Insurance words to know

When it comes to health insurance, there are a few terms you will come across that might be confusing. Here are some definitions to help you understand what they mean:

Insurer – A company that provides health insurance.

Health Care Provider – Sometimes shortened to "provider," this is your doctor, nurse, other health care professional or the place where you get health care services. For example: Planned Parenthood, your local hospital and Dr. Smith are all health care providers.

HMO – HMO is one type of health insurance plan and stands for "Health Maintenance Organization." HMO plans typically have a lower premium, but patients can only use their insurance to receive care at in-network health care providers. An HMO plan may offer fewer options in providers as well. If you have an HMO, and you visit a health care provider that is out-of-network, you will not be able to use your insurance, and you will have to pay the full cost of your services on your own.

PPO – PPO is one type of health insurance plan and stands for "Preferred Provider Option." This type of plan allows a patient to receive services from out-of-network providers, but usually the patient pays more than if they received the same services from an in-network provider.

Premium – The money you pay your insurer for your health insurance plan. The cost varies depending on the plan you choose and is usually paid monthly.

Note: Millions of Americans will be able to get help paying their premium. In fact, most individuals making less than $45,960 per year, and most families of four making less than $94,200 can get financial help.

Deductible – The amount of money you need to pay each year for certain health care services before your insurer starts to help cover the costs. Plans with lower premiums tend to have higher deductibles, and plans with higher premiums tend to have lower deductibles. Some plans have no deductible at all. For example: If your plan has a $1,000 deductible, and your first health care cost of the year is a hospital bill for $1,500, you will have to pay the first $1,000 to reach your deductible, then your insurer will pay the remaining amount covered by your plan.

Copay – Short for "copayment," this is what you pay when you get care; like visiting the doctor or getting a prescription medication, to share the expense with your insurer. For example: You may have a $30 copay to visit the doctor, and then your plan will pay your doctor for the rest of the cost of your visit.

Note: Under the law, if you have health insurance, annual well-woman exams and the full range of prescription birth control options (with the exception of some brands) are available for free – with no copay or deductible.

Coinsurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

In/out of network – Every insurance company has a "network," a list of specific health care providers where you can use your insurance. If you visit an “in-network” provider, your insurance company will cover the cost of your care according to your plan. If you visit an “out-of-network” provider, you will likely have to pay much more for your health care – or pay for all of the cost yourself at the time of service. And some insurance plans don’t cover any of the costs for out-of-network providers.

Note: Planned Parenthood is an in-network for some insurance plans, but is out-of-network for others. If you want to come to Planned Parenthood or have us as an option for care with your new insurance, look for a health insurance plan that includes us. To find out which plans include Planned Parenthood, use our plan finder tool.

Out-of-pocket maximum – This is the total amount of money you would ever have to pay in one year for health care, no matter how much care you need. For example: If you have an out-of-pocket maximum of $6,000 and you have a very expensive surgery or treatments, your plan will pay everything after $6,000.

Health care law words to know

When it comes to the health care law, there are a few terms you will come across that might be confusing. Here some definitions to help you understand what they are talking about:

Health Insurance MarketplaceA website where you can see all of the new insurance plans available in your state. You can use the website to search for a plan, compare plan coverage and costs side by side, find out if you qualify for financial help and sign up for a plan right there.

Your state might call the Marketplace an “Exchange” or something else. For example, in California, the Marketplace is called Covered California.

Open Enrollment – This is the time when you can sign up for a new insurance plan. You can only sign up on the Marketplace during this time period. The open enrollment period for 2014 to sign up for a plan on the Marketplace begins October 1, 2013, and ends on March 31, 2014.

NavigatorsPeople who are trainedMarketplace experts, available to help you on the phone, online or in person. There will also be people called certified application counselors and in-person assisters.  All of these people (Navigators , certified application counselors, in person assisters) are not salespeople, and they are there only to help you and answer questions, not sell you a plan. To find a Navigator in your state visit: healthcare.gov/local-help

Health Plan Categories – Health plans available on the Marketplace will be organized into categories: Bronze, Silver, Gold and Platinum. All plans are required to offer coverage for essential health care services—including hospitalizations, maternity care, prescription drugs and preventive care.

The different categories reflect different price structures. Platinum plans will have higher monthly premiums, but lower out-of-pocket costs when you get care. Bronze plans will have lower monthly premiums, but higher out-of-pocket costs when you get care. Silver and Gold plans will fall somewhere in the middle.

Essential Health Benefits – The basic health care services all plans must cover, like: preventive care (including annual well-woman exams and birth control), prescription drugs, hospital stays, emergency services, maternity and newborn care and more.

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