Agent: A person licensed to sell insurance plans from a single insurance company that can help you choose the plan that is right for you (provided that plan comes from the insurer the agent represents). These people must act in your best interest and are forbidden from trying to push unnecessarily expensive plans on you. You can find a list of them on your state or federal health exchange.
NOTE: New York is one of a number of states that differentiate between agents and brokers (who sell insurance from a number of companies), but in other states, these individuals or businesses are known simply as “producers” and they can sell insurance in either capacity.
Broker: A person licensed to sell health plans from a variety of insurance companies. You can find a list of them on your state or federal health exchange. These people must act in your best interest and are forbidden from trying to push unnecessarily expensive plans on you. You can find a list of them on your state or federal health exchange.
NOTE: New York is one of a number of states that differentiate between brokers and agents (who only sell insurance plans from a single company), but in other states, these conduits are known simply as “producers” and they can sell insurance in either capacity.
Coinsurance: A percentage that you are required to pay for certain health services, with your insurer covering the rest. Oftentimes, you will only have access to a coinsurance for services after you have reached your deductible (see “deductible”). For instance, if you have a $100 doctor visit and your insurer gives you 30% coinsurance subject to a deductible, you will be charged $30 for the visit if you have reached your deductible for the year and the full $100 if you have not.
Co-pay: A flat fee you are required to pay for certain health services, after which your insurer will cover the rest. Oftentimes, you will only have access to a co-pay for services after you have reached your deductible (see “deductible”). For instance, if you have a $125 doctor visit and your insurer gives you a $20 co-pay subject to a deductible, you will be charged $20 for the visit if you have reached your deductible for the year and the full $125 if you have not.
Deductible: An amount of money you have to spend before your insurer will start helping cover the costs of certain health services. The number of services subject to your deductible (i.e. that your insurer won’t help you with until you’ve reached this threshold) varies from plan to plan.
Dependents: Other people who will be covered under your health care plan. Usually, a spouse, child or “family.”
Federal health exchange: A healthcare marketplace created by the federal government that people can use if they live in a state that does not have its own exchange. Plans bought on this exchange can be subsidized if people make below a certain amount of money (see “healthcare subsidy”). You can find the federal health exchange here.
HMO: A health maintenance organization. These kinds of insurance plans only cover services provided by in-network doctors and hospitals. They also usually require people to choose a single primary-care physician, who then refers them to specialists when necessary.
Individual mandate tax: Under the Affordable Care Act (aka Obamacare), people who can afford healthcare but don’t purchase it must pay a tax. People are deemed by the law to be capable of buying healthcare if a) the cheapest plan available to them would cost more than 8.05% of their annual household income AND b) they make enough money that the IRS requires them to file an income tax return. In 2015, this tax is either $325 for every uninsured adult member of your household or 2% of your annual household income, whichever number is greater. You can find out more about this individual mandate tax, and whether you’re subject to it, here.
In-network: Health care providers that your insurance company has negotiated rates with. If you have an HMO (see “HMO”), your insurer will only cover services received from in-network providers. If you have a PPO (“PPO”), your insurer might cover some services received from out-of-network providers, but you’ll have to pay more than you would if you had used an in-network provider.
Navigator: Someone paid by the government to help people understand the federal and state exchanges and get a better sense of what plans might be good for them. You can find a list of them on your state or federal health exchange.
Open enrollment: The timespan during which people are expected to purchase their health insurance on the federal and state health exchanges for the coming year. For 2016, the open enrollment period will be between November 1, 2015 and January 31, 2016. In addition to the open enrollment period, you can buy insurance on the exchanges if you have recently experienced a life event that changed your insurance status like marriage, the birth of a child, or the discontinuation of your previous insurance plan (see “special enrollment period”).
Out-of-pocket maximum: The highest amount of money you can pay in a year for health care services covered by your insurer.
POS: A point of service plan, which splits the difference between a PPO (prefered provider organization and an HMO (health maintenance organization). In a POS plan, you have the option of seeing out-of-network doctors for a higher fee (similar to a PPO), but you need to get a referral from your primary care doctor to see a specialist (as would be the case if you had signed up for an HMO).
PPO: A preferred provider organization. These kinds of insurance plans sometimes cover services provided by out-of-network doctors and hospitals. However, you’ll get greater savings from in-network providers.
Premium: A flat, monthly fee that you have to pay your health insurer — regardless of whether or how often you access health care services. [There are other less common types of premiums, including annual or weekly, depending on the type of insurance and the agreement with the carrier. However, as the number of payments increases over the course of a year, the fees also increase for processing.]
Private health exchange: A health marketplace operated by a private organization. These marketplaces give people access to plans not available on the state or federal exchanges, but you will not have access to government subsidies if you use them. There are more plans available this way, as the federal and state exchanges have a limit on the number of plans offered and all plans must meet specific guidelines.
Special enrollment period: When it is not during open enrollment, you can only purchase insurance on a federal or state exchange during a special enrollment period, which is granted to people after life events like having a child or losing the insurance they were previously on. You can see if you qualify here.
State health exchange: A healthcare marketplace created by one of 16 states that residents can use to purchase plans. Plans bought on these exchanges can be subsidized if people make below a certain amount of money (see “healthcare subsidy”). You can find your state’s marketplace here.
Subsidy: The amount of money the federal government will give you in tax credits to help you pay for health care purchased on a state or federal marketplace. You’re likely to be eligible for a subsidy if you as individual make less than $46,680 annually, or if your family of four earns less than $95,400 per year. You can figure out how much you’ll likely be able to get using this calculator from the nonprofit Kaiser Foundation. Subsidies can often be taken as either a reduction in your monthly premiums or as a tax credit at the end of the year.
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