The whole vocabulary, in one page

See Form 1095-A. The single most-lost document of the tax year.

See also Form 1095-A

The share of total covered medical costs a plan pays for a standard population - 60% for Bronze, 70% Silver, 80% Gold, 90% Platinum. It describes the plan, not your year.

See also Metal tier

Paying the premium tax credit monthly to the carrier on your behalf rather than claiming it as a lump sum on your return.

See also APTC

The maximum a plan will recognise for a covered service. In-network providers agree to it; out-of-network providers may bill you the difference.

Advance Premium Tax Credit. The subsidy paid directly to your carrier each month, reduced from your bill before you ever see it, and reconciled at tax time.

See also Premium tax credit, Form 8962

When an out-of-network provider bills you for the gap between their charge and the plan's allowed amount. Largely prohibited for emergencies under federal surprise-billing rules.

The second-lowest-cost Silver plan in your rating area. Your premium tax credit is calculated from it, whatever plan you actually buy.

See also SLCSP

Your percentage share of a bill after the deductible - 20% coinsurance on a $2,000 procedure is $400 from you.

A flat amount for a service, often payable before the deductible is met. Predictable in a way coinsurance is not.

Everything you pay at the point of care - deductible, copays and coinsurance. It excludes your premium.

Extra help that lowers deductibles, copays and the out-of-pocket maximum for households between 100% and 250% FPL. It attaches only to Silver plans.

See also CSR variant

The specific enriched version of a Silver plan - 73, 87 or 94 - assigned by income band. A 94 variant behaves better than most Gold plans.

What you pay for covered services in a year before the plan begins sharing most costs. Preventive care and many copay services sit outside it.

A family plan where each individual has their own deductible inside the family one, so a single member's care starts sharing sooner.

The share of household income you are expected to put toward the benchmark plan, set by an income-graded percentage schedule.

The statement a carrier sends after a claim. It is not a bill, and it is the document to check before you pay one.

The Marketplace statement listing your monthly premium, benchmark premium and advance credit. Issued by January 31 and required to file.

See also Form 8962

The IRS form that reconciles the advance credit you took against the credit your actual income entitled you to. Under-estimating income means paying some back.

The annual ceiling on your in-network cost sharing. Once you reach it, the plan pays 100% of covered in-network care for the rest of the year.

The monthly cost of holding the policy, owed whether or not you use any care.

A refundable federal credit that reduces the cost of a Marketplace plan, sized to the gap between the benchmark premium and your expected contribution.

See also APTC, Benchmark plan

Second-Lowest-Cost Silver Plan. The technical name for the benchmark, and a line item on your 1095-A.

See also Benchmark plan

The historical hard cut-off at 400% FPL, since replaced by an 8.5%-of-income cap that tapers rather than drops.

An out-of-network charge arising from care you had no practical way to decline - an emergency, or an anaesthetist inside an in-network hospital.

The 60% actuarial value tier. Lowest premium, largest deductible, and the right answer only for households with an emergency fund.

A high-deductible Marketplace plan available to people under 30 or with a hardship exemption. No premium tax credit may be applied to it.

Exclusive Provider Organization. In-network only, but no referrals required. The quiet middle option most people never hear about.

The ten categories every Marketplace plan must cover, including ambulatory care, emergency services, maternity, mental health and prescriptions.

The plan's covered drug list, arranged in tiers. If a drug is not on it, coverage requires an exception request.

The 80% tier. Higher premium, materially lower cost when you actually use care.

A policy in force before March 2010 that is exempt from some ACA requirements. A shrinking population.

Health Maintenance Organization. In-network care only outside emergencies, with a primary care physician gatekeeping specialist referrals. Lowest premium.

A qualifying high-deductible plan that permits contributions to a health savings account. Usually a Bronze or Silver design.

The four-step ladder - Bronze, Silver, Gold, Platinum - that describes how a plan splits costs, not how good its network is.

A deliberately restricted provider set traded for a lower premium. Fine until the one specialist you need is outside it.

The set of providers contracted with a plan. Two plans from the same carrier at the same tier can have completely different networks.

The 90% tier. Not filed by every carrier in every rating area, and often poor value without heavy utilisation.

Point of Service. HMO referral discipline with a limited out-of-network allowance attached.

Preferred Provider Organization. Out-of-network care is covered at a higher cost share, and no referrals are needed. Highest premium.

Graded screenings and immunisations covered with no cost sharing when delivered in network - even before the deductible.

Approval the plan requires before a service or drug is covered. Getting it after the fact is much harder than getting it before.

The carrier's list of in-network providers. Directories go stale; confirm with the practice and the carrier both.

A non-ACA policy that may underwrite, exclude pre-existing conditions and omit essential health benefits. It is not Marketplace coverage.

The 70% tier, the benchmark tier, and the only tier that carries cost-sharing reductions.

A requirement to try a cheaper drug first before the plan will cover the one prescribed.

The standardised four-page plan summary every carrier must publish in the same format. It exists so plans can be compared honestly.

If you do nothing, the Marketplace usually re-enrols you into your current plan or a crosswalked substitute - often at a worse credit.

The first premium payment. Coverage is not in force until it clears, whatever the enrolment confirmation says.

The mapping a Marketplace applies when your plan is discontinued, moving you into the carrier's nearest surviving design.

A flag raised when your application data does not match federal records. It carries a document deadline, and missing it ends the credit.

The day coverage begins. Enrol by December 15 for January 1; later in the window usually means February 1.

The window after a missed premium before termination. Subsidised enrollees generally get three months; unsubsidised get far less.

The annual federal window, November 1 to January 15, when anyone eligible may enrol or change plans without a qualifying event.

Marriage, birth, adoption, a permanent move, or losing other coverage. Voluntarily dropping coverage is not one.

A 60-day window opened by a qualifying life event, allowing enrolment outside Open Enrollment.

See also Qualifying life event

The end of coverage, whether for non-payment, a plan change, or a move out of the service area.

If job-based coverage costs less than a set percentage of household income, you cannot claim a Marketplace credit.

The Children's Health Insurance Program. Children may qualify for it even when the adults in the household do not qualify for Medicaid.

Households under 100% FPL in states that did not expand Medicaid: too poor for credits, ineligible for Medicaid.

The former rule that judged family affordability on the employee-only premium. Fixed by regulation in 2022.

The federal income yardstick that eligibility is measured against. Subsidy bands, CSR variants and Medicaid all key off it.

Your tax family - the people you claim on the return, whether or not they live with you.

The immigration-status requirement for Marketplace eligibility. Many statuses qualify; the list is longer than most people expect.

Modified Adjusted Gross Income. The income figure the Marketplace uses, which is not the same as take-home pay.

A carrier's authorisation for a specific agent to sell and be paid on its products in a specific state.

The set of households an agent services, and the renewal commission stream attached to it. An agent's actual asset.

The documented permission from a consumer for an agent to access and act on their Marketplace application. Required, and auditable.

State-mandated coursework required to renew a producer licence, usually on a two-year cycle.

Errors and omissions insurance. Professional liability cover, required by most carriers before appointment.

Federally-facilitated Marketplace. The federal exchange platform used by states that did not build their own.

The annual CMS training and two agent-broker agreements a producer must complete before assisting with Marketplace enrolments.

National Producer Number. The unique identifier for a licensed insurance producer, verifiable in the national registry.

Commission paid to an agency or upline on business written by an agent beneath it in the hierarchy.

Per member per month. The dominant ACA commission structure: a flat amount for each covered life, each month the policy stays in force.