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Glossary

Overview

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Glossary

Accountable Care Organization

A group of health care providers who give coordinated care and chronic disease management, thereby improving the quality of care patients receive. The organization’s payment is tied to achieving health care quality goals and outcomes that result in cost savings.

Glossary

Actuarial Value

The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70 percent, on average you would be responsible for 30 percent of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year depending on your actual health care needs and the terms of your insurance policy.

Glossary

Affordable Care Act

The comprehensive health care reform law enacted in March 2010, also referred to as ‘Obamacare’. 

Glossary

Affordable Coverage

Affordable coverage is health insurance that costs no more than 9.5 percent of the insured’s income for the tax year. 

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Allowed Charge

Discounted fees that insurers will recognize and pay for covered services. Insurers negotiate these discounts with providers in their health plan network, and network providers agree to accept the allowed charge as payment in full. Each insurer has its own schedule of allowed charges.

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Annual Limit

A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.

Overview

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Glossary

Benefits

The health care items or services covered under a health insurance plan. 

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Biosimilar Biological Products

The generic version of more complicated medications.

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Care Coordination

The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.

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Catastrophic Plan

Plans with a high deductible, so that your plan begins to pay only after you’ve first paid up to a certain amount for covered services.

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Children’s Health Insurance Program (CHIP)

Insurance program jointly funded by state and Federal government that provides health insurance to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage.

Glossary

Chronic Disease Management

An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment and patient education. If you have a chronic disease, this approach can improve your quality of life while reducing your health care costs by preventing or minimizing the effects of the disease.

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Claim

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

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Co-insurance

The percentage of allowed charges for covered services that you’re required to pay. For example, the health insurance may cover 80 percent of charges for a covered hospitalization, leaving you responsible for the other 20 percent. This 20 percent is known as the co-insurance.

Glossary

COBRA

A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event occurs. If you elect COBRA coverage, you pay 100 percent of the premiums, including the share the employer used to pay, plus a small administrative fee.  Because of the subsidies available, Covered California plans may be cheaper than COBRA coverage. 

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Community Rating

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

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Competitive Bidding

Open bidding for federal contracts between independent groups that compete for the contract by providing the best bid.

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Conversion

The ability, in some states, to switch your job-based coverage to an individual policy when you lose eligibility for job-based coverage. Family members not covered under a job-based policy may also be able to convert to an individual policy if they lose dependent status (for example, after a divorce).

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Copayment

A flat dollar amount you must pay for a covered program. For example, you may have to pay a copayment for each covered visit to a primary care doctor.

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Cost Sharing

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

Glossary

Creditable Coverage

Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government or a foreign country); Children’s Health Insurance Program (CHIP); or a state health insurance high-risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.

Overview

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Glossary

Deductible

The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. For example, under one plan a comprehensive deductible might apply to all services, while another plan might have separate deductibles for benefits such as prescription drug coverage.

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Dependent Coverage

Insurance coverage for family members of the policyholder, such as spouses, children or partners.

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Dependents

Children up to age 26.

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Disability

A limit in a range of major life activities. This includes activities like seeing, hearing and walking and tasks like thinking and working. Because different programs may have different disability standards, please check the program you’re interested in for its disability standards.

The list of activities mentioned above isn’t exhaustive. A legal definition of disability can be found here. For the proposed EEOC ADA Amendments Act regulations and related resources, see http://edocket.access.gpo.gov/2009/E9-22840.htm.

 

Glossary

Donut Hole, Medicare Prescription Drug

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Overview

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Glossary

Early Periodic Screening, Diagnostic & Treatment Services (EPSDT)

A term used to refer to the comprehensive set of benefits covered for children in Medicaid.

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Emergency Room Services

Evaluation and treatment of an illness, injury or condition that needs immediate medical attention in an emergency room.

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Employer Responsibility

The health care law does not require employers to provide health insurance for their employees. However, employers with 50 to 99 or more full-time employees that do not offer insurance or offer insurance that is unaffordable will be subject to fees beginning January 1, 2016.  Those with 100 or more full time equivalent employees will face fees beginning January 1, 2015 if they do not offer coverage to at least 70 percent of their full time workforce. 

Glossary

Essential Health Benefits

A set of health care service categories that must be covered by certain plans, starting in 2014.

The Affordable Care Act defines essential health benefits to “include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.”

Insurance policies must cover these benefits in order to be certified and offered in Marketplaces, and all Medicaid State plans must cover these services by 2014. Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014. The Department of Health and Human Services is working with a number of partners to develop the essential health benefits package. In the fall of 2011, HHS launched an effort to collect public comments and heard directly from many Americans who were interested in sharing their thoughts on this important issue. 

Glossary

Exchange

A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Marketplaces will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Marketplaces and you will be able buy your insurance through Marketplaces too.

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Exclusions

Items or services that aren’t covered under your contract for insurance and which an insurance company won’t pay for. For example, your policy may not cover pregnancy care or any services related to a pre-existing condition.

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Exclusive Provider Organization (EPO) Plan

A managed care plan where services are covered only if you go to doctors, specialists or hospitals in the plan’s network (except in an emergency).

Overview

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Glossary

Family and Medical Leave Act (FMLA)

A Federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.

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Federal Poverty Level (FPL)

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

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Federally Qualified Health Center (FQHC)

Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.

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Fee for Service

A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.

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Flexible Benefits Plan

A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage. Also known as a Cafeteria Plan or IRS 125 Plan.

Glossary

Flexible Spending Account (FSA)

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.

Glossary

Formulary

A list of drugs your insurance plan covers. A formulary may include how much you pay for each drug. (If the plan uses “tiers,” the formulary may list which drugs are in which tiers.) Formularies may include both generic drugs and brand-name drugs.

Glossary

Full-Time Employee

An employee who is employed an average of at least 30 “hours of service” per week.

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Fully Insured Job-based Plan

A health plan purchased by an employer from an insurance company.

Overview

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Glossary

Grandfathered

As used in connection with the Affordable Care Act: Exempt from certain provisions of this law.

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Grandfathered Health Plan

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

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Guaranteed Issue

A requirement that health plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn’t limit how much you can be charged if you enroll.

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Guaranteed Renewal

A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Except in some states, guaranteed renewal doesn’t limit how much you can be charged if you renew your coverage.

Overview

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Glossary

Health Care Workforce Development

The use of incentives and recruiting to encourage people to enter into health care professions such as primary care and to encourage providers to practice in underserved areas.

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Health Maintenance Organization (HMO)

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Glossary

Health Savings Account (HSA)

A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit.

Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.

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Health Status

Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability and disability.

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High Deductible Health Plan

A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

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High-Cost Excise Tax

Under the Affordable Care Act starting in 2018, a tax on insurance companies that provide high-cost plans. This tax encourages streamlining of health plans to make premiums more affordable.

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High-Risk Pool Plan (State)

Similar to the new Pre-Existing Condition Insurance Plan under the Affordable Care Act, for years many states have offered plans that provide coverage if you have been locked out of the individual insurance market because of a pre-existing condition. High-risk pool plans may also offer coverage if you’re HIPAA eligible or meet other requirements. High-risk pool plans offer health insurance coverage that is subsidized by a state government. Typically, your premium is up to twice as much as you would pay for individual coverage if you were healthy.

Glossary

HIPAA Eligible Individual

Your status once you have had 18 months of continuous creditable health coverage. To be HIPAA eligible, at least the last day of your creditable coverage must have been under a group health plan; you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare or Medicaid; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. When you’re buying individual health insurance, HIPAA eligibility gives you greater protections than you would otherwise have under state law.

Glossary

Home and Community-Based Services (HCBS)

Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing. This care is covered when provided by care workers or, if your state permits it, by your family.

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Home Health Care

Health care services and supplies a doctor decides you may get in your home under a plan of care established by your doctor.

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Hospital Readmissions

A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn’t properly organized, or that you weren’t fully treated before discharge.

Overview

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Glossary

Individual Health Insurance Policy

Policies for people that aren’t connected to job-based coverage. Individual health insurance policies are regulated under state law.

Glossary

Individual Responsibility

Under the Affordable Care Act, starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay an assessment. You won’t have to pay an assessment if you have very low income and coverage is unaffordable to you, or for other reasons including your religious beliefs. You can also apply for a waiver asking not to pay an assessment if you don’t qualify automatically.

Glossary

Insurance Co-Op

A non-profit entity in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state or local level, and can include doctors, hospitals and businesses as member-owners.

Overview

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Glossary

Job-based Health Plan

Coverage that is offered to an employee (and often his or her family) by an employer.

Overview

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Glossary

Large Employers

For purposes of employer responsibility, a “large employer” is defined as an employer that employed an average of at least 50 full-time or full-time equivalent (FTE) employees on business days during the preceding calendar year.  This is determined based on the actual hours employees worked during the prior calendar year. 100 half-time employees are considered equivalent to 50 full-time employees.

Glossary

Lifetime Limit

A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

Glossary

Long-Term Care

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

Overview

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Glossary

Marketplace

A transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Marketplaces will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Marketplaces and you will be able buy your insurance through Marketplaces too.

Glossary

Medicaid

A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities and in some states, other adults. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.

Glossary

Medical Loss Ratio (MLR)

A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80 percent. A medical loss ratio of 80 percent indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses such as marketing, profits, salaries, administrative costs and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

Glossary

Medical Underwriting

A process used by insurance companies to try to figure out your health status when you’re applying for health insurance coverage in order to determine whether to offer you coverage, at what price and with what exclusions or limits.

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Medically Necessary

Services or supplies that are needed for the diagnosis or treatment of your health condition and meet accepted standards of medical practice.

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Medicare

A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Glossary

Medicare Advantage (Medicare Part C)

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all of your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Glossary

Medicare Hospital Insurance Tax

A tax under the Federal Insurance Contributions Act (FICA) that is a United States payroll tax imposed by the Federal government on both employees and employers to fund Medicare.

Glossary

Medicare Part D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

Glossary

Medicare Prescription Drug Donut Hole

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Glossary

Minimum Essential Coverage

The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage. Minimum essential coverage refers to health insurance coverage under an insured or self-insured group health plan, which does not include “excepted benefit” coverage.  Coverage provides “minimum value” if it covers at least 60 percent of the total allowed cost of benefits provided under the plan as determined using the HHS and IRS minimum value calculator.

Overview

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Glossary

New Plan

As used in connection with the Affordable Care Act: A health plan that is not a grandfathered health plan and therefore subject to all of the reforms in the Affordable Care Act.

In the individual health insurance market, a plan that your family is purchasing for the first time will generally be a new plan.

In the group health insurance market, a plan that your employer is offering for the first time will generally be a new plan. Please note that new employees and new family members may be added to existing grandfathered group plans – so a plan that is “new to you” and your family may still be a grandfathered plan.

In both the individual and group markets, a plan that loses its grandfathered status will be considered a new plan. A plan loses its grandfathered status when significant changes are made to the plan, such as reducing benefits or increasing cost-sharing for enrollees.

A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

Glossary

Nondiscrimination

A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can’t be charged more because of your health status. Job-based plans can restrict coverage based on other factors that aren’t related to health status such as part-time employment.

Overview

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Glossary

Open Enrollment Period

The period of time set up to allow you to choose from available plans, usually once a year.

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Out-of-Pocket Costs

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance and copayments for covered services plus all costs for services that aren’t covered.

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Out-of-Pocket Limit (OOP)

The maximum amount you will have to pay for covered services in a year. Generally, this includes the deductible, coinsurance and copayments. This definition may vary from plan to plan. For example, in some plans the out-of-pocket limit doesn’t include cost sharing for all services, such as prescription drugs. Plans may have different out-of-pocket limits for different services. In Medicaid and CHIP, the limit includes premiums.

Overview

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Glossary

Patient Protection and Affordable Care Act

In March 2010, Congress passed and the President signed into law the Patient Protection and Affordable Care Act (PPACA), making sweeping changes to the U.S. health care system. These changes put in place comprehensive health insurance reforms that aim to hold insurance companies accountable, lower health care costs, create more choice and flexibility and enhance the quality of care for you and your employees.

Read the entire law

Glossary

Patient-Centered Outcomes Research

Research that compares different medical treatments and interventions to provide evidence on which strategies are most effective in different populations and situations. The goal is to empower you and your doctor with additional information to make sound health care decisions.

Glossary

Payment Bundling

A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors and reducing unnecessary or duplicative tests and treatments.

Glossary

Plan Year

A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).

Glossary

Point-of-Service Plan (POS) Plan

A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

Glossary

Policy Year

A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer. (Note: In group health plans, this 12-month period is called a “plan year”).

Glossary

Pre-Existing Condition (Individual Policy)

A condition, disability or illness (either physical or mental) that you have before you’re enrolled in a health plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. This term is defined under state law and varies significantly by state.

Glossary

Pre-Existing Condition (Job-based Coverage)

Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.

Glossary

Pre-Existing Condition Exclusion Period (Individual Policy)

The time period during which an individual policy won’t pay for care relating to a pre-existing condition. Under an individual policy, conditions may be excluded permanently (known as an “exclusionary rider”). Rules on pre-existing condition exclusion periods in individual policies vary widely by state.

Glossary

Pre-Existing Condition Exclusion Period (Job-based Coverage)

The time period during which a health plan won’t pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.

Glossary

Pre-existing Condition Insurance Plan (PCIP)

A new program that will provide a health coverage option for you if you have been uninsured for at least six months, you have a pre-existing condition, and you have been denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. This program will provide coverage until 2014 when you will have access to affordable health insurance choices through a Marketplace, and you can no longer be discriminated against based on a pre-existing condition.

Glossary

Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

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Premium

A monthly payment you make to your insurer to get and keep insurance coverage. Premiums can be paid by employers, unions, employees or individuals or shared among different payers.

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Prevention

Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

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Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Learn more about preventative care and services.

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Pricing Information

HealthCare.gov’s Insurance Finder tool provides price estimates and detailed benefit information for private health insurance plans.

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Primary Care

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

Glossary

Public Health

A field that seeks to improve lives and the health of communities through the prevention and treatment of disease and the promotion of healthy behaviors such as healthy eating and exercise.

Overview

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Glossary

Qualified Health Plan

Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by a Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

Overview

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Glossary

Rate Review

A process that allows state insurance departments to review rate increases before insurance companies can apply them to you.

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Reinsurance

A reimbursement system that protects insurers from very high claims. It usually involves a third party paying part of an insurance company’s claims once they pass a certain amount. Reinsurance is a way to stabilize an insurance market and make coverage more available and affordable.

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Rescission

The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.

Glossary

Rider (exclusionary rider)

A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy.) In most states today, an exclusionary rider is an amendment, permitted in individual health insurance policies that permanently excludes coverage for a health condition, body part, or body system. Starting in September 2010, under the Affordable Care Act, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.

Glossary

Risk Adjustment

A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs.

Overview

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Glossary

Self-Insured Plan

Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.

Glossary

Skilled Nursing Facility Care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Glossary

Special Enrollment Period

A time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other job-based health coverage.

Glossary

Special Health Care Need

The health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.

Glossary

State Continuation Coverage

A state-based requirement similar to COBRA that applies to group health insurance policies of employers with fewer than 20 employees. In some states, state continuation coverage rules also apply to larger group insurance policies and add to COBRA protections. For example, in some states, if you’re leaving a job-based plan, you must be allowed to continue your coverage until you reach the age of Medicare eligibility.

Overview

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Glossary

Uncompensated Care

Health care or services provided by hospitals or health care providers that don’t get reimbursed. Often uncompensated care arises when people don’t have insurance and cannot afford to pay the cost of care.

Overview

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Glossary

Value-Based Purchasing (VBP)

Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.

Overview

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Glossary

Waiting Period (Job-based coverage)

The time that must pass before coverage can become effective for an employee or dependent, who is otherwise eligible for coverage under a job-based health plan.

Glossary

Well-baby and Well-child Visits

Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

Glossary

Wellness Programs

A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.

Commands