Glossary of Terms
The percent of the doctor, clinic or other provider’s bill for covered services that you must pay when the provider is in your plan’s network, for example 20% of the bill amount. In-network co-insurance usually costs less than out-of-network co-insurance.
A fixed amount (for example, $15) you pay at each visit for covered health care services, from providers who contract with your health plan. Most plans will cover some cost from out-of-network providers. This coverage will be at a lower level than in-network.
A doctor that is on a health plan’s approved list of health care providers. The health plan will cover approved services provided by this doctor.
Policies for people who are not connected to job-based coverage. Individual health insurance policies are regulated under state law.
Under the Affordable Care Act, most people must purchase health insurance or pay a tax penalty. This is called the “individual mandate” or “individual responsibility”. However, the Affordable Care Act exempts several groups from the individual mandate, meaning that they do not have to get health coverage.
Health care that you get when you are admitted as an inpatient to a health care facility, such as a hospital or skilled nursing facility.
A nonprofit entity in which the same people who own the company are insured by the company. Insurance cooperatives (co-ops) can be formed at a national, state, or local level. They can include doctors, hospitals, and businesses as member-owners.