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.

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)

The part of Medicare that covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.

Medicare Part B (Medical Insurance)

The part of Medicare that covers outpatient care, doctor visits, preventive services, and medical equipment, and typically requires a monthly premium.

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

An alternative way to get Medicare benefits through a private insurance company, often bundling Part A, Part B, and usually Part D, plus extra benefits.

Medicare Part D (Medicare Prescription Drug Coverage)

The part of Medicare that covers outpatient prescription drugs through private plans that contract with Medicare.

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.