Key insurance terms that start with "P"

Plan comparison is the process of evaluating health insurance options side by side before choosing a plan. On the ACA Marketplace, you can compare up to three plans at once using HealthCare.gov’s built-in comparison tool — or work with a broker who can model total annual costs across plans based on your household’s expected care use.

Premium alone is a poor comparison metric. The plan with the lowest monthly premium often has the highest deductible and cost-sharing, which can make it more expensive overall if you use care regularly. Effective plan comparison looks at:

• Net premium: Your monthly cost after any APTC subsidy
• Deductible: What you pay before coverage kicks in
• Copays and coinsurance: Your share for specific services you use
• Out-of-pocket maximum: Your worst-case annual exposure
• Formulary: Whether your prescriptions are covered and at what tier
• Network: Whether your current doctors are included

For families near income thresholds, comparing CSR-enhanced Silver plans against Gold options is especially important — the right choice can save thousands per year.

A list or searchable database of doctors, hospitals, and other health care providers in your insurance plan's network. You can use your plan's provider directory to find in-network providers and verify they're accepting new patients before scheduling care.

A health care professional or facility that provides medical services. Providers include doctors, nurses, hospitals, pharmacies, and clinics. Your insurance company contracts with providers to offer you care at negotiated rates.

A Primary Care Physician (PCP) is a doctor who serves as your main point of contact for routine health care. Your PCP handles general checkups, preventive care, managing chronic conditions, diagnosing new symptoms, and coordinating referrals to specialists when needed. Common PCP specialties include family medicine, internal medicine, general practice, and pediatrics.

Whether you need to designate a PCP depends on your plan type:

• HMO: A PCP is required. You must choose one and get referrals through them to see specialists.
• POS: A PCP is typically required for in-network specialist referrals, though some plans vary.
• PPO / EPO: No PCP designation required. You can book directly with specialists without a referral.

Even on PPO or EPO plans, establishing a relationship with a PCP is valuable. A PCP who knows your health history can catch issues early, coordinate your care across providers, and serve as an advocate if you need specialist referrals or appeals support.

Preventive visits with your PCP — including annual physicals and screenings — are covered at $0 cost-sharing on all ACA-compliant plans.

Preventive care refers to health services designed to prevent illness, detect conditions early, and keep you healthy before problems develop. Under the ACA, all Marketplace plans are required to cover a defined set of preventive services at no cost to you — no copay, no coinsurance, and no deductible — as long as you use an in-network provider.

Covered preventive services include:

• Annual wellness exams and physicals
• Blood pressure, cholesterol, and diabetes screenings
• Cancer screenings (colonoscopy, mammogram, cervical cancer screening)
• Vaccinations (flu, COVID-19, hepatitis, shingles, and others)
• Depression and anxiety screenings
• Prenatal care visits
• Well-child visits and developmental screenings
• Contraception and family planning counseling

The $0 cost-sharing requirement only applies when the visit is coded as preventive. If your doctor addresses a new complaint or orders additional tests during the same visit, those services may be billed separately and subject to your normal cost-sharing.

Prescription drug coverage is the benefit within your health insurance plan that helps pay for medications prescribed by a licensed provider. Under the ACA, prescription drugs are one of the 10 Essential Health Benefits — all Marketplace plans are required to cover them, though what’s covered and how much you pay varies by plan.

Your plan’s formulary is the list of covered drugs organized into cost tiers. How much you pay for a prescription depends on:

• Which tier the drug falls on (generic drugs cost less; specialty drugs cost more)
• Whether you’ve met your deductible (some plans require it, others apply drug copays before)
• Whether the pharmacy is in your plan’s network
• Whether the drug requires prior authorization

Using a generic drug instead of a brand-name equivalent almost always saves money. Generics contain the same active ingredients and are FDA-approved as equivalent — ask your doctor or pharmacist if a generic version is available.

Mail-order pharmacies (offered by many plans) often provide 90-day supplies at a lower cost per dose than 30-day retail fills. If you take a maintenance medication regularly, ask your insurer about mail-order options.

The Premium Tax Credit (PTC) is a federal subsidy that lowers your monthly health insurance premium when you enroll through the ACA Marketplace. It’s calculated based on your household income and size, and the cost of benchmark Silver plans in your area.

Most people take it as an Advance Premium Tax Credit (APTC) — the credit goes directly to your insurance company each month, so your bill is already reduced. You can also take the full credit as a lump sum when you file your taxes, but most families benefit more from the monthly reduction.

For 2026, the premium tax credit phases out entirely once household income exceeds 400% of the Federal Poverty Level (FPL). This is the subsidy cliff, which returned after enhanced subsidies expired December 31, 2025.

Your actual credit amount is reconciled when you file your federal tax return using Form 8962. If your income came in lower than projected, you may receive additional credit. If it came in higher, you may owe some back.

Your premium is the monthly amount you pay to keep your health insurance active — regardless of whether you use any medical services that month. Think of it as the price of staying covered.

Your premium is separate from your deductible, copays, and coinsurance. You pay those when you actually use care. The premium is due every month no matter what.

Several factors affect how much your premium costs:

• Plan tier: Bronze plans have the lowest premiums but highest out-of-pocket costs. Platinum plans have the highest premiums but lowest out-of-pocket costs.
• Age: Older enrollees pay more under ACA rules, up to 3x more than younger enrollees.
• Location: Premiums vary significantly by state and county.
• Household income: If you qualify for a Premium Tax Credit (APTC), it reduces your monthly premium — sometimes to $0.

If you miss a premium payment, most plans have a 30-day grace period before your coverage is terminated. If you’re receiving an APTC, the grace period extends to 90 days, but claims may be held after day 30.

A Preferred Provider Organization (PPO) is a type of health insurance plan that gives you flexibility to see almost any doctor or specialist — without needing a referral first. You pay less when you use providers in the plan's network, but you can still get coverage for out-of-network care at a higher cost share.

PPOs are the most flexible plan type on the Marketplace, which is why their premiums tend to run higher than HMOs or EPOs. If you have an existing specialist you want to keep, or if you travel frequently and need coverage away from home, a PPO's out-of-network coverage is a real advantage.

When a PPO makes sense

• You have doctors or specialists you want to keep seeing
• You travel often and need coverage outside your home network
• You're willing to pay a higher premium for maximum flexibility

When a PPO may not be worth it

• Your preferred providers are all in-network on a less expensive plan type
• Cost is the priority and you're comfortable with a smaller network

A doctor, hospital, or pharmacy that your insurance company prefers you to use. Preferred providers have agreed to discounted rates, so you pay less when you use them. Your plan's provider directory shows which providers are preferred.

Prior authorization (also called preauthorization or pre-approval) is a requirement that your doctor or health care provider get approval from your insurance company before delivering certain services, procedures, or medications. Without it, your insurer may deny the claim and you could be responsible for the full cost.

Services that commonly require prior authorization include:

• Elective surgeries and procedures
• Specialist referrals (on some plan types)
• Brand-name and specialty medications
• Imaging (MRI, CT scans, PET scans)
• Inpatient hospital admissions (non-emergency)
• Home health care and durable medical equipment
• Mental health and substance use treatment (certain levels of care)

Prior authorization is your insurer’s way of reviewing medical necessity before paying. It does not guarantee payment — a claim can still be denied after authorization if the service is billed differently than approved. If authorization is denied, you have the right to appeal.

A Point-of-Service (POS) plan combines features of an HMO and a PPO. Like an HMO, you choose a primary care physician who coordinates your care and provides referrals. Like a PPO, you have the option to see out-of-network providers — though at a significantly higher cost share.

How a POS plan works in practice:

• You designate a PCP who manages your care and issues referrals for specialist visits
• In-network care (with referral) is covered at the lower in-network cost-sharing rate
• Out-of-network care is covered, but at a higher rate — and typically requires a referral from your PCP
• Emergency care is covered regardless of network status, as with all ACA plans

POS plans are less common on the ACA Marketplace than HMOs, PPOs, and EPOs. When available, they offer a middle ground: more provider flexibility than an HMO with more structure than a PPO. The premium typically falls between the two.

A Platinum plan is the highest metal tier on the ACA Marketplace. It covers approximately 90% of average health care costs — you pay about 10% through deductibles, copays, and coinsurance. Platinum plans have the highest monthly premiums of any metal tier, but the lowest out-of-pocket costs when you use care.

Platinum makes the most financial sense for people who use a significant amount of health care throughout the year — those with chronic conditions, regular specialist visits, ongoing prescriptions, or planned procedures. The higher premium is typically offset by dramatically lower cost-sharing on every service.

Things to consider before choosing Platinum:

• Platinum plans are less commonly available than Bronze, Silver, or Gold — not all markets offer them
• Cost-Sharing Reductions (CSR) do not apply to Platinum — CSR is Silver-only. If you’re in the 100%–250% FPL range, a CSR-enhanced Silver may actually provide comparable or better out-of-pocket performance at a lower premium
• Run a total annual cost comparison (premium + expected cost-sharing) before defaulting to Platinum based on coverage level alone

A provider network is the group of doctors, hospitals, specialists, labs, pharmacies, and other health care providers that have agreed to accept your insurance plan’s negotiated rates. Using providers in your network is almost always significantly cheaper than going outside it.

Network size and composition vary widely between plans and carriers. A narrow network plan may have lower premiums but fewer provider choices. A broad network plan offers more flexibility but typically costs more per month.

Your network affects more than just cost — it determines which providers you can see at all on certain plan types:

• HMO: In-network only (no out-of-network coverage except emergencies)
• EPO: In-network only (no out-of-network coverage except emergencies)
• PPO: In-network preferred, out-of-network covered at higher cost
• POS: In-network preferred, out-of-network covered with a referral

Before enrolling in any plan, use the insurer’s provider directory to verify that your current doctors and any specialists you see are in the network. Directories can be outdated — always call the provider’s office to confirm as well.