Guides
Insurance words, explained.
Every one of these turns up on a plan document sooner or later. Here's what they actually mean.
What you pay
The four numbers that decide what a plan actually costs you.
- Deductible
- The amount you pay for care yourself before the plan starts paying its share.With a $3,000 deductible, you cover the first $3,000 of care. Preventive visits usually don't count against it — they're free from day one.
- Copay
- A flat fee for a particular visit or prescription.$30 every time you see your family doctor, whatever the visit costs.
- Coinsurance
- A percentage of the bill rather than a flat fee. It usually kicks in after your deductible.20% coinsurance on a $1,000 procedure means you pay $200.
- Out-of-pocket maximum
- The most you can pay in one year for covered care. After that, the plan pays 100%.This is the number that matters if something serious happens. Premiums don't count toward it.
Doctors and prescriptions
Who you can see, and what's covered.
- Network
- The doctors, hospitals and pharmacies your plan has an agreement with. Staying inside it is almost always cheaper.
- Out-of-network
- A provider without an agreement with your plan. Some plans pay less for this; some pay nothing at all.Worth checking before an appointment, not after. This is the most common reason a bill is bigger than expected.
- Primary care provider (PCP)
- Your main doctor — the one who handles everyday care and refers you on when you need a specialist.
- Referral
- Your PCP formally sending you to a specialist. Some plans need one before they'll cover the specialist visit.
- Formulary
- The list of prescriptions your plan covers, usually sorted into tiers that cost you different amounts.If a medication you take isn't on it, that's worth knowing before you pick a plan.
Paperwork you'll see
Documents that arrive and look like bills but usually aren't.
- Explanation of benefits (EOB)
- A summary from your insurer showing what a visit cost, what they paid, and what's left for you.It is not a bill. The bill comes from the doctor's office.
- Summary of benefits and coverage (SBC)
- A short standard document describing what a plan covers and what it costs. Every plan has one, in the same format, so plans can be compared side by side.
Enrolling and staying covered
When you can sign up, and what help you might qualify for.
- Open Enrollment
- The yearly window when anyone can start, switch or drop a Marketplace plan.
- Special Enrollment Period (SEP)
- A window outside Open Enrollment that opens after certain life events — losing coverage, moving, marriage, a new baby.Usually 60 days from the event. Miss it and you may have to wait for Open Enrollment.
- Qualifying life event
- The change that opens a Special Enrollment Period for you.
- Cost-sharing reduction
- Extra help that lowers your deductible, copays and out-of-pocket maximum. Only available on Silver plans, and only at certain income levels.
- Effectuation
- Your carrier switching the policy on, which normally happens once the first premium is paid.Enrolled and effectuated are not the same thing. Until the first payment clears, you're enrolled but not yet covered.
- Minimum essential coverage
- Coverage that counts as real health insurance under the law — a job plan, Medicare, Medicaid, or a Marketplace plan.Losing it is what opens a Special Enrollment Period. Short-term or discount plans usually don't count.
- Data matching issue (DMI)
- The Marketplace couldn't match something on your application — income, citizenship, a Social Security number — against its own records, so it asks for a document.There's a deadline, and missing it can cost you coverage or your subsidy. Anything we need from you shows up in your portal.
These explain how coverage generally works. Your own plan is what decides what you pay. Give us a call and we'll look it up with you.