Common Terms

Advanced Premium Tax Credit

A tax credit that can help you afford coverage bought through the Marketplace. Sometimes known as APTC, “advance payments of the premium tax credit,” or premium tax credit. Unlike tax credits you claim when you file your taxes, these tax credits can be used right away to lower your monthly premium payments.

Children's Health Insurance Program (CHIP)

Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.

Co-insurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Co-payment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Cost Sharing

The share of costs covered by your insurance that you pay out of your own pocket. This generally includes deductibles, co-insurance, and co-payments, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

Deductible

The amount you owe for eligible health care services before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won't pay anything until you've met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Emergency Room Care

Emergency services you get in an emergency room.

Health Insurance Marketplace (Exchange)

A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. In some states, the Marketplace is run by the state. In others it is run by the federal government.

Health Reimbursement Account (HRA)

Health care accounts that employers fund for covered workers or retired persons. The IRS does not tax this money and an employer may allow any money left in these accounts at the end of the year to roll over to be used the next year.

Health Savings Account (HSA)

A medical savings account available to taxpayers who are enrolled in a qualified High Deductible Health Plan. The funds contributed to the account aren't subject to federal income tax at the time of deposit (subject to limits). Funds must be used to pay for qualified medical expenses.

High-Deductible Health Plan

A plan that features higher deductibles than traditional insurance plans. High deductible health plans can be paired with a health savings account to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

Medicaid

A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.

Medicare

A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Open Enrollment Period

The period of time when you can re-enroll in the health plan you are already in or choose to enroll in another health plan.

Out-of-pocket Maximum

The most you pay during a policy period (usually a calendar year) before your health insurance or plan starts to pay 100% for covered health benefits. This limit must include deductibles, co-insurance, co-payments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the health benefits.

Premium

The amount that must be paid for your health insurance or plan,  usually monthly, quarterly or yearly.

Premium Tax Credit

The Affordable Care Act provides a tax credit to help qualifying individuals and families afford health coverage purchased through the Federally Facilitated Marketplace or state operated Exchange, depending on the state you reside in. If eligible, advance payments of the tax credit can be used right away to lower your monthly premium costs.

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary Care Physician (PCP)

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Qualifying Life Event

An event defined by the IRS that allows an individual to change their benefit selections. Examples of events may include marriage, divorce, adoption or birth of a child or death of a dependent.

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.

Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Well-Baby and Well-Child Visits

Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.