Glossary

Healthcare words, in plain English.

Short, accurate definitions. No jargon for jargon's sake.

32 terms

B

Benchmark Plan: The second-lowest-cost Silver plan in your area, used to calculate your premium tax credit.

Catastrophic Plan: A low-premium, high-deductible ACA plan available to people under 30 or with a hardship exemption, for worst-case protection.
Coinsurance: The percentage of a covered bill you pay after meeting your deductible — for example, 20% while the plan pays 80%.
Copayment: A fixed dollar amount you pay for a specific covered service, such as $30 for a doctor visit, often payable even before you meet your deductible.
Cost-Sharing Reduction: Extra savings for lower-income enrollees who choose a Silver Marketplace plan, reducing the deductible, copays, and out-of-pocket maximum.

Deductible: The amount you pay for covered care each year before your plan starts paying its share. Preventive care is usually covered before you meet it.

Essential Health Benefits: Ten categories of care every ACA-compliant plan must cover, including hospitalization, prescriptions, maternity, mental health, and preventive care.
Explanation of Benefits: A statement from your plan showing what it paid and what you owe for a claim. It is not a bill.

Federal Poverty Level: An annual income measure used to determine eligibility for subsidies, Medicaid, and other programs.
Flexible Spending Account: An employer account for pre-tax medical spending, generally with a use-it-or-lose-it rule each year.
Formulary: A health plan’s tiered list of covered prescription drugs. A drug’s tier determines how much you pay for it.

Health Reimbursement Arrangement: An employer-funded arrangement, such as an ICHRA, that reimburses employees tax-free for health costs or individual coverage.
Health Savings Account: A tax-advantaged account paired with an HSA-eligible high-deductible plan, offering deductible contributions, tax-free growth, and tax-free medical withdrawals.
High-Deductible Health Plan: A plan with a lower premium and higher deductible that, if HSA-eligible, lets you contribute to a Health Savings Account.

In-Network: A provider or facility that has agreed to your plan’s negotiated rates, so your cost for their care is lower.

Medicaid: Free or low-cost coverage for people with limited income, jointly funded by states and the federal government.
Medicare Advantage: A private all-in-one alternative to Original Medicare that bundles Parts A, B, and usually D, often with extra benefits and a network.
Medigap: A private policy that pays much of Original Medicare’s out-of-pocket costs, offering predictable, nationwide coverage.
Metal Tiers: The Bronze, Silver, Gold, and Platinum categories that describe how you and a Marketplace plan split costs — Bronze lowest premium, Platinum highest.
Minimum Essential Coverage: Coverage that satisfies the ACA’s standard, including Marketplace, employer, Medicare, and Medicaid plans.

Network: The group of doctors, hospitals, and facilities that have contracted with a plan at negotiated rates. In-network care costs far less.

Open Enrollment: The annual window when anyone can enroll in or change a Marketplace plan without a qualifying life event.
Out-of-Network: A provider that has not contracted with your plan. Care costs more and, on HMO/EPO plans, is usually not covered except in emergencies.
Out-of-Pocket Maximum: The most you pay for covered in-network care in a plan year. After you reach it, the plan pays 100% of covered costs.

Premium: The amount you pay for your health plan each month, regardless of whether you use care. It never counts toward your deductible or out-of-pocket maximum.
Premium Tax Credit: An income-based subsidy that lowers your monthly Marketplace premium by capping your cost for the benchmark plan at a percentage of income.
Preventive Care: Services like checkups, screenings, and vaccines that ACA plans cover at no cost to you, even before the deductible.
Primary Care Physician: The doctor who manages your general care and, on HMO plans, coordinates referrals to specialists.
Prior Authorization: Approval a plan requires before it will cover certain services or drugs, used to confirm medical necessity.

Qualifying Life Event: A change such as losing coverage, marriage, a new baby, or a move that opens a Special Enrollment Period.

Referral: A primary care doctor’s authorization to see a specialist, required by most HMO plans.

Special Enrollment Period: A window, usually 60 days, to enroll outside Open Enrollment after a qualifying life event.

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