Basic Health Insurance Terms

Need to enroll in a health insurance policy or update the one you have?

Open Enrollment for the Health Insurance Marketplace (Healthcare.gov) is Nov. 1, 2021, to Jan. 15, 2022.

There are a lot of special terms in the health insurance world, and they can be difficult to understand. We’re here to help you make sense of terms you see on Healthcare.gov.

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

Catastrophic Health Plan
The premium amount you pay each month for healthcare is generally lower than for other plans, but the out-of-pocket costs for deductibles, copayments and coinsurance (see terms defined below) are generally higher. To qualify for a Catastrophic plan, you must be under 30 years old OR get an “affordability exemption” (the Marketplace determines that you’re unable to afford health coverage).

COBRA
A federal law that may allow you to temporarily keep health coverage after your employment ends. If you choose COBRA coverage, you pay 100% of the premiums, including the portion that your employer used to pay, plus a small administrative fee.

Coinsurance
Like a copayment (see next term), but in the form of a percentage of the cost of a healthcare service (e.g. you pay 20% of the cost of a visit or procedure).

Copayment
A set amount that you pay for a medical service or item, like a doctor’s visit. The insurance company covers the rest.

Deductible
The amount you have to pay for covered health care services (e.g. doctor and hospital visits, labs, etc.) before your health insurance or plan begins to pay. Often, the health insurance company will only pay a percentage of the costs after you reach your deductible. If you think you will need a lot of healthcare services in a year, you should look for plans with a low deductible.

Metal Categories of Health Plans
In addition to catastrophic plans, Healthcare.gov plans come in four metal categories: Bronze, Silver, Gold and Platinum. Bronze plans are usually best for individuals who have few health needs but want to be prepared in case of an emergency. Bronze plans have the lowest monthly premiums, but they have a high deductible. Gold and Platinum plans are often best for people who use a lot of health services. They have the highest monthly premiums, but each visit to the doctor and each prescription will have a low copay/coinsurance. Plans in all metal categories provide free preventive care (for example, a yearly wellness visit to your doctor).

Silver plans are ideal for individuals/families with income less than 250% FPL. If you select a Silver plan, you will receive cost sharing reductions, which means your out of pocket costs (deductible, coinsurance and copays) are also subsidized and may be very low.

Network
The doctors, hospitals and suppliers your health insurer has contracted with to deliver health care services to their members. Ask a healthcare provider if they accept your insurance before you visit. If you go out of network, your care will be more expensive.

Out-of-pocket Maximum
Usually a larger number than your deductible. This is the absolute maximum amount of money you will have to spend in the year on healthcare costs. After you reach this amount, the health insurance company will cover all services 100%.

Plans and Prices Toolhttps://www.healthcare.gov/see-plans/#/ 
Saves you time! This tool allows you to see what plans are available in your area and how much financial assistance you qualify for before you fill out an application. 

Pre-existing Conditions
A health problem, like asthma, diabetes, or cancer, that you had before the date that new health coverage starts. Insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.

Premium
The amount you pay for your plan each month.

Premium Tax Credit
The “subsidies” that lower the cost of your monthly premiums. You can take the premium tax credits in advance to lower your monthly cost, or you can take them as a refund at tax time.

To look up more key terms, visit the Healthcare.gov glossary.