Health Insurance Glossary

Plain-language definitions for the health insurance terms you'll run into while comparing plans, from premiums and deductibles to ACA marketplace and Medicare terminology.

A C D E H M N O P

A

ACA Marketplace (Health Insurance Marketplace) (Health Insurance Marketplace, Obamacare Exchange, Healthcare.gov)

The government-run online system, created under the Affordable Care Act, where individuals can compare and enroll in health plans and apply for premium subsidies.

ALS (Amyotrophic Lateral Sclerosis) (Lou Gehrig's Disease, Amyotrophic Lateral Sclerosis)

A progressive neurological disease that damages the nerve cells controlling voluntary muscle movement and breathing. ALS is also called Lou Gehrig's disease.

C

COBRA (Consolidated Omnibus Budget Reconciliation Act Continuation Coverage)

A federal law that lets you temporarily keep your employer-sponsored health coverage after leaving a job, usually by paying the full premium yourself.

Coinsurance (Cost-Sharing Percentage)

The percentage of a covered service's cost you pay after meeting your deductible, with your insurance plan paying the rest.

Copay (Copayment) (Copayment)

A fixed dollar amount you pay for a specific covered service, like a doctor visit or prescription, regardless of the service's actual cost.

D

Deductible (Annual Deductible)

The amount you must pay out of pocket for covered care each year before your health plan starts sharing costs through copays or coinsurance.

E

EPO (Exclusive Provider Organization) (Exclusive Provider Organization)

A health plan that only covers care from its network, like an HMO, but typically doesn't require referrals to see a specialist.

Explanation of Benefits (EOB) (EOB, Explanation of Benefits Statement)

A statement your health plan sends after a claim is processed, showing what was billed, what the plan paid, and what you may owe.

H

HMO (Health Maintenance Organization) (Health Maintenance Organization)

A health plan that covers care mainly through a network of contracted providers and usually requires you to pick a primary care physician and get referrals to see specialists.

HSA (Health Savings Account) (Health Savings Account)

A tax-advantaged savings account, available with certain high-deductible health plans, used to pay for qualified medical expenses.

M

Medicaid (Medical Assistance)

A joint federal and state health coverage program for people with low income, run differently in each state within federal guidelines.

Medicare Part A (Hospital Insurance)

Hospital insurance that helps cover inpatient hospital care, limited skilled nursing facility care, hospice, and some home health care.

Medicare Part B (Medical Insurance)

Medical insurance that helps cover doctors, outpatient care, preventive services, medical equipment, and many tests and treatments.

Medicare Part C (Medicare Advantage) (Medicare Advantage, MA Plan)

Medicare Advantage, a private-plan alternative for receiving Part A and Part B benefits, usually with Part D drug coverage included.

Medicare Part D (Medicare Prescription Drug Coverage)

Prescription drug coverage offered by private plans that follow Medicare rules, either separately or through most Medicare Advantage plans.

N

Network (In-Network / Out-of-Network) (Provider Network, In-Network, Out-of-Network)

The group of doctors, hospitals, and other providers that have agreed to accept a health plan's negotiated rates; using providers outside that group usually costs more.

O

Open Enrollment Period (OEP, Annual Enrollment Period)

The yearly window during which you can enroll in or change health insurance coverage without needing a qualifying life event.

Out-of-Pocket Maximum (Out-of-Pocket Limit, OOP Max)

The most you'll have to pay in a plan year for covered services before your health insurance starts paying 100% of covered costs.

P

POS (Point of Service) Plan (Point of Service Plan)

A hybrid health plan that requires a primary care physician and referrals like an HMO, but still allows out-of-network care at a higher cost like a PPO.

PPO (Preferred Provider Organization) (Preferred Provider Organization)

A health plan that gives you a network of preferred providers for the lowest cost, but still lets you see out-of-network providers and specialists without a referral.

Premium (Monthly Premium)

The amount you pay, usually monthly, just to keep your health insurance coverage active, regardless of whether you use any care.