting married or divorced, having a baby, adopting a child, moving to a new ZIP code or county, or changes in household income. See entry, you'll have to wait until next year's Open Enrollment to get or change Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry coverage.
Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry run directly by the federal government: Medicare Part A: Medicare's hospital insurance. It helps pay for inpatient hospital stays, care in a skilled nursing facility, hospice, and some home health care. See entry (Medicare's hospital insurance) plus Medicare Part B: Medicare's medical insurance. It helps pay for doctor visits, medical equipment like walkers and wheelchairs, and many preventive services like screenings and vaccines. See entry (Medicare's medical insurance). After you meet the Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Medicare pays its share of the approved amount and you pay your share. You can see any doctor or hospital that takes Medicare.
ExampleYou keep your longtime doctor because she accepts Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry, with no Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry to check.
Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies.
ExampleYou go to an out-of-network Urgent care: Medical care for conditions that require prompt attention but are not life-threatening emergencies. Urgent care centers are generally less expensive than emergency rooms and treat things like minor injuries, infections, flu symptoms, and other non-emergency conditions. See entry clinic. Your plan covers 50% of the Allowed amount: The maximum amount a plan will pay for a covered health care service. Also called eligible expense, payment allowance, or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference (called balance billing) if you're out of network. See entry out-of-network, but the clinic charges more than that — leaving you with a large balance bill.
What you pay for medical care that insurance doesn't pay back: your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry, and Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry for covered care, plus the full cost of anything your plan doesn't cover.
ExampleYour Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, and a non-covered test together were your out-of-pocket costs this year.
The most you have to pay for covered services in a Plan year: The 12-month period when your health plan's benefits and cost-sharing rules are in effect. For most Marketplace plans, the plan year runs January 1 – December 31. Your deductible and out-of-pocket maximum reset at the start of each plan year. See entry. After you spend this amount on Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry for In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry care, your health plan pays 100% of covered benefits for the rest of the year. Monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry, Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry costs, and costs above the Allowed amount: The maximum amount a plan will pay for a covered health care service. Also called eligible expense, payment allowance, or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference (called balance billing) if you're out of network. See entry do not count toward the OOP max.
ExampleYour OOP max is $7,000. After a tough year of medical bills, once you've paid $7,000 total in Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry — insurance covers 100% of covered services for the rest of the year.
The 12-month period when your health plan's benefits and cost-sharing rules are in effect. For most Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plans, the plan year runs January 1 – December 31. Your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry and Out-of-pocket maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care, your health plan pays 100% of covered benefits for the rest of the year. Monthly premiums, out-of-network costs, and costs above the allowed amount do not count toward the OOP max. See entry reset at the start of each plan year.
ExampleYour Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry resets every January 1. Even if you met your $3,000 deductible in December, it starts over on New Year's Day — any care in January counts against a fresh $3,000.
A Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health plan category where the plan pays about 90% of covered costs and you pay about 10%. Platinum plans have the highest monthly Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry but the lowest Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry when you get care. Best suited to people who use health care very frequently.
ExampleYou need ongoing specialty care and multiple prescriptions. A Platinum plan's high Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry is justified because your share of costs per visit is tiny — your Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry throughout the year are predictable and low.
A type of plan where you pay less if you use doctors, hospitals, and other providers in the plan's Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry. Like an HMO, POS plans require you to get a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry from your primary care doctor to see a Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry. Like a PPO, they allow Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry care at higher cost.
ExampleYou have a POS plan. Your Primary care physician (PCP): A doctor who provides and coordinates your basic health care. In HMO and POS plans, your PCP is your first point of contact for most health issues — and the person who refers you to specialists. In PPO and EPO plans, a PCP isn't always required. See entry refers you to an In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry cardiologist — low Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry. You could also self-refer to an Out-of-network: Providers, hospitals, or facilities that do not have a contract with your insurance company. Using out-of-network care usually means higher costs — and some plan types (like HMOs and EPOs) may not cover out-of-network care at all except in emergencies. See entry cardiologist, but you'd pay significantly more.
A type of health insurance plan where you pay less if you use providers in the plan's Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers typically means lower costs for you than going out of network. See entry, but you can also use doctors, hospitals, and providers outside the network without a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry — just at a higher cost. PPOs offer the most flexibility of the major plan types.
ExampleYou have a PPO. You want to see a Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry out of state. You can go without a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry — you'll just pay a higher Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry rate than you would for an In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry visit.
A health problem you had before your new coverage started, like asthma, diabetes, or cancer. Insurance companies can't refuse to cover it or charge you more because of it.
ExampleYou have diabetes when you enroll, and your new plan still covers your insulin.
The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles.
ExampleYour monthly premium is $280. You pay that every month regardless of whether you see a doctor. If you visit a Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry, you then also pay any applicable Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry or Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry on top of that.
A tax credit you can use to lower your monthly health insurance payment (your Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry) when you enroll through the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry. The amount depends on your household income and family size. You can apply it in advance to reduce each monthly payment, or claim it all when you file your tax return.
ExampleYour household qualifies for a $350/month Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry tax credit. Instead of paying $600/month for a Silver plan: A Marketplace health plan category where the plan pays about 70% of covered costs and you pay about 30%. Silver plans are the only tier where you can get cost-sharing reductions if your income qualifies — which can dramatically lower your deductible, copays, and coinsurance. If you qualify for extra savings, Silver is almost always the best value. See entry, you only pay $250/month. The government pays the rest directly to your insurer.
Health care services recommended to prevent illness or detect problems early, before symptoms appear. Under the Affordable Care Act, Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plans must cover a set of preventive services at no cost to you — no Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry or Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry — as long as you use an In-network: Providers, hospitals, and other health care facilities that have a contract with your insurance company to provide services at pre-negotiated rates. Using in-network providers almost always means significantly lower out-of-pocket costs compared to going out-of-network. See entry provider.
ExampleAnnual physicals, flu shots, blood pressure screenings, mammograms, and colorectal cancer screenings are all covered as preventive services — you pay $0 even if you haven't met your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry.
A doctor who provides and coordinates your basic health care. In HMO and POS plans, your PCP is your first point of contact for most health issues — and the person who refers you to Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry. In PPO and EPO plans, a PCP isn't always required.
ExampleYour HMO requires you to choose a PCP. When you develop knee pain, you call your PCP first. She examines you and writes a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry to an orthopedic Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry — which your plan then covers.
Approval from your health insurer that is required before you can receive certain services, procedures, medications, or equipment. Without prior authorization, your insurer may not cover the service — or may cover it at a reduced rate. It is your provider's (and your) responsibility to get authorization in advance.
ExampleYou need an MRI. Your plan requires prior authorization. Your doctor submits the request — your insurer approves it. If you'd skipped this step and had the MRI anyway, your insurer could deny the Claim: A request for payment that you or your health care provider submits to your health insurer after you receive care. The insurer reviews the claim and pays its portion according to your plan terms, then notifies you of any remaining balance you owe. See entry.
A plan the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry has certified. It covers the Essential health benefits: A set of 10 categories of services that all Marketplace and Medicaid plans must cover. They include: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use services, prescription drugs, rehabilitative services, lab services, preventive care, and pediatric services including dental and vision for children. See entry, stays within limits on Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry and Out-of-pocket costs: What you pay for medical care that insurance doesn't pay back: your deductible, coinsurance, and copays for covered care, plus the full cost of anything your plan doesn't cover. See entry, and meets the Affordable Care Act's other rules.
ExampleEvery plan you see when shopping on HealthCare.gov is a qualified health plan.
A change in your situation that makes you eligible for a Special Enrollment Period (SEP): A time outside the yearly Open Enrollment Period when you can sign up for or change health insurance. You qualify if you have certain life events — losing health coverage, moving to a new area, getting married, having a baby, or adopting a child. You typically have 60 days before or after the event to enroll. See entry to sign up for or change health insurance outside of Open Enrollment. Examples include losing health coverage, getting married or divorced, having a baby, adopting a child, moving to a new ZIP code or county, or changes in household income.
ExampleYou get married in June. That's a qualifying life event. You have 60 days to add your spouse to your plan or enroll in a new plan together through the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry.
Checking at tax time whether you used the right amount of Premium tax credit: A tax credit you can use to lower your monthly health insurance payment (your premium) when you enroll through the Health Insurance Marketplace. The amount depends on your household income and family size. You can apply it in advance to reduce each monthly payment, or claim it all when you file your tax return. See entry. You compare what you used during the year with what you qualify for based on your final income, on IRS Form 8962. Used too much, you pay back the difference; used too little, you get it back as a credit.
ExampleYour income went up mid-year, so reconciling shows you owe part of the credit back.
A written order from your primary care doctor for you to see a Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate.
ExampleYou have an HMO and want to see a cardiologist. You call your Primary care physician (PCP): A doctor who provides and coordinates your basic health care. In HMO and POS plans, your PCP is your first point of contact for most health issues — and the person who refers you to specialists. In PPO and EPO plans, a PCP isn't always required. See entry, describe your symptoms, and get a referral. Without that referral, the Specialist: A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a referral from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care. See entry visit would not be covered.
Care that helps you get back, keep, or improve skills you lost because you were sick, hurt, or disabled. It can include physical, occupational, and speech therapy.
ExampleAfter a stroke, you get physical therapy to walk again; that's rehabilitative care.
Second lowest cost Silver plan (SLCSP)Saving money
The second-cheapest Silver plan: A Marketplace health plan category where the plan pays about 70% of covered costs and you pay about 30%. Silver plans are the only tier where you can get cost-sharing reductions if your income qualifies — which can dramatically lower your deductible, copays, and coinsurance. If you qualify for extra savings, Silver is almost always the best value. See entry available to you in the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry. Your Premium tax credit: A tax credit you can use to lower your monthly health insurance payment (your premium) when you enroll through the Health Insurance Marketplace. The amount depends on your household income and family size. You can apply it in advance to reduce each monthly payment, or claim it all when you file your tax return. See entry is based on its price, even if you picked a different plan. You'll usually find its Premium: The amount you pay for your health insurance every month — whether or not you use any health care services that month. In addition to your premium, you also pay a deductible, copayments, and coinsurance when you get care. Plans with lower premiums generally have higher deductibles; plans with higher premiums tend to have lower deductibles. See entry on Form 1095-A.
ExampleAt tax time you check the SLCSP amount on your Form 1095-A to settle your Premium tax credit: A tax credit you can use to lower your monthly health insurance payment (your premium) when you enroll through the Health Insurance Marketplace. The amount depends on your household income and family size. You can apply it in advance to reduce each monthly payment, or claim it all when you file your tax return. See entry.
SHIP (State Health Insurance Assistance Program)Government programs
A state program, funded partly by the federal government, that gives people with Medicare: Federal health insurance for people 65 and older, and for some younger people with certain disabilities or with End-Stage Renal Disease (ESRD). Medicare is separate from the Health Insurance Marketplace. See entry free, local, one-on-one counseling about their coverage.
ExampleUnsure between two Medicare Advantage (Part C): A Medicare plan from a private insurance company approved by Medicare. It covers everything Part A (Medicare's hospital insurance) and Part B (Medicare's medical insurance) cover, and most plans include drug coverage. You may need to use the plan's network. See entry plans, you book a free call with your state's SHIP counselor.
SHOP (Small Business Health Options Program)Enrollment
The Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry program that helps small businesses offer health or dental insurance to their employees. The business needs at least one employee who isn't an owner, partner, or family member, and it can enroll any time of year.
ExampleA bakery with eight employees offers them a plan through SHOP.
A Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry health plan category where the plan pays about 70% of covered costs and you pay about 30%. Silver plans are the only tier where you can get Cost-sharing reduction (CSR): A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance on a Silver Marketplace plan. You qualify based on your income. Cost-sharing reductions are only available with Silver plans — you must enroll in Silver to get the extra savings. See entry if your income qualifies — which can dramatically lower your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry, Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry, and Coinsurance: The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, if your coinsurance is 20% and an allowed office visit costs $100, you pay $20 and your insurance pays $80. Plans with lower monthly premiums generally have higher coinsurance. See entry. If you qualify for extra savings, Silver is almost always the best value.
ExampleYou qualify for Cost-sharing reduction (CSR): A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance on a Silver Marketplace plan. You qualify based on your income. Cost-sharing reductions are only available with Silver plans — you must enroll in Silver to get the extra savings. See entry. On a Silver plan, your Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry drops from $4,000 to $800 and your Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry are cut in half — making Silver far more valuable than going with a cheaper Bronze plan: A Marketplace health plan category where the plan pays about 60% of covered health care costs, and you pay about 40%. Bronze plans typically have the lowest monthly premiums but the highest deductibles and out-of-pocket costs. Starting in 2026, Bronze plans are compatible with Health Savings Accounts (HSAs). See entry.
A time outside the yearly Open Enrollment Period: The yearly period — November 1 through January 15 — when people can enroll in or change a Marketplace health insurance plan. Coverage starting January 1 requires enrollment by December 15. Outside of Open Enrollment, you can only enroll if you qualify for a Special Enrollment Period. See entry when you can sign up for or change health insurance. You qualify if you have certain life events — losing health coverage, moving to a new area, getting married, having a baby, or adopting a child. You typically have 60 days before or after the event to enroll.
ExampleYou lose your job and employer coverage on March 15. That triggers a Special Enrollment Period — you have 60 days to pick a Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry plan. Miss that window and you may be uninsured until November.
A physician who focuses on a specific area of medicine or a group of patients — such as a cardiologist (heart), dermatologist (skin), or neurologist (nervous system). In HMO and POS plans, you usually need a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry from your primary care doctor to see a specialist. Specialist visits often have higher Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry than primary care.
ExampleYou need to see a rheumatologist for joint pain. In your HMO, you first see your Primary care physician (PCP): A doctor who provides and coordinates your basic health care. In HMO and POS plans, your PCP is your first point of contact for most health issues — and the person who refers you to specialists. In PPO and EPO plans, a PCP isn't always required. See entry, who provides a Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In HMO and POS plans, referrals are typically required. Without one, your insurer may not cover the specialist visit — or may cover it at a much lower rate. See entry. In a PPO, you can self-refer — you just pay a higher Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry than for a PCP visit.
A Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry dental plan bought separately from your health plan. Useful if your health plan has no dental, or you want different dental coverage.
ExampleYour health plan has no dental, so you add a stand-alone dental plan at checkout.
State medical assistance officeGovernment programs
The state agency that runs your state's Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry program. It can tell you about programs in your state that help people with limited income pay medical bills.
ExampleYou call your state's office to apply for Medicaid: A joint federal and state program that provides free or low-cost health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary by state. You can apply year-round — there is no enrollment period. See entry directly instead of through the Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry.
Summary of Benefits and Coverage (SBC)Understanding your plan
A standard document that health plans must provide to help you understand and compare your coverage options. The SBC summarizes key details: what the plan covers, what it doesn't, cost-sharing amounts, and examples of how it handles two common medical events.
ExampleAlways read the SBC when comparing plans — it uses a standardized format so you can do apples-to-apples comparisons of Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles. See entry and Out-of-pocket maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care, your health plan pays 100% of covered benefits for the rest of the year. Monthly premiums, out-of-network costs, and costs above the allowed amount do not count toward the OOP max. See entry across plans.
The people on one federal tax return: you, your spouse if you file jointly, and anyone you claim as a dependent. The Health Insurance Marketplace: The government-run place to compare and buy individual health plans, created by the Affordable Care Act. In most states it's HealthCare.gov; some states run their own site. One application also tells you whether you qualify for savings, Medicaid, or CHIP (the Children's Health Insurance Program). Sometimes called "the exchange." See entry uses it to figure your savings.
ExampleYou, your husband, and the two kids you claim make a tax household of four.
Medical care for conditions that require prompt attention but are not life-threatening emergencies. Urgent care centers are generally less expensive than emergency rooms and treat things like minor injuries, infections, flu symptoms, and other non-emergency conditions.
ExampleYou cut your hand badly on a Saturday. It needs stitches but isn't life-threatening. An urgent care visit costs $50 Copayment: A fixed dollar amount you pay for a covered health care service — such as a doctor visit or prescription — usually at the time of the visit. The amount can vary by the type of service. Your insurance pays the rest of the allowed amount. See entry — much less than an ER visit that might cost $250+.
