Not really sure what an HMO really is? Do you only “Kinda, sorta” understand deductibles? Health insurance seems to have a language of its own and you want to be sure you’re choosing the right plan. Here, we’ll try to help you by explaining some of the most common terms you’ll see while you’re shopping for insurance.

Co-insurance

If a health care service has co-insurance, you pay a percentage (part) of the cost for that service. Usually, you start to pay co-insurance after you meet your deductible. It is not a fixed cost like a co-pay. The amount you pay depends on the total cost of the service.

  • Co-pay

    A fixed price you pay when you get certain health care services. Not all services require a co-pay.

Deductible

The total amount you must pay in a plan year before your plan will pay for part or all of your services. Some services may not have a deductible. They may be free or just have a co-pay, even though you haven’t met the deductible yet.

  • HMO

    HMO stands for Health Maintenance Organization. If you choose a plan that is an HMO, you must use in-network providers in order to get your services covered. If you go to an out-of-network provider, the plan won’t cover the cost of your care, except in an emergency. If you enroll in an HMO, you will also need to choose a primary care provider (PCP). You may need to get a referral from your PCP if you need care from specialists. Most of the plans offered through the Health Connector are HMOs.

Maximum out-of-pocket cost (MOOP)

The most you pay in one year for health care services. Once you pay this, your plan pays for all of your covered services for the rest for the year.

Metallic Tier

The Health Connector’s plans are in tiers (levels) named after metals: Platinum, Gold, Silver, and Bronze. These metallic tiers are based on how you and your insurance plan split costs. A plan’s metallic tier has nothing to do with quality of care you get, but does make it easier for you to compare plans.

Here’s how it works:

  • Platinum and Gold plans have the highest premiums (monthly cost) but the lowest costs (deductibles and co-pays) when you get health care services.
  • Silver plans have lower premiums but higher costs when you get health care services.
  • Bronze plans have the lowest premiums but the highest costs when you get health care services.

  • Plan Type (ConnectorCare)

    There are different ConnectorCare Plan Types that you may qualify for, based on your household size and income. All of the plans in each Plan Type have the same costs for covered benefits.

  • PPO

    PPO stands for Preferred Provider Organization. You will pay less if you use providers that belong to the plan’s network. If you go to providers outside of a PPO’s network, the plan will only cover part of the cost of your services. You may be able to see specialists without a referral from a primary care physician (PCP) if you are enrolled in a PPO.

  • Premium

    The amount you pay each month for your health insurance. You must pay your premium every month, whether or not you use health care services. The Health Connector will send you a bill for your premium each month. The premium will always be due by the 23rd of the month.

  • Primary Care Physician (PCP)

    The primary (main) doctor that you go to for care are and services. If you need a specialist, your PCP will coordinate that care and give you a referral. If you enroll in an HMO or EPO, you will need to choose a PCP.

Provider network

A provider network is a group of doctors, hospitals and other providers that works with the health plan to give you care. Each plan has a network. There are different types of networks.

  • In-network means the provider is part of the health plan network. If you get care from an in-network provider, it will cost you less.
  • Out-of-network means the provider is not part of the health plan network. If you get care from an out-of-network provider, your plan may not pay for those services and you could have to pay all or part of the cost yourself.

Before you enroll, make sure any providers you want to use are in the plan’s provider network. If you get care from a provider that is not in the plan’s network, you could have to pay out-of-pocket for all or part of the costs.

  • Standardized Plans

    We offer standardized plans within each metallic tier (level). Standardized plans have a set of 21 major benefits with the same out-of-pocket costs, to make it easier for members to compare the plans. Non-standardized plans can have varying out-of-pocket costs for all benefits and are also offered within each metallic tier. If you see the word “Standard” in a plan name, it means that the benefits are standardized and the plan may be easier to compare with other standardized plans in the same metallic tier.

    Within each metallic tier, the cost sharing (out-of-pocket costs) for standardized benefits are the same.

    • Plan names. Names of standardized plans vary by the insurer (insurance company) that offers the plan.
    • Provider networks. The health care providers (such as doctors and hospitals) may be different in each plan’s network. Go to our plan comparison tool to see which plans have the providers you want.
    • Costs for other services. Be sure to check each plan’s Summary of Benefits and Coverage (SBC) for more details.

Help is Here

Click here now to get shopping guides and a list of Navigator organizations across Massachusetts for free, in-person help.