Glossary

Insurance glossary

Plain-language definitions for every term the site uses to describe plans, costs, and coverage. Jump to a letter or scroll through the list.

A

Acupuncture: What you pay for acupuncture treatment. Coverage is limited and often restricted to specific diagnoses.
Adult Basic Dental Care: What you pay for basic adult dental services like fillings and simple extractions.
Adult Major Dental Care: What you pay for major adult dental work like crowns, bridges, and dentures.
Adult Orthodontic: What you pay for adult orthodontic treatment like braces. Adult ortho is rarely covered by medical plans.
Adult Routine Dental: What you pay for adult routine dental services like cleanings and checkups. Most ACA medical plans do not include adult dental — check carefully.
Adult Routine Eye Exam: What you pay for an adult routine eye exam. Glasses and contacts usually require a separate vision plan.
Annual Cost (Premiums): Your monthly premium multiplied by 12. This is the minimum you will spend on the plan in a year, before any care.

B

Bariatric Surgery: What you pay for weight-loss surgery. Coverage usually requires meeting specific medical criteria ahead of time.
Brand Drugs: Brand-name prescription drugs on the plan’s preferred list. These cost more than generics; ask your doctor whether a generic equivalent exists.

C

Chemotherapy: What you pay for chemotherapy and cancer infusion treatments. These are often billed under both office-visit and specialty-drug categories.
Chiropractic Care: What you pay for chiropractic adjustments. Many plans cap the number of covered visits per year.
Coinsurance: The percentage of a covered bill you pay after meeting your deductible. If coinsurance is 20%, you pay 20% and the plan pays 80% until you hit the out-of-pocket max.
Cost-Sharing Reductions (CSRs): Lower your out-of-pocket costs — deductibles, copays, coinsurance, and out-of-pocket maximums. Only available with Silver-tier plans.
CT / PET / MRI: What you pay for advanced imaging — CT scans, PET scans, and MRIs. These cost more than basic x-rays and are often billed separately.

D

Delivery & Inpatient Maternity: What you pay for childbirth itself, including the delivery and the inpatient hospital stay that follows.
Dialysis: What you pay for kidney dialysis treatment for patients with kidney failure.
Durable Medical Equipment: What you pay for durable medical equipment — wheelchairs, CPAP machines, crutches, oxygen equipment, and other long-term-use medical gear.

E

Effective Date: The date your coverage starts. Medical services received before this date are not covered by the plan.
Emergency Room: What you pay for an emergency room visit. ER visits are the most expensive type of care; the copay is often waived or reduced if you’re admitted as an inpatient from the ER.
EPO (Exclusive Provider Organization): EPOs combine elements of HMOs and PPOs. Like a PPO, you do not need referrals for specialists, but like an HMO, only in-network care is covered (except in emergencies).

F

Family Deductible: The combined amount your whole family must pay out of pocket before the plan starts sharing costs for everyone on the plan. Individual deductibles roll up into the family deductible.
Family Out-of-Pocket Max: The most your family will pay out of pocket combined in a year. Once hit, the plan covers 100% of further covered costs for everyone on the plan.

G

Generic Drugs: Generic prescription drugs on the plan’s preferred list. These are the cheapest tier and should be your default whenever a generic is available.

H

Habilitation Services: What you pay for services that help you develop skills you haven’t had before (different from rehab, which restores lost skills). Commonly used for children with developmental conditions.
HDHP (High-Deductible Health Plan): HDHPs have lower monthly premiums but significantly higher deductibles. They are typically pairable with a Health Savings Account (HSA), which lets you set aside pre-tax dollars for medical expenses.
Hearing Aids: What you pay toward hearing aids. Many plans cover the exam but not the device, or cap coverage to once every few years.
HMO (Health Maintenance Organization): HMOs require you to choose a primary care physician (PCP) who coordinates your care and provides referrals to specialists. Care is generally only covered when you stay inside the plan’s network, except in emergencies. HMOs typically have the lowest premiums and predictable copays.
HSA Eligible: When yes, this plan qualifies you to open a Health Savings Account — a tax-advantaged savings account you can use for medical expenses. HSA-eligible plans are always high-deductible plans.

I

Individual Deductible: The amount one person must pay out of pocket for covered services before the plan starts sharing costs. Preventive care is usually covered before you meet the deductible.
Individual Out-of-Pocket Max: The most one person will pay out of pocket in a year for covered in-network services. Once you hit this cap, the plan covers 100% of further covered costs for that person.
Infertility Treatment: What you pay for infertility evaluation or treatment if the plan covers it. Coverage varies a lot by state and plan.
Inpatient Hospital: What you pay for hospital stays where you’re admitted overnight or longer. Usually billed as a per-stay or per-day cost after you meet your deductible.

M

Medicaid & CHIP: Unlike Marketplace plans, Medicaid and CHIP accept applications year-round. If your income qualifies, you can enroll at any time.
Medicaid Expansion: In states that expanded Medicaid, adults with incomes up to 138% of the FPL may qualify for free or very low-cost coverage.
Mental Health Inpatient: What you pay for inpatient mental health or substance abuse care — hospitalizations or residential treatment.
Mental Health Outpatient: What you pay for mental health office visits and therapy sessions where you’re not admitted to a facility.
Mental Illness / Substance Abuse: What you pay overall for the treatment of mental illness or substance use disorders. Under federal parity rules, these cannot be covered less generously than medical care.
Monthly Premium: The amount you pay each month to have a plan, whether or not you use any medical services. Think of it as the plan’s subscription fee.

N

Network: The group of doctors, hospitals, and other providers the plan has contracts with. Visiting in-network providers almost always costs less than going out of network.
Non-Preferred Brand: Brand drugs that aren’t on the plan’s preferred list. These are typically the second-most expensive drug tier.
Non-Preferred Generic: Generic drugs that aren’t on the plan’s preferred list. They cost more than preferred generics but are still usually cheaper than any brand option.
Non-Preferred Specialty: Specialty drugs that aren’t on the plan’s preferred list. These are usually the highest-cost drug tier.

O

Open Enrollment Period (OEP): The annual window when anyone can sign up for a Marketplace plan, switch plans, or renew existing coverage. For most states using HealthCare.gov, OEP runs from November 1 through January 15.
Outpatient Hospital: What you pay for hospital services that don’t require an overnight stay — for example, same-day surgery, infusions, or outpatient procedures.
Outpatient Rehabilitation: What you pay for outpatient physical, occupational, or speech therapy — usually to restore function lost to injury, surgery, or illness.
Outpatient X-ray & Diagnostics: What you pay for basic imaging like x-rays and ultrasounds, plus standard lab work and diagnostic tests done on an outpatient basis.

P

Pediatric Basic Dental: What you pay for pediatric basic dental services like fillings.
Pediatric Dental Check: What you pay for pediatric dental exams and cleanings. Pediatric dental is an Essential Health Benefit under the ACA, so most marketplace plans include it.
Pediatric Eye Glasses: What you pay toward eye glasses for children. Most ACA plans cover one pair of standard glasses per year.
Pediatric Major Dental: What you pay for pediatric major dental work like crowns or root canals.
Pediatric Orthodontic: What you pay for pediatric orthodontic care like braces. Pediatric ortho is more widely covered than adult ortho.
Pediatric Routine Eye Exam: What you pay for pediatric routine eye exams. Pediatric vision is an Essential Health Benefit under the ACA.
Plan Type: The structural type of the plan — HMO, PPO, EPO, POS, or HDHP. Each type has different rules about referrals, in-network requirements, and out-of-network coverage.
PPO (Preferred Provider Organization): PPOs let you see any doctor or specialist without a referral and offer partial coverage for out-of-network providers. This flexibility comes at a cost: PPOs usually have higher premiums and deductibles than HMOs.
Premium Tax Credit (PTC / APTC): A federal subsidy that reduces what you pay each month for your insurance premium, based on household income and family size. You can take it in advance (APTC — paid directly to your insurer each month to lower your bill) or claim it when you file taxes. On the health-plan detail page, the “Monthly Premium with Credit” line shows your premium after APTC is applied.
Prenatal & Postnatal Care: What you pay for doctor visits and routine care during and immediately after pregnancy. Most ACA plans cover prenatal screenings with no cost-sharing.
Preventive Screening & Immunization: What you pay for covered preventive care — wellness exams, vaccinations, and recommended screenings. Under the ACA, in-network preventive care is usually free.
Primary Care Visit: What you pay out of pocket to see your primary care doctor — the generalist who handles checkups, routine illnesses, and referrals.
Primary Care Visits Before Deductible: The number of primary care visits the plan covers at the copay rate before your deductible applies. After this many visits, the deductible kicks in for further visits that year.
Private Duty Nursing: What you pay for one-on-one nursing care at home, typically for patients who need continuous medical attention outside the hospital.

R

Referral Required: When yes, you must get a referral from your primary care doctor before your visit to a specialist is covered. HMO plans typically require referrals; PPOs usually don’t.

S

Skilled Nursing Facility: What you pay for short-term care at a skilled nursing facility, typically for recovery or rehabilitation after a hospital stay.
Special Enrollment Period (SEP): Triggered by a qualifying life event such as losing other coverage, moving to a new area, getting married or divorced, or having a baby. SEPs typically last 60 days from the date of the event.
Specialist Visit: What you pay to see a specialist — a cardiologist, dermatologist, orthopedist, and so on. Specialists often cost more per visit than primary care.
Specialty Drugs: Complex, high-cost drugs — often injections or biologics — used to treat conditions like cancer, multiple sclerosis, or rheumatoid arthritis.

U

Urgent Care: What you pay at an urgent care center. Urgent care handles same-day, non-life-threatening issues and is usually much cheaper than the ER.