The words on your plan, written for humans.

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) is expected to pay 80% of covered costs for a standard population — you'd pay the remaining 20% on average through deductibles, copays, and coinsurance.

ExampleA Bronze plan has ~60% actuarial value: the plan pays 60% of covered costs on average, you pay 40%. A Platinum plan has ~90% actuarial value — you pay only 10% on average.

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.

ExampleYour plan's allowed amount for an MRI is $800. If your out-of-network provider charges $1,200, your insurance may only cover its share of the $800 — you could owe the rest.

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.

ExampleAn out-of-network surgeon charges $5,000. Your insurer's allowed amount 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, meaning higher copays or coinsurance 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 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).

ExampleYou're young and healthy. You choose a Bronze plan with a $450/month premium and a $6,000 deductible. You pay for most routine visits yourself, but you're covered if something catastrophic happens.

A low-cost Marketplace 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 premiums but very high deductibles — 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 is over $9,000), but you're protected if you're in an accident or get seriously ill.

A federal-state program that provides low-cost health coverage to children in families that earn too much to qualify for Medicaid 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 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 (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 yourself (your employer no longer contributes).

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.

ExampleYou've met your deductible. A specialist 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.

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 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.

ExampleYou qualify for cost-sharing reductions. On a standard Silver plan your deductible might be $4,000. With your CSR applied, it drops to $800 — significantly lowering your out-of-pocket costs 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 or coinsurance for covered services — your insurance company pays the rest. Plans with lower monthly premiums generally have higher deductibles.

ExampleYour deductible is $1,500. You visit a specialist 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.

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, specialists, or hospitals in the plan's network — except in an emergency. Unlike PPOs, EPOs don't cover any out-of-network care, but unlike HMOs, they usually don't require referrals to see specialists.

ExampleYou have an EPO. You can see any in-network specialist without a referral. But if you see an out-of-network provider for a non-emergency, your plan pays nothing — you owe the full amount.

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.

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 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.

ExampleYour plan's formulary lists your blood pressure medication as a Tier 1 generic — $10 copay. 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 copays throughout the year — all tax-free.

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 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.

ExampleYou have a chronic condition and see doctors frequently. A Gold plan's higher premium is worth it because your deductible is low — you hit it quickly and pay much less per visit throughout the year.

A health plan with a higher deductible 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 premiums but require you to pay more out of pocket before coverage kicks in.

ExampleYour HDHP has a $1,600 deductible. You pay for most routine care yourself until you hit that amount. But your monthly premium is lower than a Gold plan — and you can use an HSA to set aside pre-tax money to cover those costs.

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 care except in an emergency. HMOs usually require you to choose a primary care physician (PCP) who coordinates your care and provides referrals to see specialists.

ExampleYou have an HMO. To see a dermatologist, you first visit your primary care doctor, who writes you a referral. If you see a dermatologist without a referral, or see one outside the network, your plan likely won't pay.

An employer-funded account that reimburses employees for qualified out-of-pocket medical expenses, and in some cases, individual health insurance premiums. 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 deductibles, copayments, coinsurance, 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 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 compared to going out-of-network.

ExampleYour in-network cardiologist costs a $60 copay. The same visit out of network could cost $600 or more with no insurance discount applied.

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.

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.

ExampleYour plan's network includes Dr. Smith at City Medical but not Dr. Jones at Regional Hospital. Seeing Dr. Smith means lower copays and your costs count toward your deductible.

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.

ExampleOpen Enrollment runs November 1 – January 15. If you miss it and don't have a qualifying life event, you'll have to wait until next year's Open Enrollment to get or change Marketplace coverage.

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 clinic. Your plan covers 50% of the allowed amount out-of-network, but the clinic charges more than that — leaving you with a large balance bill.

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.

ExampleYour OOP max is $7,000. After a tough year of medical bills, once you've paid $7,000 total in deductibles, copays, and coinsurance — 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 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.

ExampleYour deductible 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 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.

ExampleYou need ongoing specialty care and multiple prescriptions. A Platinum plan's high premium is justified because your share of costs per visit is tiny — your out-of-pocket costs 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. Like an HMO, POS plans require you to get a referral from your primary care doctor to see a specialist. Like a PPO, they allow out-of-network care at higher cost.

ExampleYou have a POS plan. Your PCP refers you to an in-network cardiologist — low copay. You could also self-refer to an out-of-network 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, but you can also use doctors, hospitals, and providers outside the network without a referral — 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 out of state. You can go without a referral — you'll just pay a higher coinsurance rate than you would for an in-network visit.

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.

ExampleYour monthly premium is $280. You pay that every month regardless of whether you see a doctor. If you visit a specialist, you then also pay any applicable copay or coinsurance on top of that.

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.

ExampleYour household qualifies for a $350/month premium tax credit. Instead of paying $600/month for a Silver plan, 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, 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.

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.

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.

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 to an orthopedic specialist — 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 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.

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 Marketplace.

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.

ExampleYou have an HMO and want to see a cardiologist. You call your PCP, describe your symptoms, and get a referral. Without that referral, the specialist visit would not be covered.

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.

ExampleYou qualify for cost-sharing reductions. On a Silver plan, your deductible drops from $4,000 to $800 and your copays are cut in half — making Silver far more valuable than going with a cheaper Bronze plan.

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.

ExampleYou lose your job and employer coverage on March 15. That triggers a Special Enrollment Period — you have 60 days to pick a Marketplace 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 from your primary care doctor to see a specialist. Specialist visits often have higher copays than primary care.

ExampleYou need to see a rheumatologist for joint pain. In your HMO, you first see your PCP, who provides a referral. In a PPO, you can self-refer — you just pay a higher copay than for a PCP visit.

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 deductibles and out-of-pocket maximums across plans.

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 copay — much less than an ER visit that might cost $250+.