Every insurance term you'll encounter — from premium and deductible to APTC and CSR — defined simply so you can shop with confidence.
Calculate My Cost →The monthly amount you pay for your health insurance plan — regardless of whether you use any healthcare that month. Like a subscription fee for coverage.
The amount you pay out-of-pocket for covered services before your insurance starts paying. Example: $3,000 deductible means you pay the first $3,000 of medical bills each year.
A fixed dollar amount you pay for a covered service, regardless of the total bill. Example: $25 co-pay for a primary care visit, $50 for a specialist.
Your share of costs after you've met your deductible, expressed as a percentage. Example: 20% co-insurance means your insurer pays 80% and you pay 20% of the remaining bill.
The most you'll pay in a year for covered services. After hitting this cap, insurance pays 100%. In 2026, the ACA out-of-pocket maximum is $9,450 (individual) and $18,900 (family).
The ACA subsidy — a government tax credit that reduces your monthly premium. Based on your income and household size. Can be applied in advance (APTC) directly to your monthly bill.
When your ACA subsidy is paid directly to your insurance company each month, reducing what you owe. You reconcile the actual amount on your tax return.
An extra discount on Silver ACA plans for households earning 100–250% FPL. Lowers your deductible, co-pays, and out-of-pocket maximum significantly. Only available on Silver plans.
A government income measure used to determine subsidy eligibility. In 2026: $15,060/yr for a single person. ACA subsidies are available at 100–400%+ FPL.
The annual window (November 1 – January 15) when you can enroll in or change ACA marketplace plans. Outside this window, you need a qualifying life event.
A 60-day window to enroll in health insurance outside Open Enrollment, triggered by a qualifying life event such as job loss, marriage, birth of a child, or moving.
An event that triggers a Special Enrollment Period. Includes: losing job-based coverage, getting married or divorced, having a baby, adopting a child, moving to a new coverage area.
Doctors, hospitals, and providers that have a contract with your insurance company. You pay less (or nothing after deductible) when you use in-network providers.
Providers without a contract with your insurer. You typically pay much more, or everything, for out-of-network care (except emergencies).
Your main doctor for general health needs. HMO plans require you to choose a PCP who manages referrals to specialists. PPO plans don't require one.
A written authorization from your PCP to see a specialist. Required by most HMO plans. Not required by PPO or EPO plans.
Your plan's list of covered prescription drugs. Drugs are organized into tiers — generic drugs cost less than brand-name or specialty drugs. Always check if your medications are on the formulary before enrolling.
A federal law allowing you to keep your employer's group health coverage after leaving a job — but you pay 100% of the premium plus a 2% admin fee. Usually far more expensive than ACA marketplace alternatives.
A plan type with lower premiums that requires you to use a specific network of providers and get referrals from a PCP to see specialists. No out-of-network coverage except emergencies.
A plan type with higher premiums but more flexibility — no referrals needed, larger network, and partial coverage for out-of-network providers.
A hybrid plan — no referrals required like a PPO, but no out-of-network coverage like an HMO. Lower premiums than a PPO.
A plan with a deductible of at least $1,650 (individual) in 2026. Lower premiums but higher out-of-pocket costs. Must be paired with an HSA.
A tax-advantaged savings account for medical expenses, available only with an HDHP. Triple tax benefit: contributions are deductible, growth is tax-free, and medical withdrawals are tax-free. 2026 limit: $4,300 individual, $8,550 family.
ACA plan categories by cost-sharing level: Bronze (you pay ~40%), Silver (~30%), Gold (~20%), Platinum (~10%). Higher tiers = higher premiums but lower out-of-pocket when you use care.
A joint federal-state program providing free or very low-cost health coverage to low-income adults, children, pregnant women, elderly, and people with disabilities. Eligibility is income-based.
Provides free or low-cost coverage to children in families that earn too much for Medicaid but can't afford private insurance. Available in all states.
The second-lowest-cost Silver plan in your area. Used to calculate ACA premium tax credits. Your subsidy = benchmark plan cost minus your required contribution.
10 categories of services all ACA plans must cover: outpatient care, emergency services, hospitalization, maternity/newborn, mental health, prescriptions, rehab, lab services, preventive care, and pediatric services.
ACA requirement that insurers must sell you a plan regardless of your health history or pre-existing conditions. No medical underwriting during Open Enrollment.
The group of doctors, hospitals, and other healthcare providers that have agreed to provide services to members of a specific health plan at negotiated (lower) rates.
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