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Health Care Reform:

Health Insurance & Affordable Care Act

Back to ACA Health Insurance Terms List

Summary of benefits or benefits package

This is a list of medical services and supplies a health insurance plan covers and the associated costs. These summaries are useful when comparing different plans. 

The summary includes:

Covered services: Any care and treatment a health plan pays for in part or in full is considered a covered benefit.

Deductible amounts: The deductible is how much you must spend before insurance starts to pay its part.

Copay or coinsurance amounts: A copay is a fixed amount you pay at the time of care. For instance, you might have a $20 copay for a doctor's appointment and a $30 copay to see a specialist.

Coinsurance is a percentage of the cost of services that you must pay. For instance, if your coinsurance for an MRI is 20%, you pay 20% of the charge. So if the bill was $100, you would owe $20 (usually after your deductible is met).

Cost for prescription medicines: This section will outline what you will pay for both generic and brand-name drugs.

Limits to coverage: Health plans must limit how much you pay toward services covered by your health plan. This an out-of-pocket limit. Once you reach that limit, the plan pays 100% for your care.

The Affordable Care Act does not allow plans to impose annual or lifetime limits on essential health benefits. However, plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.  

There may also be an annual limit on nonessential health services. For instance, you may be covered for only one eye exam per year or face limits on physical therapy sessions. 

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