Copayment (Copay)

A fixed amount an individual pays for a covered healthcare service, such as a doctor visit or prescription, after meeting their deductible. The amount varies by service and insurance plan.

Coverage Gap (Donut Hole)

A temporary limit on what Medicare Part D will cover for prescription drugs. After reaching a certain spending threshold, beneficiaries may pay more out-of-pocket for prescriptions until they reach the catastrophic coverage phase.

Deductible

The amount an individual must pay out-of-pocket for covered healthcare services before their insurance plan starts to cover costs. Deductibles apply to various types of insurance, including Medicare, Medicaid, ACA, and CHIP plans.

Gold Plan (ACA)

A health insurance plan offered through the ACA Marketplace that covers approximately 80% of healthcare costs, with the remaining 20% paid by the enrollee. Gold plans have higher premiums but lower out-of-pocket costs compared to Bronze and Silver plans.

Gap Coverage

Insurance coverage that fills the gaps in a primary health insurance policy. Medicare Supplement (Medigap) plans are a common form of gap coverage, helping pay for out-of-pocket costs not covered by Original Medicare (such as copayments, coinsurance, and deductibles).

High-Deductible Health Plan (HDHP)

A health insurance plan with a higher deductible and lower premiums. HDHPs are often paired with a Health Savings Account (HSA) to help cover out-of-pocket expenses. These plans are available through the ACA Marketplace and employer-sponsored coverage.

Hospital Indemnity Insurance

A type of supplemental insurance that provides a cash benefit for each day an individual is hospitalized. This insurance can help cover out-of-pocket costs not paid by Medicare, Medicaid, or private health insurance.

Medicare Supplement Insurance (Medigap)

Private health insurance that helps cover the out-of-pocket costs associated with Original Medicare (Parts A and B), such as copayments, coinsurance, and deductibles. Medigap plans are standardized and regulated by federal and state laws.

Out-of-Pocket Costs

Medical expenses that are not covered by insurance, such as copayments, deductibles, and coinsurance, which must be paid directly by the individual. Out-of-pocket costs apply to Medicare, Medicaid, CHIP, and ACA plans.

Urgent Need Care (Medicare)

Immediate medical care required for sudden illnesses or injuries that are not life-threatening but require prompt attention. Medicare Advantage plans typically cover urgent care services, and they may have lower out-of-pocket costs than emergency room visits.