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Below you’ll find definitions for the most common words and phrases used in the insurance industry. There are probably a lot more, but we tried to list the most common ones, the ones our clients always ask us about.
We separated the definitions into seven categories. We also added a search bar INSIDE the tab that ONLY searches for words in THAT category (very helpful and very quick).
Each tab (insurance category) has it’s own distinct definitions, so be sure to choose the correct one.
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A set dollar amount you pay for a procedure or office visit. (Look at your plan summary very carefully) A copay is helpful because you’ll GENERALLY pay just the copay (unless other procedures are billed by your doctor in addition to the copay). For example, let’s say you see your family doctor for a sore throat. If your plan had a copay of $35 dollars, you’d pay the $35.
But wait, there’s more: Sometimes you can be billed more than just a copay. For example, let’s say you went to a specialist (specialist copays are generally more than a primary care doctor) to have a spot on your skin looked at. The office copay may be $50. You’d pay the $50 for the office visit. But if the doctor wanted to remove the spot, he could charge you/your insurance company for a “procedure”. That charge would be in addition to the copay. So the procedure could be billed to your insurance company and you’d pay whatever your insurance company had negotiated with the doctor for that procedure.
If your family size and income ranks you at under 250% of the Federal Poverty Level, this cost reduction will reduce your total out of pocket responsibilities in overall medical costs. You’ll get additional financial assistance to cover more of your portion of the medical expenses for your “Silver” plan (70/30.) So in addition to getting the “Advanced Premium Tax Subsidy,” you’ll also have the “Cost Sharing Reductions” to reduce deductibles, co-pays, and co-insurance. Your overall medical costs will be a smaller percentage of your income to pay for medical bills and expenses.
The Cost Sharing Reduction is ONLY available on SILVER Plans.
What are “Essential Health Benefits”? If your plan does not cover these services, it is not a “Qualified Health Plan”:
♦ Ambulatory patient services (clinics, doctors office, same-day surgery centers, etc.)
♦ Emergency services
♦ Hospitalization
♦ Maternity and newborn care
♦ Mental health and substance use disorder services, including behavioral health treatment
♦ Prescription drugs
♦ Rehabilitative and habilitative services and devices
♦ Laboratory services
♦ Preventive and wellness services and chronic disease management
♦ Pediatric services
Dental for “Pediatrics” means anyone under the age of 19. Check the plan “Summary of Benefits” to see if a dental plan for children under the age of 19 is already built into the plan. ON Exchange pediatric dental is offered for purchase separately, OFF Exchange there may be a plan built into the health plan or not. You’ll need to look at the “Summary of Benefits” in your plan.
