Healthcare terms, translated into plain English.
Healthcare is notorious for confusing jargon. Here is a clear glossary of every acronym and rule you'll encounter during coverage decisions.
COBRA
Consolidated Omnibus Budget Reconciliation Act. A federal law requiring group health plans of employers with 20+ workers to offer temporary continuation of coverage when job-based benefits end.
Premium
The fixed amount you pay each month for your health insurance policy, whether you visit the doctor or not.
Deductible
The amount you must pay out-of-pocket for covered medical services before your health insurance begins paying its share.
Coinsurance
Your share of the costs of a covered healthcare service, calculated as a percentage (e.g., 20%) after meeting your deductible.
Copayment (Copay)
A fixed dollar amount (e.g., $25) you pay for a covered medical service at the time of care.
Out-of-Pocket Maximum
The absolute maximum amount you have to pay for covered services in a plan year. Once reached, the insurer pays 100% of covered benefits.
Special Enrollment Period (SEP)
A 60-day window outside the standard Open Enrollment period when you are allowed to enroll in Marketplace health coverage due to a qualifying life event (like losing job-based insurance).
Premium Tax Credit (Subsidy)
A refundable federal tax credit that helps eligible moderate- and low-income individuals and families pay for health insurance purchased through the ACA Marketplace.
HMO (Health Maintenance Organization)
A plan type that usually limits coverage to care from doctors who work for or contract with the HMO. Out-of-network care is generally not covered except in emergencies.
PPO (Preferred Provider Organization)
A plan type that contracts with medical providers. You pay less if you use providers that belong to the network, but you can use outside doctors without a referral for an additional cost.
EPO (Exclusive Provider Organization)
A managed care plan where services are covered only if you use doctors and hospitals in the plan's network (except in emergencies), but usually without needing specialist referrals.
Qualifying Life Event (QLE)
A change in your life situation — like losing job-based coverage, getting married, having a baby, or moving — that qualifies you for a Special Enrollment Period.
Formulary
A list of prescription medications covered by a health insurance plan, organized into different tiers with varying copay and coinsurance amounts.
In-Network vs. Out-of-Network
In-network providers have contracted with your insurance plan to provide services at pre-negotiated discount rates. Out-of-network doctors have no agreement, leading to higher bills.
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