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5 health insurance terms you need to know

5 health insurance terms you need to know

Health insurance can be confusing. But it’s important to stay informed so you can make the best decisions for you and your family. So, we’ve identified five terms that you need to know:

  1. Marketplace – The Marketplace is an online market where individuals and small businesses can shop for, compare, and buy health coverage. To shop for health insurance plans, you’ll need to fill out a Marketplace application. You can enroll for 2015 health coverage beginning on Nov. 15, 2014.
  1. Qualified Health Plan (QHP) – Coverage sold on the Marketplace must be qualified, which means it must meet certain requirements. These include:
  • Being certified by the Marketplace.
  • Providing Essential Health Benefits (read on, we’ll explain these below).
  • Following established limits on cost-sharing, or how much you have to pay for health care services versus how much your health plan will cover (this includes things like deductibles, copayments, and out-of-pocket maximum amounts).
  • Meeting various other requirements, such as having a variety of options of health care providers and using a standard enrollment form.

Bronze, Silver, Gold, and Platinum (also called the metallics) are categories that the Marketplace uses to label different QHPs. Each “metal” represents a different average percentage of covered health costs that a plan will pay for. For example, Platinum plans pay for, on average, about 90 percent of covered health care costs, while Bronze plans pay for about 60 percent. UPMC Health Plan offers a variety of plans at each metallic level. Learn more about QHPs here.

  1. Essential Health Benefits (EHB) – Essential health benefits are a list of services that must be covered by plans in the Marketplace – things like emergency services, maternity and newborn care, and laboratory services. Other benefits and services that are considered EHBs include hospitalization, preventive and wellness services and chronic disease management, as well as pediatric services, including oral and vision care. Get the full list of EHBs here.
  1. Advance Premium Tax Credits (APTC) – These are tax credits that help reduce the cost of health insurance premiums for those who qualify. Wondering if you qualify? Your eligibility will be determined when you apply on the Marketplace. Remember, you won’t be able to purchase coverage for 2015 until Nov. 15, 2014, but you can start the shopping process here and learn what UPMC Health Plan has to offer.
  1. In-network – The term “in-network” refers to health care providers, hospitals, and other facilities that are contracted with your health insurance plan. It’s important to know if your doctor is in your network, since health plans usually provide a higher level of coverage for in-network providers. Individuals and families insured with UPMC Health Plan can locate doctors and other health care providers in their network using online directories and their MyHealth OnLine account.

Are there other terms you’re not familiar with? Check out our Health Care Glossary for more information.