Health insurance, in plain English.

For all adults

Covered with no copay or coinsurance on every Marketplace plan.

• Blood pressure screening
• Cholesterol screening — certain ages, or at higher risk
• Depression screening
• Obesity screening and counseling
• Tobacco use screening, and help quitting
• Alcohol misuse screening and counseling
• Diet counseling — adults at higher risk of chronic disease
• Immunizations — flu, COVID-19, shingles, tetanus and others
• Colorectal cancer screening — ages 45 to 75
• Lung cancer screening — ages 50 to 80, at high risk
• Type 2 diabetes screening — ages 40 to 70, overweight or obese
• Hepatitis C screening — ages 18 to 79
• Hepatitis B screening — higher-risk adults
• HIV screening — ages 15 to 65, and other ages at higher risk
• PrEP — medication to prevent HIV — HIV-negative adults at high risk
• Syphilis screening — higher-risk adults
• Tuberculosis screening — certain higher-risk adults with no symptoms
• Sexually transmitted infection prevention counseling — higher-risk adults
• Statin medication — ages 40 to 75, at high risk
• Aspirin to prevent heart disease and colorectal cancer — ages 50 to 59, at high risk
• Abdominal aortic aneurysm screening, once — men of certain ages who have smoked
• Fall prevention — exercise, physical therapy and vitamin D — ages 65 and over

For women

In addition to everything on the list above.

• Well-woman visits
• Breast cancer screening mammogram — every 1 to 2 years from age 40
• Cervical cancer screening (Pap test) — ages 21 to 65
• BRCA genetic test counseling
• Breast cancer chemoprevention counseling
• Bone density screening — age 65 and over
• Birth control — FDA-approved methods, and sterilization procedures
• Chlamydia screening
• Urinary incontinence screening
• Domestic violence screening and counseling
• Diabetes screening — with a history of gestational diabetes

If you're pregnant, or might become pregnant

Covered before, during and after pregnancy.

• Folic acid supplements
• Gestational diabetes screening
• Preeclampsia prevention and screening
• Hepatitis B screening — at the first prenatal visit
• Rh incompatibility screening
• Urinary tract infection screening
• Gonorrhea and syphilis screening
• Maternal depression screening
• Breastfeeding support, counseling and supplies
• Tobacco counseling

For children

From newborn checks through to the teenage years.

• Well-baby and well-child visits
• Immunizations
• Height, weight and BMI measurements
• Vision screening
• Hearing screening — newborns, then regularly
• Newborn blood screening
• Bilirubin, hypothyroidism and PKU screening — newborns
• Sickle cell screening — newborns
• Antibiotic eye ointment — newborns, to prevent gonorrhea infection
• Developmental screening — under age 3
• Autism screening — at 18 and 24 months
• Behavioral assessments
• Depression screening — routinely from age 12
• Blood pressure screening
• Obesity screening and counseling
• Oral health risk assessment — 6 months to 6 years
• Fluoride varnish — infants and children with teeth
• Fluoride supplements — where drinking water has no fluoride
• Lead screening — at-risk children
• Hematocrit or hemoglobin screening
• Dyslipidemia (cholesterol) screening — ages 9 to 11 and 17 to 21
• Alcohol, tobacco and drug use assessment — adolescents
• Tuberculin testing — higher-risk children
• HIV and hepatitis B screening — higher-risk adolescents
• PrEP — medication to prevent HIV
• Sexually transmitted infection counseling and screening — higher-risk adolescents

What you pay

The four numbers that decide what a plan actually costs you.

Premium

The monthly bill for having the plan. You pay it whether or not you see a doctor.Miss it and coverage can end, even if everything else is in order.

Deductible

The amount you pay for care yourself before the plan starts paying its share.With a $3,000 deductible, you cover the first $3,000 of care. Preventive visits usually don't count against it — they're free from day one.

Copay

A flat fee for a particular visit or prescription.$30 every time you see your family doctor, whatever the visit costs.

Coinsurance

A percentage of the bill rather than a flat fee. It usually kicks in after your deductible.20% coinsurance on a $1,000 procedure means you pay $200.

Out-of-pocket maximum

The most you can pay in one year for covered care. After that, the plan pays 100%.This is the number that matters if something serious happens. Premiums don't count toward it.

Doctors and prescriptions

Who you can see, and what's covered.

Network

The doctors, hospitals and pharmacies your plan has an agreement with. Staying inside it is almost always cheaper.

Out-of-network

A provider without an agreement with your plan. Some plans pay less for this; some pay nothing at all.Worth checking before an appointment, not after. This is the most common reason a bill is bigger than expected.

Primary care provider (PCP)

Your main doctor — the one who handles everyday care and refers you on when you need a specialist.

Referral

Your PCP formally sending you to a specialist. Some plans need one before they'll cover the specialist visit.

Prior authorization

Your plan agreeing in advance to cover something — often a scan, a surgery, or an expensive drug.Skipping it can mean the plan refuses the bill afterwards.

Formulary

The list of prescriptions your plan covers, usually sorted into tiers that cost you different amounts.If a medication you take isn't on it, that's worth knowing before you pick a plan.

Paperwork you'll see

Documents that arrive and look like bills but usually aren't.

Explanation of benefits (EOB)

A summary from your insurer showing what a visit cost, what they paid, and what's left for you.It is not a bill. The bill comes from the doctor's office.

Summary of benefits and coverage (SBC)

A short standard document describing what a plan covers and what it costs. Every plan has one, in the same format, so plans can be compared side by side.

Enrolling and staying covered

When you can sign up, and what help you might qualify for.

Open Enrollment

The yearly window when anyone can start, switch or drop a Marketplace plan.

Special Enrollment Period (SEP)

A window outside Open Enrollment that opens after certain life events — losing coverage, moving, marriage, a new baby.Usually 60 days from the event. Miss it and you may have to wait for Open Enrollment.

Qualifying life event

The change that opens a Special Enrollment Period for you.

Premium tax credit (subsidy)

Help from the government paying your monthly premium, based on your household income and size.It's usually applied straight to the premium, so you see a smaller bill rather than waiting for tax time.

Cost-sharing reduction

Extra help that lowers your deductible, copays and out-of-pocket maximum. Only available on Silver plans, and only at certain income levels.

Effectuation

Your carrier switching the policy on, which normally happens once the first premium is paid.Enrolled and effectuated are not the same thing. Until the first payment clears, you're enrolled but not yet covered.

Minimum essential coverage

Coverage that counts as real health insurance under the law — a job plan, Medicare, Medicaid, or a Marketplace plan.Losing it is what opens a Special Enrollment Period. Short-term or discount plans usually don't count.

Data matching issue (DMI)

The Marketplace couldn't match something on your application — income, citizenship, a Social Security number — against its own records, so it asks for a document.There's a deadline, and missing it can cost you coverage or your subsidy. Anything we need from you shows up in your portal.