Updated March 2026 • By Open Enrollment Health
Health insurance has its own language, and it's designed to confuse you. Here's every important term translated into words that actually make sense.
What it means: The amount you pay every month for your health insurance, whether you use it or not. Think of it like a subscription fee.
Example: Your plan costs $200/month. That's your premium. You pay it January through December regardless of whether you see a doctor.
Key point: ACA subsidies can reduce your premium to $0.
What it means: The amount you pay out of your own pocket before insurance starts covering things. Think of it as the "entry fee" before insurance kicks in.
Example: Your deductible is $2,000. You break your arm and the bill is $3,000. You pay the first $2,000, then insurance covers the rest (minus coinsurance).
Key point: Preventive care (annual checkups, vaccines) is covered at 100% BEFORE you meet your deductible. You don't have to pay $2,000 before getting a flu shot.
What it means: A fixed dollar amount you pay for a specific service. It's the same every time.
Example: Your plan has a $25 copay for doctor visits. Every time you see your doctor, you pay $25 at the front desk. Insurance covers the rest.
Key point: Copays often apply even before you meet your deductible (depends on the plan).
What it means: The absolute most you'll pay in a year. Once you hit this number, insurance covers 100% of everything for the rest of the year.
Example: Your OOP max is $8,000. You have a terrible year — surgery, hospital stay, tons of prescriptions. Once your total payments (deductible + copays + coinsurance) hit $8,000, you pay $0 for everything else that year.
Key point: This is your financial safety net. Even in a worst-case scenario, you know the maximum you'll spend.
What it means: The percentage you pay for a service after meeting your deductible. Insurance pays the rest.
Example: Your plan has 20% coinsurance. After meeting your deductible, you get a $1,000 procedure. You pay $200 (20%), insurance pays $800 (80%).
What it means: Your insurance company has deals with specific doctors and hospitals (the "network"). Going to in-network providers is cheaper. Going out-of-network costs way more — sometimes insurance won't cover it at all.
Key point: Always check if your doctor is in-network before scheduling. We verify this for you when you enroll.
HMO (Health Maintenance Organization): You pick a primary care doctor (PCP) who coordinates all your care. Need a specialist? Your PCP refers you. Usually cheaper, smaller network.
PPO (Preferred Provider Organization): You can see any doctor without a referral. Larger network. More flexibility, higher premiums.
EPO (Exclusive Provider Organization): Like a PPO (no referrals needed) but only covers in-network providers. No out-of-network coverage except emergencies.
What it means: The list of prescription drugs your plan covers. Drugs are organized into "tiers" — generics are cheapest, specialty drugs are most expensive.
What it means: For certain procedures or medications, your insurance company requires approval before they'll cover it. Your doctor's office usually handles this.
What it means: A statement your insurance sends after you receive care. It shows what was billed, what insurance paid, and what you owe. It is NOT a bill — it's just an explanation.
ACA plans come in four levels:
| Tier | Premium | Deductible | Insurance Pays | Best For |
|---|---|---|---|---|
| Bronze | Lowest | Highest (~$7,000) | 60% | Healthy, rarely use care |
| Silver | Medium | Medium (~$4,000) | 70% | Most people (CSR eligible) |
| Gold | Higher | Lower (~$1,500) | 80% | Regular doctor visits |
| Platinum | Highest | Lowest (~$500) | 90% | Heavy healthcare users |
This stuff is genuinely complicated. That's why we exist — to translate insurance-speak into plain English and find you the best plan for your situation.