Find your coverage path

Dave Knows · Terminology

The words behind the questions

Premium

The fixed amount you pay each month to keep coverage active, whether you use care or not. A premium is the cost of having coverage, not the cost of using it. It does not count toward your deductible or your out-of-pocket maximum. Comparing plans on premium alone hides the second half of the cost.

Deductible

What you pay for covered services before the plan starts paying its share for those services. Not every service applies to the deductible — many plans cover certain preventive care and some copay-based visits beforehand. In-network and out-of-network deductibles are often separate.

Copay

A flat amount you pay for a specific covered service, such as an office visit. Copays are predictable by design. Whether they apply before or after the deductible depends on the plan, so check the specific plan documents.

Coinsurance

A percentage of a covered service's cost that you pay after meeting your deductible. With 20% coinsurance, you pay 20% of the negotiated cost and the plan pays 80%, until you reach the out-of-pocket maximum. Because it is a percentage, the amount scales with the cost of care.

Out-of-pocket maximum

The most you would pay for covered services in a plan year. Once reached, the plan generally pays 100% of covered in-network services for the rest of the year. Premiums and non-covered services do not count toward it.

PPO

A preferred provider structure that usually allows out-of-network care at higher cost, often without referrals. PPO plans generally trade a higher premium for flexibility. Network breadth still varies significantly between PPO plans.

HMO

A structure that concentrates care in a defined network, often coordinated through a primary care physician. HMO plans typically cost less and provide little or no coverage outside the network except in emergencies. Referral rules vary by carrier.

Provider network

The set of providers contracted with a specific plan at negotiated rates. Networks belong to plans, not carriers, and they change over time. Facility and physician networks can differ inside the same hospital.

Prescription coverage

How a plan covers medications, usually organized into tiers with different cost-sharing. Drug lists change, and a medication covered on one plan may sit in a different tier — or be excluded — on another. If you take regular medications, this belongs early in your comparison.

Marketplace coverage

Plans sold through the government exchange that must meet Affordable Care Act requirements. Income-based financial help is generally only available through the Marketplace. Enrollment is typically limited to Open Enrollment or a Special Enrollment Period.

Private coverage

Plans sold outside the Marketplace. Some are ACA-compliant and some are not. Products that are not ACA-compliant may apply medical underwriting, exclude pre-existing conditions or leave out categories of care. Read what is excluded before comparing price. [INSURANCE COMPLIANCE REVIEW]

Enrollment periods

The windows during which you can enroll in or change coverage. Open Enrollment happens annually. Qualifying life events may open a Special Enrollment Period with a limited window. Some non-Marketplace products follow different timing rules.

Supplemental insurance

Products such as dental and vision that sit alongside — not instead of — major medical coverage. Benefit limits, waiting periods and exclusions are common. Value depends on how you actually use the covered services.