Common Insurance Terms

Advance Premium Tax Credit (APTC)

An APTC lowers the cost of your monthly health insurance premiums for plans purchased through Your Health Idaho. Individuals and families qualify for a tax credit based on income level, household size, and other factors.

Co-Pay

A fixed amount (for example, $15) you pay for a medical visit or for medication covered under your health plan, usually at the time you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.

Co-Insurance

After your deductible is met, co-insurance is the percentage of the cost you must pay for a medical service. Your health insurer or plan pays the rest of the allowed amount. Depending on your plan, your portion of the co-insurance could range from 10-40%.

Cost-Sharing Reduction (CSR)

A discount that lowers the amount you pay out-of-pocket for things like deductibles, co-insurance, and co-payments. To qualify for a CSR your income must be within a certain range of the Federal Poverty Level (FPL) and you must be enrolled in a Silver Tier Plan.

Deductible

The amount you must pay for health care services before your health insurance company will start paying benefits. For example, if your plan has a deductible of $1,000, you will have to pay for any covered healthcare services that are subject to the deductible until you reach the $1,000 amount. After that, your plan will start covering costs according to your plan benefits. The deductible may not apply to all services.

Essential Health Benefit (EHB)

 

Under the Affordable Care Act, health insurance plans must cover a set of 10 categories of services. Some plans may cover more services. All plans offered through Your Health Idaho cover at least the following:

 

Doctor Visits	Hospitalization
Emergency Services	Mental Health & Substance Abuse Services
Rehabilitative & Habilitative Services	Maternity & Newborn Care
Laboratory Test	Prescription Medicine
Preventive Wellness & Screenings	Pediatric Care

 

Minimum Essential Coverage (MEC)

Any insurance plan that meets the Affordable Care Act requirement for having health coverage, sometimes called “qualifying health coverage”. All plans sold through Your Health Idaho meet the MEC definition.

Network

A network is made up of the facilities, healthcare providers, and suppliers your health insurer has contracted with to provide your health services. These are considered “in-network,” and are generally less expensive. If a provider or service is out-of-network, it will likely cost you more.

Open Enrollment

The period from October 15 to December 15 each year, when Idahoans can enroll in a private health insurance plan for the coming year. During Open Enrollment, Idahoans already enrolled with Your Health Idaho can make changes or renew their existing coverage.

 

Out-of-Pocket Limit (OOP)

The most you pay during a policy period (usually one year) before your health insurance begins to pay 100% of the allowed amount. This does not include your premium, balance-billed charges, or healthcare your health insurance plan doesn’t cover.

Pre-existing Condition

Any health problem like asthma, diabetes, or cancer you had before the date  new health coverage starts.

Premium

The amount that must be paid for your health insurance. Premiums are usually paid monthly but may be paid quarterly or annually.

Qualified Health Plan (QHP)

A health insurance plan that is certified by Your Health Idaho and the Idaho Department of Insurance, provides essential health benefits, follows established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meets other requirements.

Qualified Dental Plan (QDP)

A dental insurance plan that helps pay for the cost of visits to a dentist for basic or preventive services like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan or by itself through a “stand-alone” dental plan.

Qualifying Life Event (QLE)

A change in your life that can make you eligible for a Special Enrollment Period, allowing you to enroll in health coverage outside of Open Enrollment. Examples of qualifying life events are moving to or within Idaho to a new rating area, changes in your income, loss of employer coverage, and changes in your family size e.g.,  marriage or having a baby).

Special Enrollment Period (SEP)

A time outside of the Open Enrollment period during which you and your family can enroll in health coverage. In order to qualify for a Special Enrollment Period, you must experience a Qualifying Life Event (QLE).