The help desk
A quick guide to insurance terms
The Health Insurance Marketplace
Also called the “exchange,” an Internet-based system run by federal and some state governments that standardizes health plans from different companies so they can be compared more easily and purchased by consumers. The system will show you plans available in your area based on your answers to some questions and apply any premium reduction for which you qualify. The Marketplace will also tell you if you qualify for free or low-cost coverage through Medicaid or other programs.
A category of health plan in the Marketplace. A Platinum plan will pay about 90% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Gold, Silver or Bronze plans, but premiums are higher. Do you expect a lot of doctor visits, have a chronic condition or need a lot of prescriptions? A Platinum plan may be a good choice. Platinum gives you the most protection of all plan categories.
A category of health plan in the Marketplace. A Gold plan will pay about 80% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Silver or Bronze plans, but premiums are higher. Do you expect a lot of doctor visits or need a lot of prescriptions? A Gold plan may be a good choice. Gold gives you more protection from an accident or unexpected illness than Silver or Bronze.
A category of health plan in the Marketplace. A Silver plan will pay about 70% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. Coverage is greater than Bronze plans, but premiums are higher, though not as high as Gold plans. A Silver plan may be a good choice if you expect fewer doctor visits and require no regular prescriptions. An unexpected accident or illness can cancel out the savings.
A category of health plan in the Marketplace. A Bronze plan will pay about 60% of overall costs for the average plan member, factoring in provisions like deductibles, copays and coinsurance. While coverage is less than Gold or Silver, the premium is also less. A Bronze plan may be a good choice if you expect almost no doctor visits and require no regular prescriptions. An unexpected accident or illness can cancel out the savings.
Your share of the costs of a covered health care service as a percent (for example, 20%). You pay this, plus any deductible that may apply. If the health 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 plan pays the rest.
The amount you must pay for health care services before your health insurance or plan begins to pay. If a service is covered under the plan but the deductible is $1,000, your plan won’t pay until you’ve met your $1,000 deductible. Some preventive care is not subject to a deductible.
Copayment, or copay
A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of service.
Health Maintenance Organization (HMO)
An HMO is an arrangement with a group of providers. An HMO may limit coverage to providers inside its network. If you use a doctor or facility that isn’t in the network, you may have to pay for services provided. HMO members usually have a primary care doctor are referred to see specialists.
Point-of-Service plan (POS)
These plans let you choose where to get care but if you use out-of-network providers and facilities, you’ll have to pay more than you will in-network. You can visit an in-network provider without a referral, but will need a referral for an out-of-network provider.
A list of drugs specifically chosen to be covered by a prescription drug plan. Drugs with well-proven effectiveness and reasonable cost are likely to be on this preferred list. See the formulary.
A drug that has the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand name drugs.
High Deductible Health Plan (HDHP)
HDHP plans typically have lower premiums and higher deductibles than other plans. HDHPs are used with health savings accounts or health reimbursement accounts to pay for qualified out-of-pocket medical costs. The accounts are funded with pre-tax dollars, lowering the amount of federal taxes you owe.
Covers essential health benefits but is primarily “safety net” coverage for serious accident or illness. Premiums may be lower than traditional plans but deductibles are higher. In the Marketplace, these plans are available only to people under 30 and to some with low incomes. People with catastrophic plans are not eligible for cost support.
Health Savings Account (HSA)
An account created for individuals covered under high-deductible health plans (HDHPs) to save for medical expenses the plan does not cover. Account is funded by the individual or an employer and is used to pay for qualified medical expenses such as dental, vision and over-the-counter drugs.
The portion of health care expenses paid by the individual, including deductible paid before coverage begins and copayment for services.
Health Reimbursement Account (HRA)
Plans that reimburse employees for incurred medical expenses not covered by the company’s insurance plan. The employer funds the HRA. Reimbursement dollars received by the employee are generally tax-free. The employer decides if any unused funds can be rolled over for use the following year.
Flexible Spending Account (FSA)
Also referred to as a Section 125 account or cafeteria plan. An FSA allows you to pay for qualified medical expenses with pre-tax dollars. Dollars do not carry over at the end of the year, so planning is required.
A list of doctors, hospitals, and other health care professionals that provide medical care to members of a specific health plan. The provider network for Health Tradition Health Plan is Mayo Clinic Health System, and additional community providers.
Screenings and exams intended to diagnose potential for illness or an illness in its earliest stages. Diagnosed early, many illnesses are easier and less expensive to treat with better results. Certain preventive care is covered by health plans at no charge.