In-network Coinsurance Minimum Value Standard Your share (for example, 20%) of the allowed amount A basic standard to measure the percent of permitted for covered health care services. Your share is usually costs the plan covers. If you’re offered an employer plan lower for in-network covered services. that pays for at least 60% of the total allowed costs of benefits, the plan offers minimum value and you may not In-network Copayment qualify for premium tax credits and cost-sharing A fixed amount (for example, $15) you pay for covered reductions to buy a plan from the Marketplace. health care services to providers who contract with your health insurance or plan. In-network copayments usually Network are less than out-of-network copayments. The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care Marketplace services. A marketplace for health insurance where individuals, families and small businesses can learn about their plan Network Provider (Preferred Provider) options; compare plans based on costs, benefits and other A provider who has a contract with your health insurer or important features; apply for and receive financial help plan who has agreed to provide services to members of a with premiums and cost sharing based on income; and plan. You will pay less if you see a provider in the choose a plan and enroll in coverage. Also known as an network. Also called “preferred provider” or “Exchange.” The Marketplace is run by the state in some “participating provider.” states and by the federal government in others. In some states, the Marketplace also helps eligible consumers Orthotics and Prosthetics enroll in other programs, including Medicaid and the Leg, arm, back and neck braces, artificial legs, arms, and Children’s Health Insurance Program (CHIP). Available eyes, and external breast prostheses after a mastectomy. online, by phone, and in-person. These services include: adjustment, repairs, and replacements required because of breakage, wear, loss, or Maximum Out-of-pocket Limit a change in the patient’s physical condition. Yearly amount the federal government sets as the most each individual or family can be required to pay in cost Out-of-network Coinsurance sharing during the plan year for covered, in-network Your share (for example, 40%) of the allowed amount services. Applies to most types of health plans and for covered health care services to providers who don’t insurance. This amount may be higher than the out-of- contract with your health insurance or plan. Out-of- pocket limits stated for your plan. network coinsurance usually costs you more than in- network coinsurance. Medically Necessary Health care services or supplies needed to prevent, Out-of-network Copayment diagnose, or treat an illness, injury, condition, disease, or A fixed amount (for example, $30) you pay for covered its symptoms, including habilitation, and that meet health care services from providers who do not contract accepted standards of medicine. with your health insurance or plan. Out-of-network copayments usually are more than in-network Minimum Essential Coverage copayments. Minimum essential coverage generally includes plans, health insurance available through the Marketplace or Out-of-network Provider (Non-Preferred other individual market policies, Medicare, Medicaid, Provider) CHIP, TRICARE, and certain other coverage. If you are A provider who doesn’t have a contract with your plan to eligible for certain types of minimum essential coverage, provide services. If your plan covers out-of-network you may not be eligible for the premium tax credit. services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-participating” instead of “out- of-network provider.” Glossary of Health Coverage and Medical Terms Page 3 of 6