Health insurance is sold in a vocabulary most people were never taught. Here is what each term actually means — no pitch, just the definition.
Grouped by what they decide, not alphabetically — the terms that answer the same question sit together.
The four numbers that decide what a plan actually costs you.
The amount you pay for covered care yourself before the plan starts paying its share.
Say a plan has a $3,000 deductible. You pay the first $3,000 of covered medical bills yourself. After that, the plan starts splitting the cost with you.
The deductible resets every January. Money you spent last year does not carry over.
Not everything waits for the deductible. Preventive care — annual checkups, most vaccines, many screenings — is covered at no cost to you on an ACA plan from day one. Many plans also cover a few office visits or generic prescriptions for a flat copay before the deductible is met.
Also called: copayment
A flat fee you pay for a specific service, like $30 to see your doctor.
A copay does not change with the size of the bill. If your plan says $30 for a primary care visit, you pay $30 whether the visit cost the insurer $90 or $400.
Copays are predictable, which is why plans use them for the things people do most often: office visits, urgent care, generic drugs.
Your share of a bill written as a percentage — for example, you pay 20% and the plan pays 80%.
Coinsurance usually kicks in after you have met your deductible. Where a copay is a flat fee, coinsurance is a slice of whatever the bill happens to be.
This is the term that surprises people. On a $40,000 surgery, 20% coinsurance is $8,000 — which is why the out-of-pocket maximum matters more than any other number on the plan summary.
Also called: out-of-pocket max, OOP max, maximum out-of-pocket
The most you can be made to pay in one year for covered, in-network care. After you hit it, the plan pays 100%.
This is your worst-case number. Deductible, copays and coinsurance all count toward it. Your monthly premium does not.
Once you reach it, the plan covers the rest of that year's covered in-network care in full. The counter resets in January.
Two things do not count toward it: care from an out-of-network provider, and anything the plan does not cover at all. Federal law caps this number on ACA plans and the cap is reset each year, so check the current figure on the plan itself.
Short-term and fixed indemnity products are not required to include a true out-of-pocket maximum. That is one of the biggest differences between them and a major medical plan.
How the government decides whether it lowers your price, and by how much.
Also called: CSR, extra savings
Extra help that shrinks your deductible, copays and out-of-pocket maximum — but only on a Silver plan.
A premium tax credit lowers what you pay each month. A cost-sharing reduction lowers what you pay when you actually get care.
It is available to households under a certain income level, and it only attaches to Silver plans. This is the reason a Silver plan is sometimes a better deal than a Gold plan for someone with a modest income, even though Gold sounds like the upgrade.
If you qualify and you buy Bronze instead, you give the extra help up entirely. It is worth asking about before you pick a metal tier on price alone.
Also called: modified adjusted gross income
The income figure the marketplace uses to decide what help you qualify for.
MAGI stands for modified adjusted gross income. It starts from the adjusted gross income on your tax return and adds back a few items, including tax-exempt interest and untaxed Social Security benefits.
For marketplace purposes it is a household number, and it is an estimate of the coming year — not last year's tax return. Self-employed people, people with commission income and people who changed jobs mid-year are the ones most often tripped up by that.
If your income is hard to predict, estimate honestly and update the marketplace when it changes. That is what keeps the reconciliation at tax time small.
Also called: FPL, federal poverty guidelines
A yearly income figure published by the federal government, used as the yardstick for who qualifies for help.
You will see eligibility written as a percentage of it — “138% of FPL,” “250% of FPL.” That just means your household income compared to the published figure for a household your size.
The numbers are updated every year and are higher in Alaska and Hawaii. Because they move, we do not print them here; a licensed agent or the marketplace itself can tell you where you fall for the year you are shopping.
FPL is the yardstick behind both premium tax credits and Medicaid eligibility.
Also called: CHIP
A joint federal and state program that provides free or very low-cost coverage to people with low incomes.
Medicaid is run by your state, so the income limits and even the program's name vary from state to state. CHIP is the companion program covering children in households that earn a little too much for Medicaid.
Medicaid does not have an enrollment window. You can apply any month of the year.
If your household qualifies for Medicaid, you generally cannot get a premium tax credit for a marketplace plan — the marketplace will route you to Medicaid instead. Whether your state expanded Medicaid under the ACA changes who is covered, and roughly a dozen states have not.
The rules about what has to be included and which doctors you can see.
Also called: EHB, ten essential benefits
Ten categories of care that every ACA-compliant plan has to cover.
The ten are: outpatient care, emergency services, hospitalization, pregnancy and newborn care, mental health and substance use treatment, prescription drugs, rehabilitation services and devices, lab work, preventive and chronic disease management, and pediatric services including dental and vision for children.
“Covered” does not mean free — your deductible and coinsurance still apply. It means the plan cannot simply leave the category out, and cannot cap what it will pay for it over your lifetime.
This is the clearest dividing line between a major medical plan and a short-term or indemnity product, which are not required to cover these categories at all.
Also called: pre-existing condition protection
The rule that an ACA plan must accept you regardless of your health, and cannot charge you more for being sick.
There is no medical questionnaire on a marketplace application and no way to be turned down for a diagnosis you already have. Price can vary by age, location, family size and tobacco use — not by health history.
Pre-existing conditions are covered from the day the plan starts. There is no waiting period for them.
Guaranteed issue applies to ACA-compliant plans. Short-term medical is generally medically underwritten, which means it can ask health questions and decline you.
A health problem you already had before the new coverage started.
Diabetes, asthma, a past cancer, a heart condition, a pregnancy already underway, an ongoing mental health diagnosis — all pre-existing conditions.
On an ACA plan they cannot be excluded, delayed or surcharged. On a short-term plan they typically are excluded, and an insurer can review your records after a claim to decide a condition was pre-existing.
Also called: in-network, out-of-network, network tier, provider network
The doctors, hospitals and pharmacies that have agreed to the plan's negotiated prices.
In-network care costs you the plan's discounted rate. Out-of-network care costs more, and on many plans it is not covered at all except in an emergency — and what you spend there usually does not count toward your out-of-pocket maximum.
Some plans sort in-network providers into tiers, with a lower copay for the tier the plan prefers. Same network, different price depending on who you pick.
Networks change from year to year, and a doctor who was in-network last January may not be this January. Checking your own doctors and your own prescriptions against a specific plan before you enroll is the single most useful thing you can do — and it is what a licensed agent should be doing with you on the call.
Also called: drug list
The list of prescription drugs a plan covers, and what you pay for each one.
Drugs on a formulary are sorted into tiers. Generics sit on the cheapest tier; brand names and specialty drugs cost more.
A drug that is not on the formulary at all is generally not covered, and what you spend on it does not count toward your deductible or out-of-pocket maximum.
If you take a specific medication, check it against the formulary of the specific plan before enrolling. Two plans from the same carrier can treat the same drug very differently.
Also called: Bronze, Silver, Gold, Platinum
Bronze, Silver, Gold and Platinum describe how a plan splits costs with you — not how good the care is.
Bronze has the lowest monthly premium and the highest costs when you use care. Platinum is the reverse. Silver and Gold sit in between.
The metal has nothing to do with the quality of the doctors or the hospitals. A Bronze and a Platinum plan from the same carrier can use the exact same network.
Silver is a special case: it is the only tier that carries cost-sharing reductions, and it is the tier the premium tax credit is calculated from.
Also called: second-lowest-cost Silver plan
The second-cheapest Silver plan in your county, used to calculate the size of your premium tax credit.
The marketplace works out what the benchmark plan would cost you, decides what share of your income you should have to pay for it, and the difference becomes your premium tax credit.
You do not have to buy the benchmark plan. The credit is a fixed dollar amount you can apply to any metal tier — put it toward a Bronze plan and your monthly bill drops further; put it toward Gold and you pay the difference.
Because the benchmark is set county by county, the same household income can produce a very different credit one county over.
Health insurance is not on sale year-round. These are the windows.
Also called: OEP, open enrollment
The yearly window when anyone can buy or switch a marketplace plan without needing a reason.
In most states it runs from November 1 to January 15. Several state-run marketplaces set their own, longer dates — New York's, for example, has generally run through January 31.
Enroll by mid-December in most states and coverage starts January 1. Enroll after that and it usually starts February 1.
Outside this window you need a qualifying life event. Confirm the current dates for your state before you rely on them — they have been changed by rule more than once.
Also called: SEP
A 60-day window to enroll outside of Open Enrollment, opened by a qualifying life event.
The clock is usually 60 days from the event, and it is a real deadline. Miss it and you generally wait for the next Open Enrollment.
You will normally have to prove the event happened — a termination letter, a lease, a marriage certificate, a birth record.
Some situations, like Medicaid eligibility or membership in a federally recognized tribe, are not tied to a 60-day window at all.
Also called: QLE
A life change that lets you enroll outside of Open Enrollment.
The common ones: losing other coverage (including job-based coverage, and including when a parent's plan ends at 26), moving to a new ZIP code or county, getting married or divorced, having or adopting a child, and certain income changes.
Losing coverage counts. Choosing to drop coverage generally does not — voluntarily cancelling a plan, or cancelling COBRA before it runs out, does not by itself open a Special Enrollment Period.
The products a licensed agent may put in front of you, and what separates them.
Also called: QHP
A plan certified by the marketplace as meeting ACA requirements — the kind a premium tax credit can be applied to.
A QHP covers the ten essential health benefits, is guaranteed issue, caps your out-of-pocket costs, and counts as minimum essential coverage.
You can view every qualified health plan available to you and enroll for free at HealthCare.gov or your state's exchange.
Also called: MEC
Coverage that meets the ACA's definition of real health insurance.
Employer plans, marketplace plans, Medicare, Medicaid, CHIP and TRICARE all count.
Short-term medical, fixed indemnity plans, discount cards and most health care sharing arrangements do not.
This matters for more than paperwork: losing minimum essential coverage is a qualifying life event, and losing something that was never MEC in the first place is not.
Also called: HMO, PPO, EPO, POS
Three ways a plan controls which doctors you can see and whether you need a referral.
HMO — you pick a primary care doctor, and you usually need a referral from them to see a specialist. Out-of-network care is generally not covered except in an emergency. Premiums are typically lower.
PPO — no referrals needed, and out-of-network care gets some coverage at a higher cost to you. Typically the most expensive of the three.
EPO — a middle ground. Usually no referral required, but out-of-network care is generally not covered.
Which letters are even available to you depends on your county. In much of the country the marketplace is now mostly HMO and EPO plans.
Also called: STM, short-term health insurance
Temporary coverage sold to bridge a gap. It is not ACA coverage and does not have to cover everything.
Short-term plans do not provide comprehensive medical coverage and do not satisfy minimum essential coverage under the ACA. They typically exclude pre-existing conditions, can be medically underwritten, and may cap what they pay.
They can be bought any time of year, which is why they come up when someone has missed Open Enrollment and has no qualifying life event.
How long they can last, and whether they are sold at all, is set state by state.
Also called: indemnity plan, hospital indemnity
A supplemental product that pays a set cash amount per event — not a replacement for major medical insurance.
An indemnity plan pays a fixed dollar amount when something specific happens: so much per hospital day, so much per surgery. It pays that amount regardless of what the bill actually was, and the bill is usually much larger.
It is not minimum essential coverage and has no out-of-pocket maximum. Discount cards, where offered, are not insurance at all and pay no benefits.
These products are supplements. If someone presents one to you as your health insurance, that is your signal to slow the conversation down.
Also called: COBRA continuation
The right to keep your employer's health plan after leaving the job — by paying the entire premium yourself.
The coverage is identical to what you had, including the network and any deductible you have already met this year. What changes is the price: your employer was quietly paying most of the premium, and now you pay all of it plus an administrative fee of up to 2%.
You have 60 days to elect it. A marketplace Special Enrollment Period runs during the same 60 days, so both options are open at once — and a marketplace plan can carry a premium tax credit, while COBRA never does.
Compare them early. Once the 60 days pass, the choice is usually made for you.
Don't see yours? Call a licensed agent — most answers take under two minutes.
No single one does, but the two that matter most are the monthly premium and the out-of-pocket maximum. The premium is what a quiet year costs you; the out-of-pocket maximum is what a bad year costs you. A plan with a low premium and a high out-of-pocket maximum is a bet that this will be a quiet year.
Not necessarily. Metal tiers describe how costs are split, not the quality of the doctors. And if your household qualifies for a cost-sharing reduction, it only attaches to Silver — which can make a Silver plan both cheaper and more generous than the Gold plan next to it.
Premium tax credits are calculated from the benchmark plan in your county and from your household size, ages and estimated income. Change any one of those and the number changes. Eligibility is determined by the Marketplace, not by us.
Not under the ACA. Short-term medical does not provide comprehensive coverage and does not satisfy minimum essential coverage. It typically excludes pre-existing conditions and can be declined based on your health.
No. These are plain-language explanations written by a licensed insurance agency to help you read a plan. Health Enrollment Center is operated by Sprinter Insurance Agency LLC and is not a government agency or marketplace. For official definitions and to enroll for free, see HealthCare.gov or your state exchange.
Start with your ZIP. Two quick questions, then a licensed agent brings you the plans you actually qualify for — no cost, no obligation.