We’ve translated some of the confusing terminology around health insurance into plain English so you can better understand your health insurance coverage. Here are the main health insurance terms you need to know before you enroll. Grab our list of health insurance terms to know to come back to later.
- Coinsurance: Your share of the health care service cost once you’ve met your deductible (if you have one). For example, if your bill is $100, and your coinsurance is 20%, you will pay $20 for your medical services if you have already met your deductible.
- Copay: A fixed amount of money that you may need to pay for a covered health care service or supply. For example, your health plan may require a $15 copay for an office visit or generic prescription, after which the plan will pay the remainder of the cost.
- Deductible: The amount of money that you may need to pay out-of-pocket for health care services before your health insurance plan begins to help with payments. For example, if your deductible is $100, your plan won’t pay for anything until you’ve paid the $100 deductible.
- Essential Health Benefits: A set of health care services that must be covered by plans in the Health Insurance Marketplace, as mandated by the Affordable Care Act. These services include emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, preventive and wellness services, pediatric services, and more.
- In-network: A group of doctors, hospitals, and other health care providers that a health insurance plan has partnered with to provide care to the plan’s members. These providers are called “network providers” or “in-network providers.” You can find out if a provider is in-network by checking with your health insurance plan.
- Out-of-network: Doctors, hospitals, and other health care providers who have not partnered with your health insurance plan to provide care to the plan’s members. You may have to pay more for services from an out-of-network provider.
- Out-of-pocket cost: This is the amount you pay for health care services. Out-of-pocket cost could include your deductible, coinsurance, and co-pays.
- Out-of-pocket maximum: The most you’ll pay in a policy period (usually one year), before your plan starts to pay 100% of the covered Essential Health Benefits you receive. This limit must include Deductibles, Coinsurance, and Co-payments, but does not typically count Premiums, toward your out of pocket maximum. The maximum out-of-pocket cost limit in 2016 can be no more than $6,850 for an individual plan and $13,700 for a family plan.
- Premium: Your monthly premium is the amount of money that you will pay to your insurance company for your health insurance plan. These payments are usually made monthly, quarterly, or yearly.
- Preventive Care: Health care services focused on keeping you healthy before you may become sick. These include routine check-ups, patient counseling, screening tests, and immunizations. Plans must offer these services at no cost to you when the services are provided by in-network doctors. This means they can’t charge a Copayment or Coinsurance, even if you haven’t met your deductible for the year.
Read more on preventive care. - Provider: A person or place you go to to receive health care services. Examples include doctors, hospitals, pharmacies, and more. Check with your health insurance plan to find out if a provider is in-network or out-of-network.
- Provider Network: The group of doctors, hospitals, and other health care providers who have partnered with your health insurance plan to provide care to the plan’s members. Check with your health insurance plan to see if a provider is in your provider network. The type of plan you have (HMO or PPO) can affect the size of the provider network.