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Choosing Coverage

Dave Knows · Glossary

Premium: The fixed amount you pay each month to keep coverage active, whether you use care or not.
Deductible: What you pay for covered services before the plan starts paying its share for those services.
Copay: A flat amount you pay for a specific covered service, such as an office visit.
Coinsurance: A percentage of a covered service's cost that you pay after meeting your deductible.
Out-of-pocket maximum: The most you would pay for covered services in a plan year.
PPO: A preferred provider structure that usually allows out-of-network care at higher cost, often without referrals.
HMO: A structure that concentrates care in a defined network, often coordinated through a primary care physician.
Provider network: The set of providers contracted with a specific plan at negotiated rates.
Prescription coverage: How a plan covers medications, usually organized into tiers with different cost-sharing.
Marketplace coverage: Plans sold through the government exchange that must meet Affordable Care Act requirements.
Private coverage: Plans sold outside the Marketplace. Some are ACA-compliant and some are not.
Enrollment periods: The windows during which you can enroll in or change coverage.
Supplemental insurance: Products such as dental and vision that sit alongside — not instead of — major medical coverage.