Health Care Reform Basics
Advance Premium Tax Credit (APTC)
The Affordable Care Act provides a new tax credit to help you afford health care insurance purchased through the Health Insurance Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. Learn more.
Cost Share Reductions
If you qualify, these can help you with the cost of health care. Your out-of-pocket costs like deductibles, coinsurance, and copayments may be reduced, depending on your income. Those that qualify can pay the premium of a Silver plan but get the benefits of a Gold or Platinum plan. Learn more.
Health Insurance Marketplace (Exchange)
The Health Insurance Marketplace (Exchange) is an open market for dental and health care insurance. You'll be able to compare types of health care insurance, check prices, find out if you qualify for subsidies, and enroll in a health care insurance plan.
Health Plan Categories (Metal Levels)
All health insurance plans are divided into five categories – Catastrophic, Bronze, Silver, Gold and Platinum. These are called the “metal levels.” The categories are based on the average total amount* your plan will pay for your covered medical costs: 60% for Bronze, 70% for Silver, 80% for Gold, and 90% for Platinum (catastrophic plans will vary).
*Plans in each category pay different amounts of the total covered costs of an average person’s care. This takes into account the plans’ deductibles, copayments, coinsurance and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.
Your costs for health care that aren't paid by health insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services. Costs for other services that aren't covered by your health plan are also paid out-of-pocket.
Help with paying for your health care and insurance plan costs based on your income level. You can get help with your monthly premium (Advance Premium Tax Credit) or help with your out-of-pocket expenses (Cost Share Reductions). Learn more.
Coinsurance Your share of the costs of a covered health care service. It is calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.
For example, if your plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. Your health plan pays the rest of the allowed amount.
Copayments (or Copays)
A fixed amount you pay for a covered health care service. It is usually paid at the time you get the service.
For example, if you have an office visit with your doctor, your copay may be a fixed amount such as $30. If you have a copay, this is usually the only fee you will have to pay when you visit your doctor (other services such as lab tests or x-rays may result in additional fees). Choosing a plan with a copay for services you receive often may help you minimize your out-of-pocket expenses.
Deductible The amount you pay for covered health care services before your health insurance begins to pay. If your deductible is $1,000, your health plan won’t pay anything until you’ve paid $1000. The deductible may not apply to all services.
Maximum Out-of-Pocket The most you will pay in calendar year for covered health care services. This does not include your monthly premium or out-of pocket costs for benefits that are not essential health benefits.
Out-of-Pocket Your costs for health care not paid by health insurance. These costs can include deductibles, coinsurance, and copayments. They also include costs for services that aren't covered by your health insurance.
Premium A premium is the amount that you pay each month for your health insurance.
© 2018 Quartz Health Solutions, Inc. All rights reserved.
Quartz Health Solutions, Inc., Unity Health Plans Insurance Corporation, Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota, Physicians Plus Insurance Corporation, Gundersen Health System, UnityPoint Health and UW Health are separate legal entities. Plans are underwritten by Unity Health Plans Insurance Corporation unless otherwise noted.