Insurance terms, in plain English

The words on your bills, EOBs, and plan documents. Official definitions are on the HealthCare.gov glossary.

100-80-50 dental coverage: A common way dental plans pay: 100% of preventive care (cleanings and exams), 80% of basic care (fillings, simple extractions), and 50% of major care (crowns, bridges, dentures), after any deductible and up to the annual maximum.
A check from your insurance: After a visit to an out-of-network provider, some plans send the payment to you instead of to the provider. It isn’t extra money: the provider will bill you for the visit, so use the check to pay them. The Explanation of Benefits that comes with it shows which visit it is for. If you already paid the provider in full, the check is your reimbursement.
Abortion coverage: Depends on the kind of coverage and your state. Federal Medicaid funds and Medicare cover abortion only after rape or incest or when the pregnant person’s life is in danger; some states use their own funds to cover more. Private and Marketplace plans follow state law: some states require coverage, others restrict it. Self-funded employer plans set their own rules, so check your plan documents. Legality also varies by state.
Adding a partner or family member: Large employers must offer coverage to employees’ children up to 26; covering a spouse is up to the employer, though most do. An unmarried partner can join only if the plan offers domestic partner coverage, and the employer’s share for them may count as taxable income. Parents, grandchildren, and other relatives usually can’t be added unless you are their legal guardian or, on some plans, they are your tax dependent; they can get their own Marketplace plan, Medicaid, or Medicare instead.
Advance Beneficiary Notice (ABN): A form a provider gives you before care that Original Medicare may not pay for. It names the service and what it would cost you. If you sign and get the care, you agree to pay if Medicare says no. You can still ask the provider to bill Medicare, so you get a decision you can appeal. If you were never given an ABN, the provider usually can’t bill you for a service Medicare denies.
After an approved appeal: The plan should pay the claim or approve the care; get the decision in writing and watch for a new Explanation of Benefits. If you already paid, ask the provider for a refund once the plan pays. If the plan doesn’t follow through, contact your state’s insurance department (or the Department of Labor for a self-funded job plan).
Allowed amount: The maximum your plan will pay for a covered service, meaning the negotiated price. Your coinsurance is a percentage of this, not of the provider’s list price.
Annual and lifetime limits: A plan can’t put a yearly or lifetime dollar cap on essential health benefits such as hospital care or prescriptions. It can still limit the number of visits for some services (such as 30 therapy visits a year), and dental and vision plans often have a yearly dollar maximum.
Annual Notice of Change (ANOC): A letter Medicare Advantage and Part D plans send by September 30 listing next year’s changes to costs, covered drugs, and the network. Read it before open enrollment. More
Appeal: Asking your plan to reconsider a denial. Deadlines: 180 days for job-based and Marketplace plans, 65 days for Medicare Advantage and Part D, 120 days for Original Medicare, and usually 60 days for Medicaid. If the internal appeal fails, you can usually request an independent external review. More
Authorized representative: To let someone talk to your plan or Medicaid office for you, fill out the plan’s authorization form. For Medicare, use the “Authorization to Disclose Personal Health Information” form, or form CMS-1696 to have someone handle an appeal. Without one, privacy rules keep plans from sharing your information, even with family.
Baby formula: Health plans don’t pay for regular infant formula. Special formula that a doctor prescribes for a medical condition, such as a metabolic disorder or a severe allergy, is sometimes covered: many states require it for certain conditions, and Medicaid often covers it for children when it’s medically necessary. Ask the pediatrician for a prescription and a letter saying why it’s needed, and ask the plan whether it needs prior authorization. WIC provides formula to families who qualify by income.
Balance billing: When an out-of-network provider bills you the difference between their charge and the allowed amount. Federal law bans it for most emergencies and for many services at in-network facilities.
Benefit period: How Medicare Part A counts hospital and skilled nursing care. It starts when you’re admitted and ends after 60 days in a row out of the hospital and skilled nursing, so you can pay the Part A deductible more than once a year.
Billing codes (CPT and ICD-10): A CPT code is a five-digit code for what was done: a visit, a test, a procedure. An ICD-10 code says why: your diagnosis. Both are on your bill or Explanation of Benefits, and your plan decides payment from them. Ask the office for the codes before care to check your cost, and check them on the bill afterward: a wrong code is a common reason for a denial. More
Biosimilar: A near-copy of a biologic drug (a drug made from living cells, such as Humira), approved by the FDA as working the same way. It usually costs less, and plans often prefer it over the original.
Brokers, agents, and navigators: Licensed agents and brokers help you compare plans and sign up at no cost to you; the insurance company pays them, so ask whether they show plans from every company. Navigators and certified application counselors are free helpers who don’t earn commissions. Find both under Find Local Help at HealthCare.gov or on your state’s marketplace site. For Medicare, your State Health Insurance Assistance Program (SHIP) gives free, unbiased help.
Buying your own plan instead of a job plan: You can always buy a Marketplace plan, but if your job offers coverage that counts as affordable (the employee-only premium is under about 10% of household income), you can’t get tax credits for it. Your family members can get tax credits if covering them on the job plan costs more than that share of income.
Canceling a job-based plan: A plan from a job can usually be dropped only during the employer’s open enrollment, or within about 30 days of a life change such as getting other coverage, marriage, or a new baby. Ask HR or your benefits office for the form, and line up the end date with the day your new coverage starts so you aren’t left uninsured.
Canceling a Marketplace plan: You can end a Marketplace plan any time in your HealthCare.gov or state account. Pick an end date that lines up with your new coverage so you aren’t left uninsured, and if you were getting tax credits, ending the plan stops them.
Car accident injuries: After a car crash, your auto insurance may pay first: personal injury protection (PIP) or medical payments coverage, which some states require. Your health plan generally covers the rest of your care, and it may seek repayment if another driver’s insurance pays later. Keep every bill, and tell your health plan the care was for an accident.
Care without insurance: Hospital emergency rooms must screen and stabilize anyone, insured or not. Ask for a good faith estimate before planned care, ask about the hospital’s financial assistance (charity care) policy, and use community health centers, which charge on a sliding scale. Losing coverage lets you enroll in a plan within 60 days, and Medicaid enrolls year-round. More
Case management: A nurse or care coordinator from your plan who helps people with a serious or long-term condition: setting up appointments, approvals, equipment, and care after a hospital stay. It’s free and your choice, and saying no doesn’t change your benefits. If a call surprises you, hang up and call the number on your insurance card to make sure it’s real.
Catastrophic plans: Low-premium plans with a very high deductible, open to people under 30 or with a hardship exemption. They cover preventive care and three primary care visits a year before the deductible, but tax credits can’t be used for them.
Changing Medicaid health plans: In states where Medicaid works through health plans, you can usually switch plans in the first 90 days after you join, then once a year at your state’s open enrollment, and at other times for a good reason, like your doctors not being in the plan. Call your state’s Medicaid enrollment line to switch.
CHIP: The Children’s Health Insurance Program: low-cost coverage for children (and in some states, pregnant people) in families that earn too much for Medicaid. States run it, often together with Medicaid. More
Choosing the best plan: We don’t rank insurance companies: the best plan is the one that covers your doctors and medicines at the lowest total cost for your year. Compare four things: whether your doctors are in network, whether your drugs are on the formulary, the yearly premium plus what you’d likely pay for care (up to the out-of-pocket maximum), and quality ratings (Medicare’s star ratings, or the Marketplace’s on HealthCare.gov).
Claims: A claim is the bill your doctor, hospital, or pharmacy sends your plan. Your plan decides what it pays and sends you an Explanation of Benefits. Job-based plans generally must decide within 30 days of getting a claim. If one seems stuck, call member services with the claim number from your EOB or member site, and ask whether they need anything from you or your doctor.
COBRA: A federal law that lets you keep your employer’s health plan after leaving a job or losing hours, usually for 18 months (36 for some events like divorce or a parent’s death). You pay the full premium plus up to 2%, and have 60 days to elect it. Marketplace coverage is often cheaper. More
Coinsurance: Your share of the allowed amount, as a percentage (for example, 20%) usually after you meet your deductible.
College students: Students can usually stay on a parent’s plan until 26, even living away from home, but check the plan’s network near campus: some plans cover only emergencies out of their area. Many colleges sell a student health plan. Students with little income may qualify for Medicaid in the state where they go to school, or for Marketplace tax credits.
Condoms: Health plans usually don’t pay for condoms bought over the counter. The rule that makes birth control $0 covers FDA-approved methods for women, which can include internal (female) condoms with a prescription. HSA and FSA funds can pay for condoms, and health departments and clinics often give them out free.
Continuity of care: If your doctor or hospital leaves your plan’s network while you’re in the middle of treatment (a serious condition, pregnancy, a scheduled surgery, or inpatient care), federal law lets you keep seeing them at in-network rates for up to 90 days. Ask your plan for continuity-of-care coverage. More
Coordination of benefits: When you have two health plans, one pays first (primary) and the other may pick up some of what’s left (secondary). Your own job plan is primary over a spouse’s plan; for children, it’s usually the parent whose birthday comes first in the year. With Medicare at 65 or older, coverage from your or your spouse’s current job pays first if the employer has 20 or more employees (100 or more if you have Medicare because of a disability). More
Copay: A fixed dollar amount you pay for a service, like $30 for a doctor visit. Some copays apply before the deductible.
Cost-sharing reductions (CSR): Extra savings that lower deductibles, copays, and out-of-pocket limits for Marketplace enrollees with incomes up to 250% of the poverty level. You get them only with a silver plan. More
Coverage during leave (FMLA): During FMLA leave (up to 12 weeks, unpaid, at employers with 50 or more workers), your employer must keep your health plan on the same terms, and you still pay your usual share of the premium. On other unpaid leave, the employer’s own policy decides. If coverage ends, you can use COBRA or a special enrollment period. More
Coverage gap (donut hole): A stretch of Medicare Part D where people used to pay a bigger share of drug costs. It ended in 2025: now there are three stages (deductible, initial coverage, then catastrophic at $0) and a yearly cap of $2,100 in 2026 ($2,400 in 2027). More
Coverage in two states: Original Medicare works with any doctor who takes Medicare anywhere in the U.S., which is why many people who split the year between states choose it (often with Medigap). Medicare Advantage HMOs, Medicaid, and many Marketplace plans mostly cover routine care only in their service area, with emergencies covered anywhere; some plans offer a visitor or travel benefit, so ask.
Coverage shows as inactive: If an office or pharmacy says your insurance is inactive or terminated, first check that they have your current card and the right birth date. Then call the number on your card (HR for a job plan, HealthCare.gov or your state for a Marketplace plan or Medicaid) and ask whether you are active, and from what date. Common causes are a missed premium, a renewal that wasn’t finished, or a new plan that isn’t in the system yet. If the coverage really ended, you usually have 60 days to sign up for another plan. More
Creditable coverage: Drug coverage at least as good as Medicare Part D, like many job plans. Each year your plan sends a notice saying whether it’s creditable; keep it, because it lets you sign up for Part D later without a late penalty.
D-SNP: Dual Eligible Special Needs Plan: a Medicare Advantage plan only for people with both Medicare and Medicaid, built to coordinate the two.
Data breach letters: If your plan or a provider writes that your information was exposed, the letter is usually real, but don’t call a number or tap a link from an unexpected text or email; use the number on your insurance card. Sign up for the free credit monitoring the letter offers. Read each Explanation of Benefits for care you didn’t get, and report anything you don’t recognize to the plan.
Deductible: What you pay for covered services each year before your plan starts to share costs. Preventive care is usually covered before the deductible.
Deductible after changing plans: Switching plans usually starts a new deductible and out-of-pocket maximum from $0, unless you stay with the same insurer and it credits what you’ve already paid (a deductible credit or carryover). If your job’s plan changes mid-year, ask whether amounts carry over.
Deducting health costs on your taxes: Premiums taken out of your paycheck before taxes are already tax-free, so you can’t deduct them again. If you’re self-employed, you can usually deduct the premiums you pay. Otherwise, premiums you pay with after-tax money and other medical bills count only if you itemize, and only the part above 7.5% of your income. Money you put into an HSA is deductible too. IRS Publication 502 lists what counts; a tax preparer can tell you what applies to you.
Dental discount plans: Not insurance: you pay a yearly fee for lower prices (often 10% to 60% off) at participating dentists, with no annual maximum or waiting period. They can help with big work right away; insurance usually pays more for routine care.
Dental plan annual maximum: Most dental plans pay only up to a yearly limit, often $1,000 to $2,000. After that you pay the full price until the plan year starts over, so big work is sometimes split across two plan years.
Dental PPO vs. DHMO: A dental PPO lets you see any dentist but pays more in its network. A DHMO (dental HMO) usually has a lower premium and set copays, but only covers dentists in its network, often with one assigned dentist.
Dental pre-treatment estimate: Before costly work, your dentist can send the plan a pre-treatment estimate (predetermination) showing what it expects to pay. It isn’t a guarantee, but it shows your likely share and how much of your annual maximum the work uses.
Dental waiting periods: Many individual dental plans make you wait before covering bigger work: often no wait for cleanings, about six months for fillings, and six to twelve months for crowns, root canals, or dentures. Job-based dental plans often have none, and some plans waive the wait if you had dental coverage recently.
Dependent coverage to 26: Plans that cover children must let them stay on a parent’s plan until age 26, even if they’re married, not in school, or have their own job offer. Turning 26 opens a special enrollment period. More
Dependent verification: Employers sometimes ask for proof that the family members on your plan qualify, such as a marriage or birth certificate. Answer by the deadline: a dependent who isn’t verified can be dropped from the plan.
Discharged from the hospital too soon: If you have Medicare and think you’re being discharged too soon, call the number on the “Important Message from Medicare” notice the hospital gave you to ask the Quality Improvement Organization for a fast review. Ask by your planned discharge day and you can stay while it decides, generally without paying for the extra days.
Do employers have to offer insurance?: Employers with 50 or more full-time workers must offer affordable coverage to employees working 30 or more hours a week, or they may owe a tax penalty. Smaller employers don’t have to offer health insurance.
Drug tiers: Plans sort covered drugs into levels. Tier 1 is usually preferred generics with the lowest copay; higher tiers are brand-name and specialty drugs that cost more, often as a percentage of the price. A drug’s tier differs from plan to plan, and can change each January. More
Dual eligible: Someone with both Medicare and Medicaid. Medicaid can pay Medicare premiums and cost sharing, and cover things Medicare doesn’t, like long-term care.
Durable medical equipment (DME): Reusable equipment ordered by a clinician for use at home, such as wheelchairs, CPAP machines, walkers, and hospital beds.
Embedded deductible: In a family plan with an embedded deductible, each person also has their own smaller deductible: once one person meets it, the plan starts paying for that person even if the family hasn’t met the family deductible. With a non-embedded (aggregate) deductible, the whole family deductible must be met first.
Employee assistance program (EAP): A free, confidential benefit many employers offer: a few counseling sessions, and help with things like legal or money questions. It is separate from your health plan, and using it does not file a claim. Ask HR for the phone number.
Enrolled or switched without your consent: If you were signed up for a Marketplace plan, or moved to a different one, without agreeing to it, call the Marketplace right away (HealthCare.gov: 1-800-318-2596, or your state’s marketplace). Ask them to restore the plan you chose and to record that an agent acted without your permission. It can affect your taxes, because tax credits may have been paid for a plan you didn’t pick, so keep the letters and your Form 1095-A.
EPO: Exclusive Provider Organization. You must use doctors and hospitals in the plan’s network, except in an emergency. You usually don’t need a referral to see a specialist.
EPSDT: Medicaid’s benefit for children and young adults under 21: checkups, screenings, and any medically necessary care, including dental, vision, and hearing, even when the state doesn’t cover it for adults.
Essential health benefits: Ten kinds of care that plans sold to individuals and small employers must cover under the ACA. They include emergency care, hospital stays, maternity care, mental health care, prescription drugs, and preventive care. More
Evidence of Coverage (EOC): The full legal description of a plan’s benefits and rules. Medicare Advantage and Part D plans send one each fall.
Explanation of Benefits (EOB): A statement from your plan after a claim showing what was billed, what the plan paid, and what you owe. It isn’t a bill.
External review: An independent reviewer outside your plan looks at a denial after your internal appeal. If the reviewer sides with you, the plan must pay. For job-based and Marketplace plans, ask within 4 months of the final denial. More
Extra Help: A Medicare program, also called the Low-Income Subsidy, that lowers Part D premiums, deductibles, and copays for people with limited income and savings. Apply through Social Security. More
Facility fee: An extra charge for using a hospital’s building and staff, billed when a clinic is owned by a hospital, on top of the doctor’s fee. It can make the same visit cost much more. Ask before the visit whether the location is billed as a hospital outpatient department; some states limit these fees.
Family coverage on the Marketplace: One Marketplace application covers your household, and tax credits are based on household income and size. Children may qualify for Medicaid or CHIP even when parents get a Marketplace plan; the application checks.
Filing a complaint: Start with your plan: call member services and ask to file a grievance (a formal complaint), which the plan must answer in writing. If a claim or service was denied, file an appeal instead. If that doesn’t fix it, contact your state’s insurance department; for self-funded job plans, the U.S. Department of Labor; for Medicare, 1-800-MEDICARE; for Medicaid, your state Medicaid office.
Fixing a wrong name or address: A wrong name, birth date, or address on your plan can get claims denied, so fix it soon. On a job plan, tell HR or the benefits office. On a Marketplace plan, update your application at HealthCare.gov or your state’s site. On Medicaid, tell your state Medicaid office. On Medicare, Social Security keeps your name and address (1-800-772-1213). Then ask the plan for a new card, and tell your doctor’s office and pharmacy so their records match.
Form 1095-A: A tax form from the Marketplace listing your coverage and the tax credits paid for it. You need it to fill out Form 8962 when you file taxes. Find it in your HealthCare.gov or state Marketplace account, usually by early February.
Former foster youth: Young adults who were in foster care at 18 and on Medicaid can keep Medicaid until 26, whatever their income; for those who turned 18 in 2023 or later, this works in any state they move to.
Forms 1095-B and 1095-C: Tax forms showing who in your household had health coverage. Form 1095-B comes from Medicaid, CHIP, Medicare, or some insurers; 1095-C comes from employers with 50 or more workers. You don’t need them to file taxes, but keep them. (Form 1095-A, from the Marketplace, is the one you do need.)
Formulary: A plan’s list of covered prescription drugs, organized into tiers that set your cost. More
Formulary exception: A request asking your plan to cover a drug that isn’t on its list, or to charge a lower tier. Your prescriber sends a statement explaining why you need it. Medicare drug plans and Marketplace plans must decide within 72 hours (24 if urgent). More
Gatekeeper: A primary care doctor who coordinates your care and gives referrals before you see a specialist, as most HMOs and POS plans require.
Getting your medical records: You have a right to copies of your medical records from your doctors and hospitals, usually within 30 days, and they can charge a reasonable fee. For an appeal, you can also ask your plan, for free, for your claim file and the rules or guidelines it used to decide.
Good faith estimate: A written estimate of expected charges that providers must give you before scheduled care if you’re uninsured or paying yourself. If the bill is $400 or more above it, you can dispute the difference. More
Grandfathered plan: A plan that existed before March 23, 2010 and hasn’t changed significantly. It may not have to follow some ACA rules, like $0 preventive care.
Group number: The number for your employer’s (or other sponsor’s) plan, printed on your card. Everyone on the same employer plan shares it. More
Health care sharing ministry: A group whose members share medical costs, often based on shared religious beliefs. It isn’t insurance: it doesn’t have to pay, doesn’t follow insurance laws, and many exclude pre-existing conditions.
Health privacy at work: Your health plan can’t share your medical information with your employer for job decisions like hiring, firing, or promotions; HIPAA privacy rules limit who at a plan can see it and why. Employers may get summary information, like total claim costs, without names.
Help after assault or abuse: A sexual assault forensic exam (sometimes called a rape kit) is free to you under federal law, whether or not you report to the police; you can’t be charged for the exam itself, though treatment for injuries may be billed like other care. For free, confidential support at any hour, call the National Sexual Assault Hotline at 1-800-656-4673 or the National Domestic Violence Hotline at 1-800-799-7233. If you’re on someone else’s plan and worried they’ll see a claim, ask the plan to send your mail and statements to a different address. If you’re in danger right now, call 911.
High-deductible health plan (HDHP): A plan with a higher deductible that qualifies you to open a health savings account (HSA). Preventive care is still covered before the deductible.
HMO: Health Maintenance Organization. You must use doctors and hospitals in the plan’s network, except in an emergency. You usually need a referral to see a specialist.
Hospitalist: A doctor who cares for patients only in the hospital, in place of your regular doctor while you’re admitted. Hospitalists bill separately from the hospital; at an in-network hospital, federal law protects you from surprise out-of-network bills from them.
How health insurance works: You pay a premium every month to keep the plan. When you get care, you pay part of the cost: usually the full price until you reach your deductible, then a copay (a set amount) or coinsurance (a percentage). Once what you’ve paid in a year reaches the out-of-pocket maximum, the plan pays for all covered care for the rest of that year. Preventive care, such as checkups and vaccines, is usually free even before the deductible. Staying in the plan’s network keeps your prices lower. More
How long Medicaid takes to decide: States must decide most Medicaid applications within 45 days, or 90 days when the decision depends on a disability. Coverage usually starts back on the first day of the month you applied once you’re approved.
HRA: Health Reimbursement Arrangement: an account only your employer pays into that reimburses your medical costs. It usually stays with the job.
HSA / FSA: Tax-advantaged accounts for medical costs. HSAs pair with high-deductible plans and roll over; FSAs are employer accounts that mostly expire each year.
Immigrants and health coverage: Green card holders and many other lawfully present immigrants can buy Marketplace plans, but most adults with a green card must wait five years for full Medicaid (some states cover children and pregnant people sooner). People without lawful status generally can’t get Medicaid or Marketplace coverage, though Emergency Medicaid can pay for emergencies, including labor and delivery, and some states cover more with their own funds. Federal rules for lawfully present immigrants change in 2026 and 2027, so check HealthCare.gov or your state Medicaid office for your situation. Community health centers see everyone, with fees based on income.
In network: Providers and facilities contracted with your plan to accept the allowed amount. You almost always pay less in network.
Indian Health Service: IHS and tribal clinics give care to members of federally recognized tribes at no cost, but IHS isn’t insurance. Enrolling in Medicaid, Medicare, or a Marketplace plan too lets you get care elsewhere and brings more funding to your clinic. American Indians and Alaska Natives can sign up for Marketplace plans any month, and many pay no copays.
Inpatient vs. outpatient: Inpatient means a doctor formally admitted you to the hospital. Outpatient means you get care without being admitted, even if you stay overnight under observation. The difference changes what you pay: with Medicare, Part A covers inpatient stays and Part B covers outpatient care.
Interpreters: Hospitals, clinics, and health plans that take Medicare, Medicaid, or Marketplace money must give you a qualified interpreter at no charge, including a sign language interpreter. Ask for one when you make the appointment; you don’t have to bring a relative to interpret. Your plan’s member services line has interpreters too.
IRMAA: Income-related monthly adjustment amount: extra Part B and Part D premiums for people with higher incomes, based on your tax return from two years earlier. In 2026 it starts above $109,000 for single filers and $218,000 for joint filers. You can ask Social Security to use a newer year if your income dropped after a life change. More
Is health insurance required?: There’s no federal penalty for not having health insurance since 2019. A few states charge a penalty on state taxes: California, Massachusetts, New Jersey, Rhode Island, and Washington, D.C.
Lifetime reserve days: 60 extra hospital days Medicare Part A gives you over your lifetime, for stays longer than 90 days in one benefit period. In 2026 they cost $868 a day, and once used they’re gone.
Lowering what you pay for coverage: Marketplace tax credits, based on income, can cut premiums a lot, and Medicaid and CHIP cost little or nothing for those who qualify. A plan with a higher deductible usually has a lower premium but costs more when you get care. With a job plan, compare covering family members on it with other options, and use an HSA if you have a high-deductible plan.
Mail-order pharmacy: Many plans let you get a 90-day supply of a drug you take regularly by mail, often for less than three 30-day fills at a store. Some plans require mail order or a preferred pharmacy for long-term drugs after a few fills. Your plan’s member site names its mail-order pharmacy.
Major medical insurance: Comprehensive health insurance that pays for doctor visits, hospital stays, prescriptions, and other essential health benefits, like job-based plans, Marketplace plans, Medicare, and Medicaid. It’s the opposite of limited plans, such as short-term plans, fixed-indemnity plans, or discount cards, which pay little or nothing toward big medical bills.
Managed care organization (MCO): A private health plan your state pays to run your Medicaid benefits. Most Medicaid members are in one and use its network and member services.
Manufacturer copay cards: A savings card or coupon from the company that makes a brand-name drug. With a job-based or Marketplace plan, it can cut what you pay at the pharmacy, sometimes to a few dollars. It can’t be used with Medicare, Medicaid, or other government coverage. Some plans don’t count the card’s payments toward your deductible or out-of-pocket maximum (a “copay accumulator”), so ask your plan before you rely on it. On Medicare, ask the drug maker about its patient assistance program, or check Extra Help. More
MAPD: A Medicare Advantage plan that includes Part D drug coverage. Most Medicare Advantage plans are MAPDs.
Medicaid: Health coverage run by each state for people with low income, and for some people with disabilities or who need long-term care. It costs little or nothing, has different names in some states (Medi-Cal in California), and accepts applications any time of year.
Medicaid at 19 and 21: CHIP and some Medicaid children’s categories end at 19, so a 19th birthday can mean a renewal under adult rules. Medicaid’s full children’s benefit (EPSDT, which includes dental and vision) lasts until 21, after which adult benefits apply. Your state sends a notice before anything changes.
Medicaid coverage gap: In the 10 states that haven’t expanded Medicaid, adults with income below the poverty line often earn too little for Marketplace tax credits but don’t qualify for Medicaid. Check anyway: children, pregnant people, and people with disabilities may still qualify. More
Medicaid look-back and estate recovery: When you apply for Medicaid to pay for a nursing home or other long-term care, most states look at money and property you gave away in the past 5 years (the look-back) and can delay coverage because of it. After someone 55 or older who got long-term care dies, the state must try to recover its costs from their estate, but not while a spouse, or a child who is under 21 or disabled, survives. A home is usually not counted while you or your spouse live in it. Rules differ by state: legal aid or an elder law attorney can help.
Medicaid paperwork and contacts: Your state Medicaid office’s number is on your Medicaid notices and the state Medicaid website; questions about your health plan’s doctors or benefits go to the member services number on your plan card. States check income electronically when they can and may ask for pay stubs, tax returns, or an employer letter: send them by the deadline on the notice.
Medicaid spend-down: In some states, people whose income is a little too high for Medicaid can still qualify by counting their medical bills against their income (“spending down”) until it’s under the limit. Ask your state Medicaid office whether it has a medically needy program.
Medicaid waiver: A state program that covers services Medicaid normally wouldn’t, often home and community care like personal care aides, home changes, and respite for older adults and people with disabilities. Many have waiting lists.
Medicaid work requirements: A 2025 federal law requires many adults who got Medicaid through their state’s expansion to show about 80 hours a month of work, school, volunteering, or job training, starting no later than January 1, 2027 (some states may start sooner or get more time). Parents of young children, pregnant people, and people with disabilities or serious health conditions are among those exempt. Your state Medicaid office will say what you need to report.
Medical marijuana: Health insurance, including Medicare and Medicaid, doesn’t pay for medical marijuana, because it isn’t an FDA-approved drug. Ask your HSA or FSA administrator before using those funds for it. FDA-approved drugs made from cannabis, like Epidiolex for some seizure disorders, can be covered like other prescriptions.
Medical necessity: The test a plan uses to decide whether to pay: is this care right for your condition, by accepted medical standards? A denial that says “not medically necessary” can be appealed.
Medicare: Federal health insurance for people 65 and older, and for some younger people with disabilities or kidney failure. Original Medicare (Parts A and B) covers hospital and doctor care, Part D covers prescriptions, and Medicare Advantage plans from private companies combine them, often with extras.
Medicare Advantage (Part C): Private plans that replace Original Medicare. They must cover what Medicare covers but set their own costs, networks, and authorization rules, and often add dental, vision, and hearing.
Medicare Advantage extra benefits: Many Medicare Advantage plans add extras Original Medicare doesn’t cover, like an over-the-counter allowance or flex card, dental, vision, hearing aids, or a gym membership. They vary by plan and can change each year; your plan’s Evidence of Coverage lists them.
Medicare and Social Security phone numbers: Medicare: 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, any time. Social Security, for signing up, Part B premiums, and replacement cards: 1-800-772-1213. For free one-on-one help, your State Health Insurance Assistance Program (SHIP).
Medicare and your spouse: Medicare covers one person at a time: there is no family or spouse coverage. A spouse under 65 needs their own plan (a job plan, COBRA, a Marketplace plan, or Medicaid) until they turn 65. A spouse who is 65 or older can get Part A with no premium on your work record if they haven’t worked long enough themselves. More
Medicare assignment: A provider who accepts assignment takes Medicare’s approved amount as full payment: you pay only your deductible and 20%. A provider who doesn’t can charge up to 15% more, called an excess charge. Some states ban excess charges, and Medigap Plans F and G pay them. Ask “Do you accept Medicare assignment?” when you book.
Medicare before 65: You can get Medicare before 65 after 24 months of Social Security disability benefits. People with ALS, or with kidney failure that needs dialysis or a transplant, can get it sooner.
Medicare Beneficiary Identifier (MBI): The 11-character number on your red, white, and blue Medicare card. Medicare never calls to ask for it. More
Medicare drug price negotiation: Medicare now negotiates prices for some high-cost drugs. The first 10 negotiated prices took effect in January 2026 (including Eliquis, Jardiance, Xarelto, and Farxiga), and 15 more start in 2027. What you pay depends on your Part D plan, but costs for these drugs can drop.
Medicare Part A: Hospital insurance: inpatient stays, skilled nursing after a hospital stay, hospice, and some home health care. Most people pay no premium: you, or your spouse, worked and paid Medicare taxes for about 10 years. Someone who didn’t can still buy Part A for a monthly premium. The 2026 deductible is $1,736 per benefit period. More
Medicare Part B: The part of Original Medicare that covers doctor visits, outpatient care, tests, and medical equipment. In 2026 the standard premium is $202.90 a month and the deductible is $283; after that you usually pay 20%. More
Medicare Prescription Payment Plan: A free Part D option that spreads your drug costs into monthly payments over the year instead of paying at the pharmacy all at once. It doesn’t lower the total; it can help when one expensive fill would be hard to pay. Ask your drug plan to sign up.
Medicare scams and fraud: Medicare does not call to ask for your Medicare number or to sell you anything. Don’t give your number to a caller, and hang up. Check your Medicare Summary Notice for care you didn’t get. Report a scam or a wrong charge to 1-800-MEDICARE (1-800-633-4227) or to your state’s Senior Medicare Patrol.
Medicare Summary Notice (MSN): The statement Original Medicare mails every 4 months listing your claims: what each provider charged, what Medicare approved and paid, and the most the provider may bill you. It’s Medicare’s version of an EOB, not a bill. More
Medicare vs. Medicaid: Medicare is federal health insurance for people 65 and older, and for some younger people with disabilities, whatever their income. Medicaid is health coverage run by each state for people with low incomes, at any age. Medicare has premiums, deductibles, and coinsurance; Medicaid costs little or nothing. Some people qualify for both, and then Medicaid helps pay what Medicare doesn’t.
Medicare while living abroad: Medicare generally doesn’t pay for care outside the U.S. If you live abroad, you can put off Part B, but in most cases you’ll owe a late penalty and have to wait for the General Enrollment Period (January to March) when you come back, because living abroad isn’t usually a reason for a special enrollment period.
Medigap: Supplemental insurance sold to people with Original Medicare that pays some or all of Medicare’s deductibles and coinsurance. It doesn’t cover prescriptions, so you’d add a Part D drug plan, and it can’t be combined with Medicare Advantage.
Medigap birthday rule: Some states let people with Medigap switch to another Medigap policy with equal or fewer benefits around their birthday each year without answering health questions. Your state insurance department can tell you whether yours does.
Medigap open enrollment: Your six-month Medigap open enrollment starts the month you’re 65 or older and enrolled in Part B. During it, companies must sell you any Medigap policy they offer at their best price, whatever your health. After it, in most states they can turn you down or charge more for health problems.
Member ID: Your unique number with your health plan, printed on your card. The last digits often show which family member you are. Keep it private like a credit card number. More
Metal tiers: Marketplace plans come in Bronze, Silver, Gold, and Platinum. Bronze has the lowest premiums and highest costs when you get care (the plan pays about 60% on average); Platinum the reverse (about 90%). Silver is the only tier with extra cost-sharing reductions if your income is up to 250% of the poverty level. More
Missing tooth clause: Some dental plans won’t pay to replace a tooth (with a bridge, implant, or denture) that was missing before your coverage started. Check a plan’s exclusions before buying it if you need a tooth replaced.
Network: The doctors, hospitals, and pharmacies that have a contract with your plan. Using them costs you less.
Network gap exception: If your plan has no in-network provider nearby who can treat you, you can ask it to cover an out-of-network one at in-network cost. Plans call this a network gap exception or a single case agreement. Ask before the care, in writing, and have your doctor explain why no in-network provider will do. If the plan says no, you can appeal.
Newborn coverage: A baby born to a parent with Medicaid is automatically covered by Medicaid for a year. On a job-based or Marketplace plan, add your baby within 30 days of birth (60 days on HealthCare.gov) and coverage can start on the birth date. Many states require plans to cover a newborn automatically for the first 31 days; add the baby within that window to keep coverage going. More
No coverage through work: Employers with 50 or more full-time workers must offer coverage to people who work 30 or more hours a week; smaller employers, and jobs with fewer hours, often don’t. If your job doesn’t offer health insurance (common with part-time, seasonal, and gig work), you can buy a Marketplace plan, and tax credits based on your income can lower the price. With low income, check Medicaid, which accepts applications any time of year. Losing job coverage opens a 60-day window to sign up; otherwise, Marketplace plans are sold during open enrollment.
No Surprises Act: A federal law, in effect since 2022, that bans surprise bills for most emergency care (including air ambulances, but not ground ambulances), and for out-of-network doctors at in-network hospitals. It also lets uninsured and self-pay patients dispute a bill $400 or more above their good faith estimate. More
No-show fees: Many offices charge a fee when you miss a visit or cancel late. Insurance doesn’t pay it. An office can’t charge a Medicaid patient a no-show fee, and can charge a Medicare patient only if it charges every patient the same fee. Ask the office to waive a first one. Offices may also charge for paperwork, such as disability or leave forms; insurance doesn’t pay that either.
NPI: National Provider Identifier: a 10-digit number every U.S. clinician and facility has. Giving it to your insurer avoids mix-ups when checking network status. More
Nurse practitioners and physician assistants: Nurse practitioners (NPs) and physician assistants (PAs) are licensed clinicians who examine you, order tests, diagnose, and prescribe medicine. Many work as a person’s regular primary care provider. Plans, Medicare, and Medicaid cover a visit with one as an office visit, usually at the same copay as a doctor’s visit. Check that they are in your plan’s network the same way you would for a doctor. More
Observation status: Hospital care billed as outpatient even if you stay overnight. For Medicare, observation days don’t count toward the 3-day stay needed for skilled nursing coverage.
Original Medicare: Parts A and B, run by the federal government. You can see any doctor who takes Medicare, but there’s no yearly out-of-pocket limit, and it doesn’t cover most dental care, routine eye exams or glasses, hearing aids, long-term custodial care, or care abroad. Many people add Medigap and a Part D plan. More
Other kinds of insurance: Covered answers questions about health insurance: job-based plans, Marketplace plans, Medicare, and Medicaid. For car, home, renters, life, or disability insurance, ask that insurance company or your state’s insurance department.
Out-of-network costs and your maximum: Out-of-network care usually has its own, higher deductible and out-of-pocket maximum, or isn’t covered at all with an HMO or EPO, and it often doesn’t count toward your in-network maximum. Balance bills above the plan’s allowed amount never count.
Out-of-pocket maximum: The most you’ll pay in a year for covered, in-network care. After you reach it, the plan pays 100%. Premiums don’t count toward it.
Over-the-counter (OTC) medicines: Most plans don’t cover medicines you can buy without a prescription. Some preventive ones, like folic acid during pregnancy or nicotine patches, are covered at $0 when prescribed. Many Medicare Advantage plans include a quarterly OTC allowance, and you can pay for OTC medicines with an HSA or FSA.
Part B giveback: Some Medicare Advantage plans pay part of your Part B premium, which shows up as a smaller deduction from your Social Security check. You still have to keep Part B, and these plans can come with trade-offs like a smaller network.
Part D: Medicare’s coverage for the prescription drugs you pick up at a pharmacy. You buy it as its own plan, or get it as part of a Medicare Advantage plan.
Part D out-of-pocket cap: Medicare drug plans cap what you pay for covered drugs at $2,100 in 2026 and $2,400 in 2027. After you reach it, covered drugs cost $0 for the rest of the year. The Medicare Prescription Payment Plan lets you spread those costs into monthly payments. More
Paycheck deductions for premiums: Your share of a job plan’s premium usually comes out of each paycheck before taxes. It changes each plan year, and when you add or drop a family member. Employers usually pay most of the premium, but no rule sets their share. If your own share for employee-only coverage is more than about 10% of your household income, the plan counts as unaffordable and you may qualify for Marketplace tax credits instead. More
Paying back tax credits: Marketplace tax credits are based on the income you expect. At tax time they’re squared with your actual income on Form 8962: if you made more, you may owe some back, and starting with 2026 coverage there’s no cap on how much. Report income changes to the Marketplace as they happen to avoid a surprise. If you got tax credits, you must file a tax return, even if you normally wouldn’t.
Paying before care: A hospital or clinic can ask you to pay your expected share (like a copay or what’s left of your deductible) before care that isn’t an emergency. Ask what the amount is based on, and get a refund if your plan’s Explanation of Benefits later shows you owed less. For emergencies, federal law requires a medical screening and stabilizing care first, whatever you can pay.
Paying full price before the deductible: Until you meet your deductible, many plans have you pay the plan’s full negotiated price for visits and tests that aren’t preventive. Preventive care is usually $0, and some plans charge a copay before the deductible, so check your Explanation of Benefits to see which applied.
Peer-to-peer review: A phone call between your doctor and a doctor at your insurance company about a denied or pending request. Your doctor’s office asks the plan for one, often right after a prior authorization denial, and it can reverse a denial quickly.
PEP (post-exposure prophylaxis): HIV medicine started within 72 hours after a possible exposure, taken for 28 days. Go to an emergency room, urgent care, or your doctor right away. Plans cover PEP like other prescriptions, so a copay or deductible can apply (the $0 rule is for PrEP, taken before exposure). If cost is a problem, drug makers’ assistance programs can help.
Pets and service animals: Health insurance covers people, not animals, so it won’t pay for a pet’s vet care, medicine, or therapy; that takes separate pet insurance. Health plans also don’t pay to buy or keep a service animal, though HSA and FSA funds can usually pay for a service animal’s costs.
Plan documents and the plan administrator: A job-based plan must give you its Summary Plan Description (SPD): the document that says what the plan covers and how to appeal. Ask the plan administrator, usually your employer or a company it hires. It must send plan documents within 30 days of a written request. Most job plans, including union plans, follow a federal law called ERISA.
Plan year: The 12 months your plan’s deductible and limits run. Marketplace and Medicare plans follow the calendar year; many job plans start on another date, like July 1, so their deductible resets then.
Plans that aren’t real insurance: Ads for very cheap health plans often sell short-term plans, fixed-payment plans, discount cards, or health sharing ministries. These aren’t full insurance: they can turn you down or leave out a health condition you already have, limit what they pay, and leave you with large bills. Real Marketplace plans are sold at HealthCare.gov or your state’s official marketplace, and applying is free. Before you pay, ask for the plan documents in writing, ask whether it is ACA-compliant major medical coverage, and check the company with your state insurance department.
POS: Point of Service plan: like an HMO, you pick a primary care doctor and need referrals, but you can go out of network for a higher cost.
PPO: Preferred Provider Organization: you can see out-of-network providers without referrals, but you pay more for them.
Pre-existing condition: A health problem you had before your coverage started. ACA-compliant plans, job-based plans, Medicaid, and Medicare can’t refuse you or charge more because of one. Short-term plans can, and Medigap insurers can outside your Medigap open enrollment.
Premium: What you pay each month to have insurance, whether or not you use care.
Premium grace period: Coverage doesn’t start until you pay your first premium. After that, with Marketplace tax credits you get a three-month grace period for missed payments; the plan can hold claims in the second and third months, and coverage ends back to the end of the first month if you don’t catch up. Without tax credits the grace period is usually shorter.
Prescription discount cards: Cards and apps like GoodRx, or Cost Plus Drugs, can beat your copay, especially for cheap generics. The pharmacy charges the discount price instead of billing insurance, so it usually doesn’t count toward your deductible or out-of-pocket maximum. With Medicare you can use one instead of your Part D plan for a fill, but not both together, and it won’t count toward the yearly drug cap unless you send your plan the receipt. More
Prescription drug plan (PDP): A Medicare drug plan you buy on its own. It’s for people with Original Medicare, often along with a Medigap policy.
Prescriptions while traveling: Most plans let you fill prescriptions at in-network pharmacies across the U.S. (large chains are in most networks). Before a long trip, ask your pharmacist to request a vacation override for extra supply. Outside the U.S., plans, including Medicare drug plans, usually don’t pay for prescriptions, so bring enough.
Preventive care: Screenings, checkups, vaccines, and counseling meant to prevent illness. Most plans cover recommended preventive care at $0 in network. More
Prior authorization: Approval your plan requires before certain services, drugs, or equipment. Getting it doesn’t guarantee payment, but skipping it can mean a denial. Your doctor’s office submits it. Job-based and Marketplace plans must decide within 15 days (72 hours if urgent); Medicare Advantage and Medicaid plans within 7 days (72 hours if urgent) starting in 2026. More
Proof of coverage: Your insurance card, a letter or online statement from your plan, or a tax form shows you had coverage. When coverage ends, ask your plan or employer for a letter with the end date; you may need it to sign up for new coverage.
QMB: Qualified Medicare Beneficiary: a Medicare Savings Program, run by your state Medicaid agency, that pays Medicare premiums, deductibles, coinsurance, and copays for people with low incomes. Providers can’t bill people in QMB for any of those costs. More
Quantity limits: A plan rule capping how much of a drug it covers per fill or per month, like a set number of pills. If you need more, your prescriber can ask the plan for an exception, much like a prior authorization.
Referral: Written permission from your primary care provider to see a specialist, required by many HMOs.
Refills and days’ supply: Plans usually cover a 30- or 90-day supply and let you refill once most of it should be used up, often after 75% to 80% of the days. Traveling? Ask your pharmacist to request a vacation override for an early refill; many plans allow one or two a year. A 90-day supply often costs less per month.
Reporting changes to the Marketplace: Report changes in income, household size, or address within 30 days by updating your application on HealthCare.gov or your state’s Marketplace. Your tax credit is recalculated, and some changes let you switch plans.
Retroactive Medicaid: Medicaid has been able to pay for covered care you got up to three months before you applied, if you would have qualified then. A 2025 federal law shortens that window starting in 2027, and some states already limit it, so apply as soon as you can and ask about earlier bills when you do.
RxBIN, RxPCN, RxGRP: Routing numbers on your insurance card that pharmacies use to send prescription claims to the right drug benefit manager. More
Screening vs. diagnostic: A screening test looks for a problem before you have symptoms, and most plans cover recommended screenings at $0. The same test is diagnostic when it’s done because of a symptom, or to follow up an abnormal result. Then your deductible and coinsurance usually apply. More
Self-employed coverage: Self-employed people can buy a Marketplace plan and may get tax credits based on expected income, or use a spouse’s job plan. You can usually deduct premiums with the self-employed health insurance deduction. If you have employees, a small-business plan or an ICHRA may also work. More
Self-funded (ERISA) plan: An employer plan where the employer pays claims directly. Federal law governs it, so most state insurance mandates don’t apply.
Separate drug deductible: Some plans have one deductible for medical care and a separate, usually smaller one for prescriptions. Others combine them, and many charge flat copays for generic drugs without any deductible. Your Summary of Benefits and Coverage shows which.
Short-term health plan: Temporary coverage that doesn’t follow ACA rules: it can turn you down for health problems, exclude pre-existing conditions, and leave out benefits like maternity or mental health care. Federal and state rules limit how long it can last.
Small business health insurance: Employers with fewer than 50 full-time workers don’t have to offer health insurance. Options include a small-group or SHOP Marketplace plan (businesses under 25 employees with modest average wages may get a tax credit) or an ICHRA or QSEHRA, which reimburses employees for their own individual plans.
Special enrollment period (SEP): A window outside open enrollment to sign up for or change a plan after a qualifying life event, like losing other coverage, moving, getting married, or having a baby. It usually lasts 60 days from the event. More
Special Needs Plans: Medicare Advantage plans just for people with certain needs: both Medicare and Medicaid (D-SNP), certain long-term conditions like diabetes or heart failure (C-SNP), or living in a nursing home (I-SNP). They coordinate care and benefits around those needs.
Spousal surcharge: Some employers charge extra (a spousal surcharge), or won’t cover your spouse at all (a working-spouse rule), when your spouse could get insurance through their own job. At open enrollment, compare the surcharge with the cost of your spouse’s own plan.
SSI and Medicaid: In most states, getting SSI (Supplemental Security Income) makes you eligible for Medicaid, often automatically. In a few states you apply separately through the state Medicaid office.
Stand-alone dental plans: Dental coverage sold separately from health insurance, including on the Marketplace. Children’s dental is an essential health benefit, but adult dental isn’t, so adults usually buy it separately. Marketplace tax credits generally don’t lower stand-alone dental premiums.
State Fair Hearing: Your right to have a state judge or hearing officer review a Medicaid decision, after your plan’s appeal. Ask your state Medicaid agency (not the plan), within 90 to 120 days of the plan’s final decision, depending on your state (the plan’s notice gives your deadline). If the plan doesn’t decide your appeal in time, you can ask for a hearing right away. More
State Marketplaces: Some states run their own Marketplace (like Covered California or New York State of Health) instead of HealthCare.gov. Plans, tax credits, and protections are similar, but deadlines and extra state help can differ. HealthCare.gov sends you to your state’s site if it has one.
State names for Medicaid: Medicaid goes by a different name in many states: Medi-Cal in California, MassHealth in Massachusetts, TennCare in Tennessee, AHCCCS in Arizona, BadgerCare in Wisconsin, SoonerCare in Oklahoma, Apple Health in Washington, and others. It’s the same program, with each state’s own rules on who qualifies and what’s covered.
Step therapy: A drug-plan rule requiring you to try a lower-cost drug first before the plan covers the one your clinician prescribed. You can request an exception. More
Subrogation: When someone else is responsible for your injury (a car crash, a fall), your health plan pays your bills first and can then ask to be paid back from the settlement or the other side’s insurer. That right is called subrogation. A letter asking how you were hurt is the plan checking for this: answer it, or your claims can be held up.
Subscriber, dependent, and beneficiary: The subscriber (or policyholder) is the person the plan is in the name of, usually the employee or the person who signed up. Dependents are the family members covered under that plan, such as a spouse and children up to 26. Medicare and Medicaid call their members beneficiaries. An office asks for the subscriber’s name and birth date to find your coverage.
Summary of Benefits and Coverage (SBC): A standardized federal form summarizing a plan’s costs and coverage. Upload yours to map your whole plan. More
Superbill: An itemized receipt from a provider, with diagnosis and procedure codes, that you send to your plan yourself to get reimbursed, usually for out-of-network care. Plans usually give you a year or more to submit it; check your plan’s claim form and deadline. More
Teens getting care on their own: Many states let teens agree to some care without a parent, often including counseling, sexual health care, and substance use treatment, starting at ages that vary by state and service. On a parent’s plan, the Explanation of Benefits can go to the parent, so ask the plan for confidential communications; clinics and school health centers can explain your state’s rules.
The Marketplace (Obamacare): The Marketplace is where you buy your own health plan under the Affordable Care Act (the ACA, also called Obamacare): HealthCare.gov in most states, or your state’s own site. A plan can’t turn you down or charge more for a health condition, and most people get a tax credit that lowers the monthly price. You sign up during open enrollment, or within 60 days of a life change such as losing other coverage. More
Tiered or narrow network: A narrow network has fewer doctors and hospitals in exchange for lower premiums. A tiered network sorts in-network providers into levels, and you pay less for the preferred tier. Check a doctor’s tier, not just whether they’re in network. More
Timely filing: The deadline for sending a claim to a health plan. Medicare gives 12 months from the date of service. Medicaid and private plans set their own, often between 90 days and a year; the provider manual or contract says. A claim sent late is usually denied, and an in-network provider usually can’t bill the patient for it. If the claim was late because the patient’s coverage wasn’t known in time, send proof with a request to reconsider.
Travel vaccines: Shots needed only for travel, like yellow fever, typhoid, or Japanese encephalitis, usually aren’t covered as preventive care and may not be covered at all. Routine vaccines you’re due for anyway (like hepatitis A or B, Tdap, or flu) are usually $0 in network. Travel clinics often charge cash; HSA or FSA funds can pay.
TRICARE For Life: Coverage for military retirees and their families who have Medicare Part A and Part B. Medicare pays first and TRICARE For Life pays most of what’s left, so you must keep Part B to stay covered.
Updating your Medicaid information: Report changes like a new address, income, or people in your household promptly (often within 10 days) through your state’s Medicaid website, app, phone line, or office, so renewal letters reach you and your coverage stays right.
Using your insurance at a visit: Bring your insurance card and a photo ID to every visit, and show the card at the pharmacy the first time you fill a prescription. The office checks your coverage, you pay your copay at the desk if you have one, and the office bills the plan for the rest. Later the plan sends an Explanation of Benefits that shows what it paid and what you owe; pay a bill only when it matches. Before a first visit, check that the doctor is in your plan’s network. More
VA health care and Medicare: VA health care and Medicare are separate, and you can have both. VA pays for care at VA facilities and care the VA arranges; Medicare pays when you see other doctors and hospitals. Many veterans keep Medicare Part B for that choice, since signing up late can mean a lifelong penalty.
Vitamins and supplements: Health plans generally don’t cover over-the-counter vitamins or supplements. Some are covered with a prescription when there’s a medical reason: folic acid for people who could become pregnant (a $0 preventive item with a prescription), prenatal vitamins, and vitamin D or B12 for a diagnosed deficiency. HSA or FSA funds can pay only when they treat a specific condition.
W-2 box 12, code DD: The amount in box 12 with code DD on your W-2 is the total cost of your job’s health plan for the year: what you and your employer paid together. It’s for your information only and is not taxed.
Waiting period: Time before coverage starts or before a benefit kicks in. Job-based plans can make new hires wait no more than 90 days. Dental and vision plans often have waiting periods for major work. Medigap can make you wait up to 6 months for a pre-existing condition if you didn’t have prior coverage.
Waiving a job’s coverage: You can turn down (waive) a job’s health plan, for example to stay on a spouse’s plan, Medicaid, or Medicare. HR will ask you to sign a waiver. If you later lose that other coverage, you have 30 days to join the job’s plan (60 days if Medicaid or CHIP ended); otherwise you wait for the next open enrollment. If the job’s plan counts as affordable, turning it down does not make you eligible for Marketplace tax credits.
Wellness rewards: Many plans give gift cards, lower premiums, or points for getting a checkup or a screening, or for filling out a health survey. They’re real, but check by signing in to the plan’s own website or calling the number on your card, not by following a link in a text or email. Answering a plan’s health survey can’t change your coverage or your price.
What counts toward your deductible: Usually what you pay for covered, in-network care counts until you meet the deductible. Copays often don’t count toward the deductible but do count toward the out-of-pocket maximum. Whether prescriptions count depends on the plan. Premiums never count.
What Medicaid costs you: In most states Medicaid has no monthly premium, and visits and prescriptions are free or cost a few dollars. Children, pregnant people, and emergency care generally have no copay. A doctor or hospital that takes Medicaid can’t bill you for covered care beyond that small copay. Your state’s Medicaid handbook lists the exact amounts.
When coverage starts: The day a plan begins paying, called its effective date. On the Marketplace, enrolling by December 15 during open enrollment starts coverage January 1. After a life change such as losing other coverage, it usually starts the first day of the month after you pick a plan; for a birth or adoption, it starts that day. A job’s plan starts after the employer’s waiting period, which can’t be longer than 90 days. Medicaid can start the day you apply, and sometimes earlier. Most plans don’t start until the first premium is paid. Your welcome letter or card shows the exact date. More
Who to call for help: Call the member services number on your insurance card first, and write down the date, the person’s name, and a call reference number. For free, unbiased help: your state’s health insurance consumer assistance program, and for Medicare, your State Health Insurance Assistance Program (SHIP).
Why a premium went up: Premiums change every January. Common reasons: the insurance company raised its rates, you got a year older, or you were renewed into a different plan. On the Marketplace, your tax credit may also have shrunk because your income changed or because the extra tax credits that lowered prices from 2021 through 2025 ended. During open enrollment, update your income and compare other plans. On a job plan, the employer may have changed how much of the premium it pays. More
Why a prescription costs more than expected: Common reasons: you haven’t met your deductible yet (many plans charge the full negotiated price until then), the drug is on a higher tier or not on the formulary, or the pharmacy isn’t in your plan’s network. Ask the pharmacist which it is, ask your prescriber about a generic or preferred drug, and compare a discount card’s price.
Workers’ compensation: Insurance your employer carries that pays for medical care and lost wages after an injury or illness caused by your job. Report the injury to your employer right away. Your health plan may refuse to pay for a work injury, or pay and then seek repayment from workers’ comp.
Workplace wellness programs: Many employers lower premiums or give rewards for wellness programs, like health screenings or quitting tobacco. Federal rules cap most rewards at 30% of the plan’s cost (50% for tobacco programs), and a program must offer a reasonable alternative if a health condition makes a goal unreasonable for you.
Your plan’s member website: Most plans have a member website or app (the address is usually on your card or plan mail) where you can see your ID card, claims, Explanations of Benefits, and plan documents. You’ll typically need your member ID to register.