Exchanges Glossary

Co-insurance. The amount you are required to pay as your share of the cost for services after you have met your deductible. This amount is usually a percentage of the total cost (for example, 20 percent).

Co-payment. The amount you are required to pay as your share of the cost of services, due at the time service is provided. This is usually a set amount, rather than a percentage. For example, a plan may have a co-payment of $15 for prescription drugs.

Deductible. The amount you must pay for health care or prescriptions before your insurance begins to pay in full or part.

Grandfathered Health Plan. A group health plan that was created – or an individual health insurance policy that was purchased – on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. However, a health plan must disclose in its plan materials if it is considered a grandfathered plan. Materials must also tell  consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions

Health Maintenance Organization (HMO). An organization that provides managed care on a prepaid basis. Each HMO member is required to select a primary care provider (PCP) who is responsible for managing and coordinating all of the member’s health care. Most, or all, services received must be performed by a provider in the plan’s network, and a member must receive a referral to see a provider other than their PCP.

High Deductible Health Plan (HDHP).   A health insurance plan that has a high minimum deductible, which does not cover the initial costs or all of the costs of medical expenses. The deductible forces the covered individuals to pay the first portion of a medical expense before the insurance coverage kicks in. The minimum deductible for an HDHP plan varies each year,

Out-of-pocket maximum. The most you pay during a policy period (typically one year) before your health insurance or plan begins to pay 100 percent of the allowed amount.

Plan network. A network made up of the facilities, providers and suppliers a health plan contracts with to provide health care services.

Point of Service Plan (POS). A type of managed care health insurance system that combines characteristics of HMOs and PPOs. Members may be required to choose a primary care physician who monitors the member’s health care. The primary care physician can make referrals to providers outside of the plan’s network.

Preferred Provider Organization (PPO). A health plan with a network of “preferred” providers from which you can choose. Unlike an HMO, you are not required to select a primary care physician and you do not need referrals to see other providers in the network. You may see out-of-network providers but will usually pay more out-of-pocket costs.

Premium. A periodic payment to an insurance company or a health care plan for health care coverage.

Provider directory. A guide to the providers within a plan’s network. Health plans must provide this guide if you request it.

Qualifying Life Event. A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples include moving to another state, certain changes in your income, and changes in your family size (having a baby, getting married or divorced).

Subsidy. Financial help from the government to help eligible individuals pay for health care coverage purchased a state or federal marketplace.