Curious about what some of these terms mean? Just ready to wonk out? We’ve put together a list of definitions for you here.
The medical services that are fully or partially paid for by a health insurance plan. Benefits included in a plan could still require a co-pay or co-insurance payment.
- Benefit limits/caps/maximums
Before the health care reform law, many plans stopped paying for your health care once they spent a certain dollar amount each year or over the course of your lifetime. The new law prevents insurance companies from capping payments and require them to pay for all the care you need.
- Catastrophic Plan or Minimum Coverage Plan
A plan with a low monthly premium but high out-of-pocket costs and a very high deductible. You must be under 30 years old or eligible for a “hardship exemption” because you can’t find other affordable health insurance coverage in order to get a catastrophic plan. These plans are not eligible for premium tax credits.
A type of cost sharing between you and your insurance company, where you each pay a percent of the costs of a covered health care service. If you have 80%/20% co-insurance, this means that when you receive care, the insurance company pays 80% of the cost and you pay the other 20%, after your deductible is met.
A co-pay is the flat fee you have to pay for a service, such as a doctor’s visit or a prescription. If you have a $15 co-pay for visits to your primary care provider, you will pay $15 for each doctor’s visit.
- Cost-sharing reductions or subsidies
A discount on your out-of-pocket costs, such as your co-pay. You can get these discounts if you buy a “silver” level health plan on the Marketplace and your yearly income is within a certain range. For example, you may qualify if your yearly income is $11,670–$29,175 as an individual or $23,850–$59,625 as a family of 4. A silver plan is a type of plan available on the new state Health Insurance Marketplaces.
The amount you pay for care before your insurance kicks in. For example, if you have a $1,000 deductible, you will pay for health services until you have spent $1,000, then your insurer will pay for your remaining covered health care services (except co-pays and co-insurance). There can be a separate deductible for a specific benefit like prescription drugs.
- Essential Health Benefits
There are 10 categories of health care services that everyone needs and all insurance plans are now required to cover. These categories of services include: ambulatory services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescriptions; rehabilitative services; laboratory services; preventive and wellness services and chronic disease management; and pediatric services.
Free or low-cost health insurance for certain low-income individuals and families. The health care reform law gave states the option to make Medicaid available to all low-income people making less than a certain yearly income. In states that have chosen this option, you may be eligible for Medicaid if your yearly income is less than $16,105 as an individual or $32,910 as a family of 4. To find out if your state expanded and if you are eligible, go to healthcare.gov/do-i-qualify-for-medicaid/.
In other states that have chosen not to expand their Medicaid programs, you may be eligible for Medicaid if you are a low-income parent, pregnant woman, child, or disabled.
If you were in foster care and covered by Medicaid, you may be eligible to stay on Medicaid after you age out of foster care until age 26.
- Minimum Essential Coverage
The health care law requires most individuals to have health insurance that meets certain standards, or else pay a fine. Health insurance that meets these quality standards is known as Minimum Essential Coverage. Marketplace health plans and Medicaid are considered Minimum Essential Coverage.
- Individual Responsibility Payment
The fine or penalty that you have to pay if you choose not to sign up for health insurance, and are not eligible for an exemption. The payment is collected when you file your taxes.
Most individuals are required to sign up for health insurance or pay a fine. But there are some exceptions to this rule. For example, you may be exempt from paying the penalty if: you have a short gap in coverage (less than 3 months); you’re undocumented; you can’t find a plan for less than 8% of your income; you’re incarcerated; or you’re found ineligible for Medicaid because your state didn’t expand Medicaid eligibility. For a full list of exemptions, and how to apply, go to: https://www.healthcare.gov/exemptions/.
Health Insurance Marketplaces (also called Exchanges) are a place to find information about health insurance, compare and purchase plans, and get help. You can access the Marketplace online, in person, or over the phone. To get a tax credit to lower the cost of buying a plan, you must purchase insurance through the Marketplace. You can find your state’s marketplace by visiting HealthCare.gov.
Doctors, hospitals, and other providers that are included in your plan. If you see doctors that aren’t “in-network,” your cost may be higher. Your health insurance company should have a full list of doctors and hospitals that are part of each plan’s network. You can check before you buy insurance to make sure your current doctor is included!
- Open Enrollment Period
You can only sign up for health insurance or change your plan during an open enrollment period. The 2015 open enrollment period for the Health Insurance Marketplaces is November 15, 2014–February 15, 2015. If you have insurance through your job, the open enrollment period could be at a different time. However, if you experience qualifying life events, you may become eligible for a Special Enrollment Period.
- Out-of-pocket Maximum/Limit
The health reform law limits the total amount you have to spend out-of-pocket on health care, through your co-insurance, co-pays, and deductible, when you have health insurance. This is known as your out-of-pocket maximum. The monthly premiums you pay for coverage may not count toward your out-of-pocket maximum. Once you reach the out-of-pocket maximum, your insurance company pays 100% of your remaining costs. The out-of-pocket limit for 2014 Marketplace plans is $6,350 for individual plans and $12,700 for family plans.
The amount you pay, usually once a month, to maintain your insurance. If you have a $200 premium, you will pay $200 a month to have health insurance.
- Premium Tax Credits
Under the health reform law, you can get a discount on your monthly premium based on your income. You can choose whether to apply this tax credit directly to your monthly premium to lower the amount you pay to your insurer each month, or get this discount in the form of a credit when you pay your taxes. You can find out if you are eligible by filling out an application for coverage though your state’s Health Insurance Marketplace.
- Pre-existing condition waiting periods or exclusions
Before the health care reform law, if you had a medical condition before getting insurance, such as diabetes, cancer, or even pregnancy, insurers may not have covered your “pre-existing condition” for a period of time—or at all. Starting in 2014, insurers cannot deny coverage due to pre-existing health conditions.
- Preventive Services
Health care services, tests, and screenings preformed to keep you healthy. Insurance plans are now required to provide these services at no additional cost to you. They include certain vaccines; diet and obesity counseling; testing for certain sexually transmitted infections; and screenings for blood pressure, cholesterol, diabetes, colorectal cancer, and depression. Covered preventive services for women include FDA-approved contraceptive methods (like birth control pills), mammograms and other cancer screenings, certain maternal care services for expectant mothers, domestic violence screenings, and well-woman visits.
- Qualifying Life Event
A life change or event that may allow you to enroll in or change your insurance plan. If you lose job-based coverage, move, get married, have a baby, or turn 26, you may be able to buy insurance even if it is not during an Open Enrollment period.
- Special Enrollment Period
A period of time outside of Open Enrollment when you may sign up for health insurance through the Marketplace if you experience certain life events. Life events may include: turning 26, moving, getting married, having a baby, or changing jobs. If you think you qualify for Medicaid, you can sign up at any time.
Schools that mandate insurance coverage often require proof that you have other insurance if you don’t want to purchase the school’s Student Health Insurance Plan. If you’re on a non-school plan, waive your school coverage by the deadline to avoid the charge.
- Find out why reform matters for you
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- Learn about what’s coming next with health care reform
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- Ready to Wonk out? View our glossary to learn more.