Insurance dictionary
The vocabulary that shows up in plans, in plain English.
- Premium
- What you pay each month to have the insurance, whether or not you use any care.
- Deductible
- What you pay out of pocket before the plan starts covering most services. Federal preventive services aren't subject to it.
- Copay
- A fixed amount you pay for a specific service — $30 for an office visit, for example.
- Coinsurance
- Your percentage of a service's cost after the deductible. 20% coinsurance means the plan pays 80%.
- Out-of-pocket maximum
- The most you can pay in a year for essential in-network services. Once you hit it, the plan covers 100% for the rest of the year.
- Network
- The doctors, hospitals and pharmacies your plan has agreements with. Going out of network costs considerably more, or isn't covered.
- Formulary
- The list of drugs a plan covers, organised into cost tiers.
- Premium tax credit
- Help that lowers your monthly premium based on your income and household size. The Marketplace sends it straight to the insurer.
- Cost-sharing reduction
- Additional help that lowers your deductible and copays. Only applies to Silver-level plans.
- Essential health benefits
- The 10 categories every Marketplace plan must cover by law.
- Pre-existing condition
- A health problem you had before coverage started. It can't be used to deny you or raise your premium.
- Open enrollment period
- The annual window when anyone can enroll or change plans.
- Special enrollment period
- A window outside open enrollment that opens after a qualifying life event.
- Qualifying life event
- A change — losing coverage, moving, marrying, having a baby — that lets you enroll outside open enrollment.
- QHP (Qualified Health Plan)
- A plan certified by the Marketplace that meets the ACA's coverage and cost requirements.
- Metal levels
- Bronze, silver, gold and platinum. They show how costs split between you and the insurer, not plan quality.
- Dependent
- Someone you cover on your plan: a spouse, children up to age 26.
- Modified adjusted gross income (MAGI)
- The income measure the Marketplace uses to calculate your financial help.
Definitions aligned with the official glossary at HealthCare.gov.