Key insurance terms that start with "B"

A brand-name drug is a prescription medication sold under the name given to it by the pharmaceutical company that developed and holds the patent. Brand-name drugs are typically more expensive than their generic equivalents because the manufacturer can set prices without competition during the patent protection period, which usually lasts 20 years from the original filing date.

On most insurance formularies, brand-name drugs are placed on higher cost tiers than generics:

• Preferred brand-name: Tier 2 or 3, moderate cost share
• Non-preferred brand-name: Tier 3 or 4, higher cost share
• Specialty brand-name drugs: Highest tier, often requiring prior authorization and carrying the highest cost-sharing

When a generic version of a brand-name drug becomes available (after patent expiration), it contains the same active ingredient, strength, and dosage form as the original and is FDA-approved as therapeutically equivalent. Switching to the generic typically results in significantly lower cost-sharing.

Your doctor can specify “dispense as written” (DAW) on a prescription if they believe the brand-name version is clinically necessary. In some cases, your insurer may require documentation to cover the brand-name drug when a generic is available.

A Bronze plan is the lowest metal tier on the ACA Marketplace. It covers approximately 60% of average health care costs — you pay the remaining 40% through deductibles, copays, and coinsurance. In exchange, Bronze plans have the lowest monthly premiums of any metal tier.

Bronze plans are best suited for people who are generally healthy, use little care, and primarily want coverage as a financial safety net against a major medical event. The trade-off is a high deductible — often $5,000–$8,000 or more — meaning you’ll pay a significant amount out-of-pocket before your plan starts covering most services.

An important exception: preventive care is covered at $0 on Bronze plans, just like every other ACA metal tier. Vaccinations, screenings, and annual wellness visits don’t require meeting the deductible first.

Bronze plans are often paired with Health Savings Accounts (HSAs), since many qualify as High-Deductible Health Plans (HDHPs). HSA contributions reduce your taxable income and can be used to pay your deductible and other qualified expenses tax-free.

The health care services your insurance plan covers, like doctor visits, hospital stays, and prescription drugs. Different plans cover different benefits, so it's important to check your plan's benefit details before you sign up. Some benefits may require a copay or coinsurance.

A benefit year is the 12-month period during which your health insurance plan’s benefits apply. For most ACA Marketplace plans, the benefit year runs January 1 through December 31. Your deductible, out-of-pocket maximum, and other cost accumulators reset to zero at the start of each new benefit year.

The benefit year matters for planning your care and finances:

• Any deductible payments you make reset on January 1 — if you have a major procedure scheduled, timing it before year-end (once your deductible is met) can save significantly
• If you switch plans during Open Enrollment, any progress toward your old plan’s deductible does not carry over to the new plan
• Premium Tax Credits and Cost-Sharing Reductions are also calculated on a per-benefit-year basis

Employer-sponsored plans may have benefit years that don’t align with the calendar year. If your employer plan runs, for example, July 1 through June 30, your deductible resets on July 1.

Balance billing is when a health care provider charges you the difference between their full rate and what your insurance company pays. It typically happens with out-of-network providers who haven’t agreed to your insurer’s rates.

Example: a specialist charges $800 for a procedure. Your insurance’s allowed amount is $500 and they pay $400. Your insurer expects you to pay $100 in coinsurance. But the out-of-network doctor also sends you a separate bill for the remaining $300 (the “balance”). That $300 is balance billing.

The No Surprises Act (effective 2022) significantly limits balance billing in two key situations:

• Emergency care at an out-of-network facility
• Non-emergency care from an out-of-network provider at an in-network facility (e.g., an out-of-network anesthesiologist at an in-network hospital)

For non-emergency, scheduled out-of-network care, balance billing is still permitted. If you choose to see an out-of-network provider knowingly, you can be billed the full difference.