Health Insurance Glossary

The fixed amount you pay every month to maintain your active health insurance coverage.

The amount you pay out-of-pocket for covered medical services before your insurance starts sharing costs.

A fixed dollar amount you pay for a covered healthcare service (e.g., $25 for a primary care doctor visit).

The percentage of covered healthcare costs you pay (e.g., 20%) after meeting your annual deductible.

The most you pay for covered in-network care during your plan year, after which your insurance pays 100% of covered benefits.

Expenses you pay directly yourself, including deductibles, copayments, and coinsurance.

Federal financial assistance based on household income that lowers your monthly health insurance premium on the ACA Marketplace.

Extra federal subsidies available exclusively on Silver plans that lower your deductibles, copays, and out-of-pocket maximums if you qualify by income.

The maximum reimbursement rate an insurance company agrees to pay an in-network provider for a covered service.

A plan structure requiring you to use its contracted network of doctors and hospitals, and obtain a Primary Care Physician (PCP) referral to see specialists (except in emergencies).

A flexible plan allowing you to see both in-network and out-of-network doctors without needing referrals from a primary care doctor (out-of-network care costs more).

A managed care plan where services are covered only if you use providers in the plan’s network (except in an emergency), generally without needing specialist referrals.

A hybrid plan combining HMO and PPO features, often requiring a PCP referral to see specialists while allowing out-of-network care at higher cost.

Healthcare providers, clinics, and hospitals that have contracted with your insurance company to provide services at discounted negotiated rates.

Doctors or healthcare facilities that do not have a contract with your health insurer, which may lead to higher copays or no coverage.

The main physician, nurse practitioner, or clinic you visit for routine checkups, preventive screenings, and specialist coordination.

An official written authorization from your primary doctor approving you to see a specific medical specialist.

Pre-approval your insurer requires before agreeing to cover certain elective surgeries, specialty medications, or complex tests.

The official tiered list of prescription medications approved and covered under your health insurance policy.

The landmark federal law that created the health insurance marketplace, established 10 essential health benefits, and prohibited pre-existing condition exclusions.

The regulated state or federal platform where individuals and families can shop, compare plans, and apply for government subsidies (e.g., Georgia Access or HealthCare.gov).

The annual window (typically November 1 through January 15) when eligible individuals can enroll in or change health plans for the upcoming year.

A 60-day window outside open enrollment triggered by a qualifying life circumstance (marriage, birth, move, job loss) allowing you to enroll immediately.

A major life change—such as moving, marriage, having a child, or loss of existing health coverage—that qualifies you for a Special Enrollment Period. View our dedicated QLE Guide »

10 mandatory core healthcare services all ACA-compliant plans must cover, including maternity, emergency services, hospitalization, mental health, and prescription drugs.

Any health insurance policy that meets the baseline statutory criteria to count as qualifying comprehensive coverage.

The calculation figure used by the ACA Marketplace to evaluate your household’s eligibility for Premium Tax Credits and cost-sharing savings.

The total number of individuals claimed on your federal income tax return, used to calculate your federal poverty percentage and subsidy level.

Annual federal income guidelines that determine your tier for healthcare tax credits and Medicaid qualification.

Routine checkups, cancer screenings, and vaccines that all ACA plans are required to cover at 100% with no copay or deductible.

A medical illness or injury you had before the start date of your health insurance. Under the ACA, plans cannot deny coverage or charge you higher rates for preexisting conditions.

An informational statement sent by your insurer explaining what was billed by your doctor, how much the insurance company paid, and what you owe. (An EOB is not a bill).

A formal payment request submitted by your doctor, hospital, or yourself to your insurance company for covered health services.

Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, or symptom according to accepted medical standards.

A set time period (typically 30 to 90 days for subsidized Marketplace plans) allowing you to pay an overdue premium before your policy is cancelled.