Common Insurance Terms

Advance Premium Tax Credit (APTC)

APTC lowers the cost of your monthly premium for insurance plans sold on Your Health Idaho. Individuals and families qualify for a tax credit based on income level, household size, and other factors. Tax credit eligibility is determined by the Idaho Department of Health and Welfare.

Co-Pay

A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when 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 cost for a medical service that you must pay. 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 and you must enroll in a Silver level health plan. CSR eligibility is determined by the Idaho Department of Health and Welfare.

Deductible

The amount you must pay for health care services before your health insurance company will start paying benefits. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your deductible for covered health care services that are subject to the deductible. The deductible may not apply to all services.

Essential Health Benefit (EHB)

Essential health benefits must include items and services within at least the following 10 general categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services.

Minimum Essential Coverage (MEC)

The Affordable Care Act requires people to have adequate and affordable healthcare coverage. If your coverage meets the minimum essential definition, then you don’t have to pay a fee for being uninsured. All plans sold through Your Health Idaho meet MEC.

Network

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health services. If a provider or service is out-of-network, it will likely cost you more.

Out-of-Pocket Limit (OOP)

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

Pre-existing Condition

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

Premium

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

Qualified Health Plan (QHP)

An 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, copayments, 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 a new state, changes in your income, a loss of employer coverage, and changes in your family size (for example, if you marry or have a baby).

Special Enrollment Period (SEP)

A time outside of the open enrollment period when individuals and families can sign up for health insurance coverage. To qualify for a SEP you must have a life changing event such as losing your current coverage, getting married, gaining a dependent, or moving.

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