Plain-English definitions of health insurance terms. No jargon, just clear explanations of what you need to know.
The amount you pay to your insurance company, usually monthly, to keep your health insurance active.
Example:
If your premium is $400/month, you pay $400 every month whether you visit the doctor or not.
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The amount you must pay out-of-pocket for covered services before your insurance starts paying.
Example:
With a $2,000 deductible, you pay the first $2,000 of covered medical costs yourself before insurance helps pay.
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A fixed amount you pay for a covered service, usually when you receive the service.
Example:
You might pay a $30 copay when you visit your primary care doctor.
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The percentage of costs you pay for covered services after meeting your deductible.
Example:
With 20% coinsurance, if a procedure costs $1,000, you pay $200 and insurance pays $800.
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The most you have to pay for covered services in a year. After you reach this amount, insurance pays 100%.
Example:
With a $7,000 out-of-pocket max, once you've paid $7,000 in deductibles, copays, and coinsurance, insurance covers everything else.
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Healthcare costs you pay yourself, including deductibles, copays, and coinsurance.
Example:
Your out-of-pocket costs for the year include your $2,000 deductible, plus copays and coinsurance up to your maximum.
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The deductible amount that resets each plan year.
Example:
If you meet your $3,000 annual deductible in December, it resets to $0 on January 1st.
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The total deductible for all family members combined on a family plan.
Example:
With a $6,000 family deductible, all family members' expenses count toward this amount.
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The deductible that applies to each person on a plan.
Example:
With a $2,000 individual deductible, each family member must meet their own $2,000 before insurance pays.
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A family plan structure where each individual has their own deductible within the family deductible.
Example:
A plan might have a $2,000 individual/$4,000 family embedded deductible.
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A family deductible that must be met by the combined expenses of all family members.
Example:
With an aggregate $6,000 deductible, all expenses combine until the family reaches $6,000.
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The maximum amount an insurer will pay for a covered service.
Example:
If the allowed amount for an office visit is $150 and the doctor charges $200, you may owe the $50 difference if out-of-network.
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When an out-of-network provider bills you for the difference between their charge and what insurance pays.
Example:
Doctor charges $300, insurance allows $200, you may be balance billed $100.
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The amount insurance determines is appropriate for a medical service in your area.
Example:
Your insurer may cover services at 80% of the reasonable and customary rate.
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The portion of healthcare costs you pay (deductibles, copays, coinsurance).
Example:
Your cost-sharing is lower with Gold plans than Bronze plans.
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Extra savings that lower deductibles, copays, and coinsurance for Silver plans if you qualify.
Example:
With CSR, your Silver plan deductible might drop from $3,000 to $1,000.
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Financial assistance that reduces your monthly premium payment.
Example:
A $200/month subsidy reduces your $450 premium to $250.
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The percentage of total covered costs a plan pays on average.
Example:
A Gold plan has 80% actuarial value, meaning it covers 80% of costs on average.
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The percentage of premium dollars insurers must spend on medical care and quality improvement.
Example:
Under ACA, insurers must spend at least 80-85% of premiums on medical care.
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Another term for out-of-pocket maximum.
Example:
Once you hit your stop-loss limit, insurance covers 100% of covered expenses.
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How insurers set premiums based on factors like age, location, and tobacco use.
Example:
Older adults may pay up to 3 times more than younger adults under ACA rating rules.
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The premium surcharge (up to 50%) for tobacco users.
Example:
A tobacco user might pay $600/month vs $400/month for non-tobacco users.
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Premium variation based on age, with older adults paying more.
Example:
A 60-year-old may pay 3x what a 21-year-old pays for the same plan.
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Premium variation based on where you live.
Example:
The same plan costs more in New York City than in rural areas.
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A limit on benefits covered by insurance. ACA plans cannot have lifetime or annual caps on essential benefits.
Example:
Old plans might have had $1 million lifetime caps; ACA plans have no lifetime limits.
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A plan design where copays don't apply until you meet your deductible.
Example:
You pay full cost until meeting your deductible, then copays kick in.
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A fixed daily amount paid for hospital stays.
Example:
Insurance might pay $1,000 per-diem for hospital days.
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Another term for out-of-pocket maximum.
Example:
Your maximum out-of-pocket for 2025 cannot exceed $9,450 for individual coverage.
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The value of employer-sponsored insurance used for comparison.
Example:
Used to determine if employer coverage is affordable under ACA.
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Different cost-sharing levels for different provider groups.
Example:
Tier 1 providers have $20 copays, Tier 2 have $40 copays.
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Lower copays for high-value services like preventive care.
Example:
Copays might be lower for generic drugs vs brand-name drugs.
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A deductible that runs January 1 - December 31.
Example:
Most ACA plans use calendar year deductibles.
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A deductible for specific services like pharmacy or medical equipment.
Example:
A plan might have a $2,000 medical deductible plus a $500 prescription drug deductible.
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A single deductible that applies to all covered services.
Example:
Medical visits, prescriptions, and hospital stays all count toward the same deductible.
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Some services may have additional costs if prior authorization requirements aren't met.
Example:
Getting an MRI without prior authorization might result in higher out-of-pocket costs.
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Health plan categories (Bronze, Silver, Gold, Platinum) that indicate how you and the plan share costs.
Example:
Bronze plans have lower premiums but higher deductibles. Platinum plans have higher premiums but lower out-of-pocket costs.
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Doctors, hospitals, and other providers that have a contract with your insurance company.
Example:
Using in-network providers costs less because they have agreed to discounted rates with your insurer.
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A health problem you had before your insurance coverage started. ACA plans cannot deny you coverage or charge more for these.
Example:
If you have diabetes or asthma, insurers must cover you at the same price as someone without these conditions.
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Providers who don't have a contract with your insurance plan.
Example:
Out-of-network care typically costs significantly more and may not be covered at all.
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Ten categories of services that ACA-compliant plans must cover.
Example:
Includes emergency services, hospitalization, prescription drugs, maternity care, and mental health.
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The minimum level of coverage required under the ACA.
Example:
ACA marketplace plans, Medicaid, and most employer plans provide minimum essential coverage.
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Medical services your insurance plan will pay for.
Example:
Check your plan's benefits summary to see which services are covered.
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Services not covered by your insurance plan.
Example:
Common exclusions include cosmetic surgery and experimental treatments.
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A period when you don't have health insurance.
Example:
Having a coverage gap can limit your enrollment options outside open enrollment.
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The group of doctors, hospitals, and other providers that contract with your insurance.
Example:
Check if your doctor is in the network before choosing a plan.
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A list of all in-network providers for your insurance plan.
Example:
Use the online network directory to find in-network specialists.
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A limited provider network with fewer doctors and hospitals.
Example:
Narrow network plans often have lower premiums but less provider choice.
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A provider network with extensive doctor and hospital choices.
Example:
Broad network plans offer more flexibility but may cost more.
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Lowest-tier ACA plan covering 60% of costs, with lower premiums and higher out-of-pocket costs.
Example:
Bronze plans work well if you're healthy and want lower monthly payments.
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Mid-tier ACA plan covering 70% of costs, eligible for cost-sharing reductions.
Example:
Silver plans are often the best value if you qualify for cost-sharing reductions.
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Higher-tier ACA plan covering 80% of costs, with higher premiums and lower out-of-pocket costs.
Example:
Gold plans are good if you use healthcare frequently.
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Highest-tier ACA plan covering 90% of costs, with the highest premiums and lowest out-of-pocket costs.
Example:
Platinum plans are best for people with high medical needs.
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Low-premium plan for under-30 or those with hardship exemptions, covering essential benefits after high deductible.
Example:
Catastrophic plans protect against worst-case scenarios but have high deductibles.
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A plan covering at least 60% of total costs.
Example:
Employer plans must provide minimum value to meet ACA requirements.
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A standard form explaining what a plan covers and costs.
Example:
Review the SBC to compare plans side-by-side.
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Document outlining your plan's benefits, exclusions, and limitations.
Example:
Your certificate of coverage contains detailed information about what's covered.
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Additional coverage you can add to your plan.
Example:
You might add a dental rider to your medical plan.
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A list of prescription drugs covered by your plan.
Example:
Check the formulary to see if your medications are covered.
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Categories of prescription drugs with different cost-sharing levels.
Example:
Tier 1 generic drugs cost less than Tier 3 brand-name drugs.
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Approval required from insurance before receiving certain services.
Example:
Your MRI may require prior authorization to ensure it's covered.
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Requirement to try lower-cost treatments before insurance covers more expensive options.
Example:
You may need to try generic drugs before insurance covers brand-name alternatives.
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Healthcare services considered essential for diagnosis or treatment.
Example:
Insurance only covers services deemed medically necessary.
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Reusable medical equipment like wheelchairs, walkers, and hospital beds.
Example:
Your plan may cover 80% of DME costs after you meet your deductible.
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Virtual healthcare services provided via phone or video.
Example:
Many plans now offer $0 copay telemedicine visits.
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Mental health and substance abuse services.
Example:
ACA plans must cover behavioral health as an essential benefit.
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A plan type that requires you to use doctors and hospitals in its network and get referrals to see specialists.
Example:
With an HMO, you must choose a primary care doctor and get their referral before seeing a cardiologist.
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A plan type that offers more flexibility to see any doctor, though costs are lower with in-network providers.
Example:
With a PPO, you can see a specialist without a referral, but pay less if you use in-network doctors.
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A plan that covers services only within its network, except emergencies.
Example:
EPOs don't require referrals but don't cover out-of-network care.
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A plan combining HMO and PPO features, requiring a primary care doctor but allowing out-of-network care at higher cost.
Example:
POS plans let you go out-of-network but you'll pay more.
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A plan with lower premiums and higher deductibles, HSA-eligible.
Example:
HDHPs have deductibles of at least $1,600 for individuals in 2025.
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A high-deductible plan that allows you to contribute to a Health Savings Account.
Example:
HSA-eligible plans let you save tax-free money for medical expenses.
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Health insurance sold through federal or state exchanges under the ACA.
Example:
You can shop for marketplace plans at HealthCare.gov.
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ACA-compliant plans sold outside the marketplace.
Example:
Off-exchange plans have the same essential benefits but you can't use subsidies.
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Health coverage provided through your employer.
Example:
Employer-sponsored insurance is often more affordable than individual plans.
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Insurance covering a group of people, typically through an employer or organization.
Example:
Group coverage often has lower rates than individual plans.
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Insurance you buy for yourself, not through an employer.
Example:
Self-employed people often need individual coverage.
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A plan covering you, your spouse, and dependents.
Example:
Family coverage typically costs more than individual coverage.
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Temporary coverage for gaps between plans, not ACA-compliant.
Example:
Short-term plans are cheaper but don't cover pre-existing conditions.
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Plans with restrictions on coverage, not meeting ACA standards.
Example:
Fixed indemnity plans pay set amounts regardless of actual costs.
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Supplemental insurance that covers Medicare gaps.
Example:
Medigap helps pay Medicare deductibles and coinsurance.
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Private insurance that replaces Original Medicare.
Example:
Medicare Advantage plans often include prescription drug coverage.
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Government health program for low-income individuals and families.
Example:
Medicaid eligibility varies by state, with some states expanding coverage.
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Low-cost health coverage for children in families earning too much for Medicaid.
Example:
CHIP provides comprehensive coverage for children at low or no cost.
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Federal health insurance for people 65+ and certain younger people with disabilities.
Example:
Medicare Part A covers hospital stays, Part B covers doctor visits.
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Health coverage for military service members, retirees, and families.
Example:
Tricare offers several plan options for military families.
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Employer plan where the employer pays claims directly instead of paying premiums to an insurer.
Example:
Large employers often use self-funded plans to control costs.
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Employer plan where premiums are paid to an insurance company that assumes the risk.
Example:
Small businesses typically use fully-insured plans.
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Plans available in multiple states through the marketplace.
Example:
Multi-state plans offer consistent coverage if you move between states.
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Coverage for small businesses and self-employed through associations.
Example:
Trade associations may offer group rates to members.
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Insurance offered by colleges and universities to students.
Example:
Student health plans often cover campus health center visits.
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Financial assistance from the government to help lower your monthly insurance premium.
Example:
Based on your income, you might get a $300/month tax credit, reducing your $500 premium to $200.
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A measure of income used to determine eligibility for subsidies and Medicaid.
Example:
If you earn between 100-400% of FPL, you likely qualify for premium tax credits.
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Federal law (Obamacare) that reformed healthcare, requiring coverage of essential benefits and prohibiting pre-existing condition discrimination.
Example:
The ACA created health insurance marketplaces and expanded Medicaid.
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Common name for the Affordable Care Act.
Example:
Obamacare made health insurance accessible to millions of previously uninsured Americans.
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Website where you shop for ACA-compliant insurance plans.
Example:
HealthCare.gov is the federal marketplace for most states.
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Another term for the Health Insurance Marketplace.
Example:
State exchanges operate their own marketplaces.
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Premium tax credit paid directly to your insurer to lower monthly premiums.
Example:
APTC reduces your premium payment each month instead of waiting for a tax refund.
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General term for financial assistance to help pay for insurance.
Example:
Subsidies include premium tax credits and cost-sharing reductions.
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ACA provision allowing states to extend Medicaid to adults earning up to 138% FPL.
Example:
40 states have expanded Medicaid as of 2025.
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Income range where you earn too much for Medicaid but too little for subsidies in non-expansion states.
Example:
In non-expansion states, earning below 100% FPL creates a coverage gap.
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Previous federal requirement to have health insurance (penalty removed in 2019).
Example:
Some states still have their own individual mandates.
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ACA requirement for large employers to offer affordable coverage or pay penalties.
Example:
Employers with 50+ full-time employees must offer coverage.
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Employer with 50 or more full-time equivalent employees subject to ACA employer mandate.
Example:
ALEs must offer minimum essential coverage to avoid penalties.
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Employer coverage costing no more than 9.12% of household income in 2025.
Example:
If employer coverage is unaffordable, you may qualify for marketplace subsidies.
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State-run marketplace instead of using HealthCare.gov.
Example:
California (Covered California) and New York have state-based exchanges.
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HealthCare.gov marketplace used by states without their own exchanges.
Example:
Most states use the federal exchange.
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Exchange model where states and federal government share marketplace operations.
Example:
Some states handle plan management while using HealthCare.gov for enrollment.
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Process of confirming income for subsidy eligibility.
Example:
You'll need to provide tax returns or pay stubs for income verification.
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Modified Adjusted Gross Income (MAGI) used to determine subsidy eligibility.
Example:
Household income includes your AGI plus tax-exempt interest and excluded foreign income.
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Income calculation used for ACA subsidy eligibility.
Example:
MAGI is your AGI from taxes plus certain exclusions and deductions added back.
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Process of comparing actual income to estimated income and adjusting tax credits.
Example:
If you earned more than estimated, you may owe back some premium tax credits.
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IRS tax form for reconciling advance premium tax credits.
Example:
You must file Form 8962 if you received APTC during the year.
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Tax form showing your marketplace coverage and APTC amounts.
Example:
You need Form 1095-A to complete Form 8962 for taxes.
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The second-lowest-cost Silver plan used to calculate premium tax credits.
Example:
Your subsidy is based on the benchmark plan even if you choose a different plan.
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The benchmark plan for subsidy calculations.
Example:
SLCSP determines your maximum premium after subsidies.
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Strategy where insurers increase Silver plan premiums to fund CSRs, making other tiers cheaper with subsidies.
Example:
Silver loading can make Gold plans cost less than Silver after subsidies.
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Silver plan with cost-sharing reductions that increases actuarial value.
Example:
CSR Silver plans can have 73%, 87%, or 94% actuarial value instead of standard 70%.
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ACA process requiring insurers to justify premium increases over 10%.
Example:
State insurance departments review and approve or deny rate increases.
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ACA requirement that insurers must sell coverage to everyone regardless of health status.
Example:
Insurers cannot deny you coverage due to pre-existing conditions.
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ACA rule limiting premium variation to age, tobacco use, location, and family size.
Example:
Insurers cannot charge more based on health status or gender.
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Geographic zone used for setting premiums.
Example:
Premiums vary by rating area based on local healthcare costs.
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Former income threshold (400% FPL) where subsidies abruptly ended.
Example:
The American Rescue Plan eliminated the subsidy cliff for 2021-2025.
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2021 law that enhanced and expanded ACA subsidies.
Example:
ARP eliminated the subsidy cliff and increased subsidy amounts.
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2022 law that extended ARP subsidy enhancements through 2025.
Example:
IRA continued enhanced subsidies beyond their original 2022 expiration.
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Trained professionals who help consumers enroll in marketplace plans.
Example:
Navigators provide free, unbiased assistance with marketplace enrollment.
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The yearly period when you can enroll in, renew, or change health insurance plans.
Example:
Open enrollment for 2025 coverage runs from November 1 to January 15.
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A time outside open enrollment when you can sign up for insurance due to a qualifying life event.
Example:
If you lose your job and health insurance, you can enroll during a 60-day special enrollment period.
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Life changes that trigger a special enrollment period.
Example:
Getting married, having a baby, or losing other coverage are qualifying life events.
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The date your insurance coverage begins.
Example:
If you enroll by the 15th of the month, coverage typically starts the 1st of the next month.
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Time after your premium due date before coverage is terminated.
Example:
Most plans have a 30-day grace period for premium payment.
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Maintaining health insurance without gaps.
Example:
Continuous coverage prevents issues with pre-existing condition waiting periods in some states.
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A period when you don't have active health insurance.
Example:
Avoid coverage lapses to maintain continuous protection.
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Coverage that applies to dates before enrollment.
Example:
Some Medicaid programs offer retroactive coverage up to 3 months.
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Automatic re-enrollment in your current plan for the next year.
Example:
If you don't actively choose a plan, you'll be auto-renewed.
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Another term for auto-renewal.
Example:
Passive renewal keeps your current plan, but premiums may change.
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The 12-month period your plan is active.
Example:
Most marketplace plans run on calendar year (January-December).
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End of insurance coverage.
Example:
Coverage terminates if you don't pay premiums or voluntarily cancel.
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Canceling your coverage by choice.
Example:
You might voluntarily terminate when switching to employer coverage.
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Coverage ended by insurer for non-payment or fraud.
Example:
Involuntary termination can occur after the grace period ends.
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A person covered under someone else's plan, typically children or spouse.
Example:
Children can stay on parent's plans until age 26 under ACA.
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ACA provision allowing young adults to stay on parent plans until 26.
Example:
Your child can remain on your plan even if married or employed.
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Continuation coverage allowing you to keep employer insurance after job loss.
Example:
COBRA lets you stay on employer plan for up to 18 months but you pay full cost.
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Temporary extension of coverage after qualifying event.
Example:
COBRA is the most common type of continuation coverage.
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Changing group coverage to individual coverage.
Example:
Some employer plans allow conversion when you leave the company.
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Time between enrollment and when coverage becomes active.
Example:
Employer plans may have up to 90-day waiting periods for new employees.
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Timeframe when you can enroll in coverage.
Example:
New employees have a limited eligibility period to enroll in benefits.
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Time when you can choose or change benefits.
Example:
Annual election period is when employees select next year's benefits.
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Last day to enroll in coverage for a specific period.
Example:
Missing the enrollment deadline means waiting until next open enrollment.
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Documentation showing you have health insurance.
Example:
Keep your insurance card as proof of coverage.
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Card showing your coverage information and identification numbers.
Example:
Bring your insurance card to doctor appointments.
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Unique identifier for your insurance coverage.
Example:
Provide your member ID when scheduling medical appointments.
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Unique number identifying your insurance policy.
Example:
Your policy number is on your insurance card and all documents.
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Primary policyholder on an insurance plan.
Example:
The subscriber is typically the employee or person who purchased the plan.
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Person who receives insurance benefits.
Example:
All covered family members are beneficiaries of the policy.
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Proof of qualifying event needed for special enrollment.
Example:
Marriage certificate, birth certificate, or job loss letter serve as life event documentation.
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Healthcare services that prevent illness or detect health problems early, covered at 100% by ACA plans.
Example:
Annual checkups, mammograms, and flu shots are preventive care services covered with no copay.
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Your main doctor who coordinates your healthcare.
Example:
HMO plans require you to choose a PCP who refers you to specialists.
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A doctor focusing on a specific area of medicine.
Example:
Cardiologists, dermatologists, and orthopedists are specialists.
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Authorization from your PCP to see a specialist.
Example:
HMO plans typically require a referral before specialist visits.
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Immediate medical attention for serious conditions.
Example:
Emergency care must be covered even if you go to an out-of-network hospital.
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Hospital department providing immediate treatment for serious conditions.
Example:
ER copays are typically higher than regular doctor visits.
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Walk-in clinic for non-life-threatening conditions needing prompt attention.
Example:
Urgent care is cheaper than ER for conditions like minor injuries or flu.
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Medical treatment requiring overnight hospital stay.
Example:
Surgery with overnight recovery is inpatient care.
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Medical services that don't require overnight stay.
Example:
Lab tests, x-rays, and same-day procedures are outpatient care.
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Another term for outpatient care.
Example:
Ambulatory surgery centers perform procedures without admission.
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Admission to a hospital for treatment.
Example:
Your plan covers hospitalization after you meet your deductible.
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Hospital stay where you're monitored but not formally admitted.
Example:
Observation status may result in different cost-sharing than inpatient admission.
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Official release from hospital or medical facility.
Example:
You receive discharge instructions when leaving the hospital.
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Medical appointments after initial treatment.
Example:
Post-surgery follow-up care monitors your recovery.
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Tests and procedures to identify medical conditions.
Example:
Blood tests, MRIs, and biopsies are diagnostic services.
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Medical tests performed on blood, urine, or tissue samples.
Example:
Lab services include blood counts, cholesterol tests, and cultures.
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Medical tests that create pictures of body structures.
Example:
X-rays, CT scans, MRIs, and ultrasounds are imaging services.
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Medication requiring a doctor's authorization.
Example:
Your plan's formulary lists covered prescription drugs.
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Lower-cost version of a brand-name medication.
Example:
Generic drugs have the same active ingredients as brand-name drugs.
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Medication sold under a manufacturer's trademark.
Example:
Brand-name drugs typically cost more than generics.
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Medications on lower formulary tiers with lower copays.
Example:
Using preferred drugs saves money on prescriptions.
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High-cost medications for complex conditions.
Example:
Specialty drugs often require prior authorization and special handling.
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Pharmacy service delivering prescriptions by mail.
Example:
Mail-order pharmacy often provides 90-day supplies at lower cost.
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Healthcare services for pregnancy, childbirth, and postpartum.
Example:
ACA plans must cover maternity care as an essential health benefit.
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Treatment for mental health conditions and substance abuse.
Example:
Mental health services must be covered equally to medical services under ACA.
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Services for addiction and substance use disorders.
Example:
Substance abuse treatment is an essential health benefit.
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Therapy to restore function after injury or illness.
Example:
Physical therapy, occupational therapy, and speech therapy are rehabilitation services.
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Treatment to improve movement and manage pain.
Example:
Physical therapy helps recovery after surgery or injury.
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Treatment to improve daily living and work skills.
Example:
Occupational therapy helps regain independence after injury.
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Medical services provided in your home.
Example:
Home health care includes nursing care, therapy, and medical equipment.
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Facility providing 24-hour nursing care.
Example:
After hospital discharge, you may need temporary skilled nursing care.
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End-of-life care focusing on comfort.
Example:
Hospice care provides medical, emotional, and spiritual support.
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Specialized care for serious illness focusing on symptom relief.
Example:
Palliative care improves quality of life alongside curative treatment.
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Tests to detect diseases early.
Example:
Colonoscopies, mammograms, and diabetes screenings are covered preventive services.
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Vaccine to prevent disease.
Example:
Flu shots, COVID vaccines, and childhood immunizations are covered preventive care.
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Annual checkup for preventive care.
Example:
Well visits are covered at 100% with no copay under ACA.
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Long-lasting health condition requiring ongoing management.
Example:
Diabetes, heart disease, and asthma are chronic conditions.
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Short-term treatment for sudden illness or injury.
Example:
Emergency room visits and urgent care are acute care services.
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Non-emergency surgical procedure.
Example:
Hip replacement and cataract surgery are elective procedures.
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Surgery to improve appearance, typically not covered.
Example:
Cosmetic procedures like facelifts are usually excluded from coverage.
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Now that you understand the terms, check your eligibility and see plans available in your area.