Plain-language definitions of common ACA and health-insurance terms you may see while comparing plans, enrolling, receiving healthcare or reviewing claims.
The amount paid regularly, usually monthly, to maintain health insurance coverage.
The amount you may pay for certain covered healthcare before the plan begins sharing applicable costs.
A fixed amount you may pay for a covered healthcare service under applicable plan terms.
A percentage of an allowed covered healthcare cost you may be responsible for.
The applicable annual limit on what you pay for covered in-network services, subject to plan rules.
A general term for the portion of covered healthcare costs paid by the member, such as deductibles, copays and coinsurance.
The doctors, hospitals, facilities and other providers that contract with a health plan under its network arrangements.
A provider or facility participating in the plan's applicable network.
A provider or facility outside the applicable plan network; coverage and consumer costs can differ significantly.
The plan's list of covered prescription drugs, often organized into tiers and subject to plan rules.
A plan requirement to obtain approval for certain healthcare services or medications before they are provided or covered under applicable terms.
A direction or authorization from a healthcare provider, often a primary care provider, to receive certain specialist care when required by the plan.
Financial assistance that may reduce qualifying Marketplace premiums for eligible consumers.
Additional savings that may reduce certain out-of-pocket costs for qualifying consumers enrolled in eligible Silver Marketplace coverage.
An enrollment opportunity outside annual Open Enrollment when applicable qualifying circumstances and Marketplace requirements are met.
A statement showing how an insurer processed a healthcare claim. It is generally not itself a bill.
A request for payment or coverage submitted to an insurer for healthcare services or items.
The amount recognized by the health plan for a covered healthcare service under applicable plan arrangements.
Next, learn how these terms appear on an Explanation of Benefits and provider bill.
Understand EOBs & Medical Bills →