The Affordable Care Act or the ACA (formally known as the Patient Protection and Affordable Care Act and informally as Obamacare) is landmark health reform legislation signed into law in March 2010. Key areas of the ACA are intended to help millions of uninsured Americans get insurance, implement measures that will lower healthcare costs and improve system efficiency. The ACA also makes it illegal to end or deny insurance due to pre-existing conditions.

An agent is a broker (insurance producer) appointed by an insurance company to act on the insurance company’s behalf. Insurance companies pay commissions to agents for selling their insurance policies to customers.

An annual limit is a limit on how much your health plan will pay for something in a year. Limits are sometimes placed on particular services, such as prescriptions or physical therapy treatments. Limits can also be placed on the dollar amount or on the number of visits. After an annual limit is reached, you must pay all related healthcare costs for the rest of the year.

An authorized representative is a person or organization who a customer optionally authorizes to act on their behalf when interacting with Access Health CT. This person or organization can help with insurance enrollment and applications, can contact the call center on your behalf and can help manage your account. This person or organization should be someone you trust to manage your health insurance and could be a spouse, parent, family member, social worker or case manager, broker, attorney, Power of Attorney, etc.

Catastrophic Plans are available to people younger than 30 years old or to those who have been granted a hardship or affordability exemption from Access Health CT. You are not eligible to get financial help to pay for Catastrophic Plans, but you can use these plans with Health Savings Accounts (HSAs). These plans have low monthly premiums and provide the lowest level of coverage but require you to pay out-of-pocket for most routine medical care until you meet the high annual deductible. 

The Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for administering several health-related government programs. They oversee Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the federal Health Insurance Marketplace, the Health Insurance Portability and Accountability Act (HIPAA), the Clinical Laboratory Improvement Amendments and several other health programs. CMS also establishes standards for healthcare providers that must be met for providers to keep certain certifications.

The Children’s Health Insurance Program (CHIP) is an insurance program funded by federal and state governments that provides health insurance to low-income children up to age 19. In Connecticut, this program is referred to as HUSKY B.

A claim is a request for payment that you or your healthcare provider submits to your health insurance company when you get items or services.

Coinsurance is a percentage of costs you pay for covered healthcare services after you have paid your deductible.

A copayment (copay) is a fixed amount (for example, $15) that you pay for a covered healthcare service, usually when you receive the service. The dollar amount can vary by the type of service.

A Cost Sharing Reduction (CSR) lowers the amount you pay out-of-pocket for deductibles, coinsurance and copayments when you get medical services. If you qualify for a CSR, you must enroll in a Silver Plan to lower your costs.

Creditable coverage is one of the following forms of coverage: A group health plan, an individual health plan, a student health plan, Medicare, Medicaid, TRICARE, Federal Employees Health Benefits Program, Indian Health Service, Peace Corps, a public health plan (such as those from the U.S. government, a state government or a foreign country), Children’s Health Insurance Program (CHIP), or a state health insurance high risk pool plan.

A deductible is an amount you pay for covered healthcare services before your insurance plan starts to pay. It may not apply to all services.

A dependent is a spouse, child or other qualifying household member covered under a primary applicant’s insurance plan.

Dependent coverage refers to insurance coverage for qualifying household members of a primary applicant/policyholder, such as a spouse, child or partner.

The Federal Poverty Level (FPL) is a measure of income issued every year by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine eligibility for certain programs and benefits, including financial help for health insurance offered by Access Health CT, and eligibility for Medicaid and CHIP coverage.

Health Reimbursement Accounts (HRAs) are accounts funded by employers. Employees are reimbursed tax-free for their qualified medical expenses, up to a set amount. Money may be rolled over and used in the next year. Employers fund and own HRAs.

Health Savings Accounts (HSAs) allow you to set aside money on a pre-tax basis to pay for qualified medical expenses. All Bronze and Catastrophic Plans through Access Health CT are eligible to be used with HSAs.

A High-Deductible Health Plan (HDHP) is a plan that requires you to pay more for healthcare services before your insurance company begins to pay. HDHPs can be combined with Health Savings Accounts or Health Reimbursement Accounts to allow enrollees to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

Your insurance company has contracted with a network of hospitals, providers and suppliers to provide services at a lower cost compared to the costs of services provided by out-of-network hospitals, providers, and suppliers. You can find out if a provider is in-network using the online provider directory provided by your insurance company or by contacting your insurance company.

Medicaid is a state-administered health insurance program for low-income individuals, children, parents and people with disabilities. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. In Connecticut, the Department of Social Services (DSS) administers HUSKY Health, which includes Medicaid and the Children’s Health Insurance Program (CHIP). Access Health CT processes applications for HUSKY Health, but only HUSKY A, B and D. HUSKY C applications are processed by DSS. HUSKY A is Medicaid for children, teens, parents, relative caregivers and pregnant women; HUSKY B is the Children’s Health Insurance Program for children and teens up to age 19; HUSKY C is Medicaid for adults 65 and older and adults with disabilities, including long-term services and supports and Medicaid for Employees with Disabilities; and HUSKY D is Medicaid for low-income adults without dependent children.

Medicare is a federal health insurance program for people who are age 65 or older and for certain younger people with disabilities. Medicare offers broad coverage — Part A is insurance for hospitalization, home or skilled nursing, and hospice; Part B is medical insurance; Part C (Medicare Advantage Plans) is a private insurance option for covering hospital and medical costs; and Part D covers prescription drugs. Part C can supplement Parts A and B, and sometimes D.

Minimum Essential Coverage (MEC) is a type of health insurance that meets federal and state standards. It can include employer-sponsored health plans, health plans through Access Health CT, and Medicare, Medicaid, Children’s Health Insurance Program and TRICARE coverage. There is no current federal tax penalty for not having Minimum Essential Coverage. To sign up for health insurance outside of Open Enrollment, you may need to show proof you had MEC for at least one of the 60 days before your Special Enrollment Period begins.

Modified Adjusted Gross Income (MAGI) is used to determine your eligibility for financial help to lower the cost of a health plan through Access Health CT. It is defined by the Internal Revenue Service (IRS) and may be similar to your Adjusted Gross Income (AGI). To calculate MAGI, add untaxed foreign income, non-taxable Social Security benefits and tax-exempt interest to your AGI. Income is counted for you, your spouse and everyone you’ll claim as a tax dependent on your federal income tax return. When calculating your MAGI for financial help, you’ll want to estimate the amount for the year in which you need insurance. If your household income or MAGI estimate changes during the year, you must let Access Health CT know right away.

The Open Enrollment Period is an annual period of time, usually beginning November 1, when you can enroll in or renew health and dental insurance through Access Health CT for the next year. Open Enrollment Periods can differ between states and insurance types.

Out-of-pocket costs are expenses for medical care that are not reimbursed by your insurance company. These costs include deductibles, coinsurance and copayments for covered services, plus all other costs for services that are not covered by your plan.

A premium is an amount you pay for your health insurance plan to your insurance company every month.

Preventive services include annual check-ups, immunizations, patient counseling and screenings. Preventive services are an Essential Health Benefit that do not count toward your deductible and are covered under all health plans offered through Access Health CT.

A primary care physician is a medical professional who provides, coordinates or helps a patient with a range of healthcare services. A primary care physician is most often your general practitioner or family doctor.

A Qualified Health Plan (QHP) is a health insurance plan that is certified by Access Health CT, provides Essential Health Benefits, follows established limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts) and meets other coverage requirements.

A Qualifying Life Event (QLE) is a change in your life — like losing health insurance, getting married, having a baby or moving to Connecticut — that can make you eligible for a Special Enrollment Period. A Special Enrollment Period allows you to enroll in health or dental insurance outside the yearly Open Enrollment Period.

A Special Enrollment Period (SEP) is a special window of time during the year when you can enroll in health or dental insurance through Access Health CT. To get a Special Enrollment Period, you must prove that you have a Qualifying Life Event such as marriage, the birth of a child, the loss of insurance through a job or a move to Connecticut. You will typically have 60 days from the date of that event to enroll in health or dental insurance.

A specialist is a doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.