Health Insurance Glossary

Affordable Care Act

Otherwise known as Obamacare, this is the healthcare reform act President Obama signed into law in March of 2010. Learn more about ACA.

Brand name drugs

A prescription drug, sold by a company, that is protected by a patent. See also generic drugs.

Bronze Plan

These plans typically have high deductibles (around $5,000 to $6,600). Some Bronze plans have copays for the first 2-3 doctor visits, and some you have to pay for everything yourself until your deductible is met. All Bronze plans are HSA eligible; however, there are no copays on brand name prescriptions. This plan is good for folks who don’t go to the doctor often; your monthly bill will be low, but you will have to pay more for medical needs. See also silver, gold, and platinum.

Catastrophic Plan

Catastrophic plans are only available if you’re under the age of 30. These plans typically have high deductibles (over $6,600), but you get 2-3 doctor visits with a copay each year. Everything else you’ll pay for out of your own pocket until you reach your deductible, then your insurance will pick up the tab.

Coinsurance

This is how much you pay after you’ve reached your deductible when your carrier doesn’t cover the full cost of service, which is typically around 30% of the cost.

Copay

A set and typically small amount you have to pay for a medical services. This amount can vary depending on your insurance plan. Example: Many insurance plans have a $25 copay for primary healthcare provider visits, which means you pay $25 for your doctor’s appointment.

Deductible

This is the amount you will pay for medical costs subject to the deductible until your carrier picks up the rest of the tab. Deductibles are different for each plan. Example: You have a silver plan with a $4,000 deductible; this means your insurance won’t pay for certain services until you’ve paid the $4,000 deductible.

EPO

Exclusive Provider Organization (EPO) is similar to a PPO. An EPO means you can see any provider or specialist within your network and you don’t need a referral to do so. You also don’t have to select a primary care physician when enrolling. EPOs have several provider options but not as many as a POS or PPO, and you have no out-of-network benefits. See also HMO, POS, and PPO.

FSA (Flexible Spending Account)

A medical savings account set up through an employer and can be deducted from employee’s paycheck. The tax-free funds can be used for a range of medical costs. Unused funds DO NOT carry over each year. See also HSA.

Generic drugs

A prescription drug that has the same ingredients as a brand name drug. Typically these pills cost less than brand name drugs and are deemed safe by FDA. See also brand name drugs.

Gold Plan

These plans have low deductibles ($1,000 to $2,000) and most have copays for unlimited doctor visits and brand name prescriptions. A few are HSA eligible. This plan is good for folks who don’t mind paying a little more on their monthly payment and who want kick-butt coverage. See also bronze, silver, and platinum.

HMO

Health Maintenance Organization (HMO) means you have to get referrals from your primary care physician in order to see a specialist. You also need to select your primary care physician when enrolling, otherwise the carrier will do it for you. HMOs typically have the least amount of providers out of all plan types. In other words, you’re paying for two doctor visits. See also EPO, POS, and PPO.

HSA (Health Savings Account)

A medical savings account typically available with high deductible health plans. The enrollee of the plan can make contributions to their HSA without being subject to federal income tax. The funds can be used for a range of medical costs. Unused funds roll over each year. See also FSA.

In-network

This means your doctors or services are covered by your insurance plan.

Lifetime limit

The amount your carrier will pay in total, period. Once that amount is met, the carrier will no longer cover expenses, which is typically around $1,000,000.

Marketplace

HealthCare.gov’s site to shop for health insurance. If you’re eligible for subsidies, this is where you’d shop for a plan.

Out-of-network

This means your doctors or services are not covered by your insurance plan.

Out-of-pocket max

This amount is the most you will pay for medical expenses in a given year. Example: No matter what your medical costs are in a year, you will never pay more than the out-of-pocket max amount, which is typically under $10,000 for an individual.

Platinum Plan

These plans have a low deductible ($1,000 and under) and have copays for unlimited doctor visits and brand name prescriptions. Platinum plans are not HSA eligible. This plan is good for folks who  have a specific medical condition that might require a lot of medical attention. See also bronze, silver, and gold.

POS

Point of Service (POS) is similar to a PPO. We all know what you’re thinking and no, a POS in this case does not mean that. A POS means you can see any provider or specialist within your network without a referral. You also don’t have to select a primary care physician when enrolling. However, a POS has slightly fewer provider options than a PPO. See also EPO, HMO, and PPO.

PPO

Preferred Provider Organization (PPO) means you can see any provider or specialist within your network and you don’t need a referral to do so. You also don’t have to select a primary care physician when enrolling. PPOs generally have the most providers out of all plan types.

In other words, you’re a free-range patient. See also EPO, HMO, and POS.

Premium

This is your monthly payment for your health insurance plan.

Silver Plan

These plans have medium deductibles ($3,000 to $4,000) and often have copays for unlimited doctor visits and brand name prescriptions. Many are HSA eligible. This plan is good for folks who have some medical needs but still like to budget their costs. See also bronze, gold, and platinum.