Insurance words, in plain English

Search terms

Agent / Broker

A licensed professional who helps you compare and enroll in plans. Paid by the insurance carrier, not by you.

ACA

The Affordable Care Act, the law that created the Marketplace, guaranteed coverage for pre-existing conditions and income-based subsidies.

Benefit year

The 12 months your plan runs, usually January 1 to December 31. Deductibles and out-of-pocket maximums reset each benefit year.

Claim

The bill your doctor or hospital sends to your insurance company after you get care.

COBRA

A federal rule that lets you keep your employer's plan after leaving a job, usually at full price.

Coinsurance

Your share of a bill after the deductible, written as a percentage, such as 20%.

Copay

A flat fee for a specific service, like $30 for an office visit.

Cost-sharing reduction

Extra savings on Silver Marketplace plans that lower your deductible, copays and out-of-pocket maximum.

Deductible

What you pay for covered care before your plan starts paying its share.

Dependent

A spouse or child covered under your plan.

EOB

Explanation of Benefits. Not a bill. It's the summary showing what the plan paid and what you may owe.

Effective date

The day your coverage actually starts.

Essential Health Benefits

Ten categories ACA-compliant plans must cover, including hospitalization, prescriptions and preventive care.

Formulary

The list of prescription drugs a plan covers, usually sorted into tiers.

Guaranteed issue

Coverage you can't be turned down for because of your health history. ACA Marketplace plans are guaranteed issue.

HMO

A plan that keeps you inside a set network and usually requires referrals to see specialists.

HSA

Health Savings Account. A tax-advantaged account you can pair with a qualifying high-deductible plan.

ICHRA

An arrangement where an employer reimburses employees tax-free for individual coverage instead of buying a group plan.

In-network

Doctors and hospitals that agreed to your plan's discounted rates. Staying in-network is the single easiest way to control costs.

Marketplace

The government exchange where ACA plans are sold, including HealthCare.gov.

Medically underwritten

A plan that reviews your health history before approving you. Good health can earn better rates.

Metal tiers

Bronze, Silver, Gold and Platinum. They describe how you and the plan split costs, not the quality of care.

Network

The group of providers contracted with your plan.

Open Enrollment

The yearly window when anyone can buy or change a Marketplace plan. It starts November 1.

Out-of-pocket maximum

The most you'll pay in a year for covered in-network care. After that, the plan pays 100%.

PPO

A plan with a broad network that usually lets you see specialists without a referral and offers some out-of-network coverage.

Pre-existing condition

A health condition you had before the plan started. ACA plans always cover them; on private plans it depends on the condition and the plan.

Premium

Your monthly payment to keep the plan active.

Premium tax credit

A subsidy that lowers your monthly Marketplace premium based on your expected income.

Preventive care

Checkups, screenings and vaccines that most ACA-compliant plans cover at no cost to you.

Provider

Any doctor, hospital, lab or clinic that delivers care.

QSEHRA

A small-employer arrangement for reimbursing employees' individual health costs tax-free.

Qualifying life event

A change like marriage, birth, moving or losing coverage that opens a Special Enrollment Period.

Referral

Approval from your primary doctor to see a specialist, required by many HMO plans.

Special Enrollment Period

A limited window, usually 30 to 60 days, to enroll after a qualifying life event.

Subsidy

General term for Marketplace savings, including premium tax credits and cost-sharing reductions.

Underwriting

The review of your health history used to decide eligibility and pricing on private plans.