Health insurance glossary

Your percentage share of a cost after you meet the deductible. If your coinsurance is 20%, you pay 20% and the plan pays 80% until you reach your out-of-pocket maximum.

A flat fee for a specific service, for example $30 for a doctor visit or $10 for a generic drug. Some copays apply even before you meet the deductible.

Extra savings that lower your deductible, copays, and out-of-pocket maximum if your income qualifies. CSRs are only available on Silver marketplace plans.

What you pay out of pocket for covered care each year before the plan starts paying its share. Many preventive services are free even before you meet it.

A statement from your insurer after a claim showing what was billed, what the plan paid, and what you owe. It is not a bill.

An employer account that lets you set aside pre-tax money for medical costs. Unlike an HSA, funds usually must be used within the plan year ("use it or lose it").

The list of prescription drugs your plan covers, organized into tiers that set your cost. A drug not on the formulary may not be covered at all.

A Health Reimbursement Arrangement is employer money that reimburses your medical costs. An ICHRA reimburses you for an individual health plan you buy yourself.

A tax-advantaged savings account you can use with an HDHP. Contributions, growth, and withdrawals for qualified medical costs are all tax-free, and the balance is yours to keep.

A plan with a higher deductible and a lower premium that meets IRS limits, which makes it eligible to pair with a Health Savings Account.

In-network providers have agreed to your plan's rates, so you pay less. Out-of-network providers have not, so you usually pay much more, and that spending may not count toward your out-of-pocket maximum.

The ACA categories (Bronze, Silver, Gold, Platinum) that describe how you and the plan split costs. They reflect cost-sharing, not the quality of care.

The doctors, hospitals, and pharmacies your plan has contracted with. In-network care costs the least; out-of-network care can cost full price.

The yearly window when you can sign up for or change a plan. ACA marketplace open enrollment generally runs November 1 to January 15 in most states.

The most you can pay in a year for covered, in-network care. Once you reach it, the plan pays 100% of covered costs for the rest of the year. Premiums do not count toward it.

The fixed amount you pay every month to keep your plan active, whether or not you use any care.

Income-based financial help that lowers your monthly premium on an ACA marketplace plan. It is based on your estimated income for the coverage year.

Services like annual check-ups, vaccines, and recommended screenings that in-network plans must cover at no cost to you, even before you meet your deductible.

Approval your plan requires before it will cover certain services or drugs. Without it, the plan can deny the claim.

A window to enroll outside open enrollment after a qualifying life event, such as losing coverage, moving, marriage, a new baby, or being newly offered an ICHRA.