Your monthly cost is based on age, zip code, plan type, and sometimes income. You may qualify for programs that lower premiums and reduce out‑of‑pocket costs.

Co‑payment (copay): fixed amount for a service (office visit, prescription).
Co‑insurance: percentage you pay after meeting your deductible.

The amount you pay out of pocket before your plan starts covering eligible expenses.

The most you’ll pay in a plan year for covered, in‑network care (deductibles, copays, co‑insurance). After you reach it, the plan pays 100% of covered in‑network benefits for the rest of the year. Monthly premiums don’t count toward this limit.

The amount you pay (usually monthly) to keep coverage active—whether or not you use medical services.

A Preferred Provider Organization has a network of doctors/hospitals. You’ll pay less in‑network, but can see out‑of‑network providers (usually at a higher cost). Often offers nationwide flexibility.

A Health Maintenance Organization uses a local network and typically requires referrals from your primary care provider to see specialists. Usually lower cost with tighter service‑area rules.

An Exclusive Provider Organization requires you to use in‑network providers (except emergencies). No referral is typically needed. Premiums are often lower than PPOs but with less out‑of‑network flexibility.

A Point‑of‑Service plan blends HMO and PPO features: you choose an in‑network PCP and often need a referral to go out‑of‑network, where some coverage is available at higher cost.

In‑network providers have contracts with your plan—lower negotiated rates and lower member costs. Out‑of‑network care usually costs more or may not be covered (plan‑dependent).

A referral is when your PCP sends you to a specialist (often required for HMO/POS).
Prior authorization is your plan’s approval for certain services/meds before they’re covered.

An HSA pairs with an HSA‑eligible high‑deductible plan; funds are yours, grow tax‑free, and roll over yearly. An FSA is employer‑sponsored; funds are usually use‑it‑or‑lose‑it (limited rollover) and don’t follow you if you leave.

Open Enrollment is the annual window to enroll or change plans. Special Enrollment is available year‑round if you have a qualifying life event (move, marriage, birth, loss of coverage, etc.).