Actuarial Value
The percentage of total covered healthcare costs that a health plan pays on average across a standard population.
Allowed Amount
The maximum amount a health insurer will pay for a covered healthcare service.
Balance Billing
When a healthcare provider bills a patient for the difference between their charge and the insurer's allowed amount.
Catastrophic Plan
A low-premium, very-high-deductible health insurance plan designed to protect against major medical expenses.
Copay
A fixed dollar amount you pay for a covered healthcare service at the time of care.
CSR
An ACA subsidy that lowers deductibles, copays, and out-of-pocket maximums for eligible lower-income Silver plan enrollees.
EOB
A statement from your health insurer explaining how a medical claim was processed and what you owe.
Formulary
A health insurer's approved list of covered prescription drugs, organized by cost-sharing tiers.
Health Insurance
Coverage that pays for medical expenses in exchange for regular premium payments.
Health OOP Max
Total out-of-pocket medical cost after deductible and coinsurance, capped at the plan's OOP maximum.
HSA
A tax-advantaged savings account available to individuals enrolled in a high-deductible health plan, used to pay for qualified medical expenses.
HSA Limit
IRS annual contribution limit for Health Savings Accounts, including the 55+ catch-up amount.
In-Network
Healthcare providers who have contracted with a health insurer to accept negotiated rates.
LTC Cost
Projects the future cost of long-term care by applying an inflation rate to today's cost.
Medicaid
A federal-state health insurance program for low-income individuals, families, and certain disabled populations.
Medicare Advantage
A private health plan alternative to Original Medicare that bundles Part A, Part B, and usually Part D coverage.
Medicare IRMAA
Additional Medicare Part B premium paid by higher-income enrollees based on MAGI.
Medicare Part A
The Medicare program component covering inpatient hospital stays, skilled nursing, and hospice care.
Medicare Part B
The Medicare component covering outpatient medical services, doctor visits, and preventive care.
Medicare Part D
A voluntary Medicare program providing prescription drug coverage through private insurers.
Medicare
The federal health insurance program for Americans aged 65 and older and certain disabled individuals.
MEC
The minimum level of health coverage required by the ACA to avoid a federal tax penalty (when applicable).
Out-of-Network
Healthcare providers who have not contracted with a health insurer, typically resulting in higher costs for the patient.
Out-of-Pocket Max
The most you pay for covered healthcare services in a plan year before your insurer covers 100% of further costs.
PPO
A health insurance plan that lets you see any doctor or specialist without a referral, with lower costs for in-network providers.
Premium Tax Credit
An ACA refundable tax credit that helps eligible individuals and families pay for health insurance on the marketplace.
Prior Auth (PA)
Advance approval required from a health insurer before certain medical services or prescription drugs will be covered.
Qualified Health Plan
An ACA-compliant health insurance plan certified for sale on a federal or state health insurance marketplace.