Glossary of Terms
Affordable Care Act (ACA)
Affordable Care Act or ACA (also known as the Patient Protection and Affordable Care Act or Obamacare) and is the landmark health reform legislation signed into law in March 2010. Key provisions are intended to extend coverage to millions of uninsured Americans, implement measures that will lower health care costs and improve system efficiency, and eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.
An agent is a state-licensed individual or entity representing one or more insurance companies. An agent solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer.
A limit on the benefits your health plan will pay in a year. Limits are sometimes placed on particular services, such as prescriptions or physical therapy treatments. They 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 health care costs for the rest of the year.
An authorized representative is a person who has been designated in the Exchange to act on someone else’s behalf.
A broker is a licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer but is paid a commission by the insurance company.
Catastrophic plans are available to people younger than 30 years old or to those who have been granted a hardship or affordability exemption. You are not eligible to get financial help to pay for catastrophic plans. These plans have low monthly premiums and provide the lowest level of coverage. Catastrophic plans offer protection when healthcare costs near or reach annual out-of-pocket cost maximums.
Centers for Medicare and Medicaid Services (CMS)
Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for administering Medicare, Medicaid, State Children’s Health Insurance, Health Insurance Portability and Accountability Act, Clinical Laboratory Improvement Amendments, and several other health-related programs. CMS also establishes standards for healthcare providers that must be complied with in order for providers to meet certain certification requirements.
Children’s Health Insurance Program (CHIP)
CHIP is an insurance program funded by state and Federal government that provides health insurance to low-income children. In Connecticut, this program is referred to as HUSKY B.
A claim is a request for payment that you or your health care provider submits to your health insurer when you get items or services.
A co-payment 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.
Cost-Sharing Reduction (CSR) lowers the amount you pay out-of-pocket for deductibles, co-insurance and co-payments when you get medical services. If you qualify for CSR, you must enroll in a Silver level plan to get these lower costs.
Credible coverage is one of the following plans: group health plan, individual health plan, student health plan, Medicare, Medicaid, CHAMPUS and TRICARE, Federal Employees Health Benefits Program, Indian Health Service, Peace Corps, public health plan (such as those from the US Government, or a state government, or a foreign country), or Children’s Health Insurance Program (CHIP)
The deductible is the 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 family member of the household obtaining health coverage under the primary applicant’s insurance plan
Dependent coverage refers to insurance coverage for family members of the policyholder, such as a spouse, child, or partner.
Essential Health Benefits
All qualified health plans (QHP) offered through Access Health CT provide the same set of 10 Essential Health Benefits. While the benefits may cost more or less in different plans at different levels, you can be assured that all plans will provide:
- Preventive and wellness services and chronic disease management
- Pediatric services
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency room coverage
- Hospitalization (such as surgery)
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance abuse services, including behavioral health treatment (includes counseling and psychotherapy)
- Prescription drug coverage
- Rehabilitation and Habilitation services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory service coverage
Federal Poverty Level (FPL)
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 your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
Health Reimbursement Account (HRA)
Health Reimbursement Accounts are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account.
Health Savings Account (HSA)
Health Savings Accounts (HRA) allow you to set aside money on a pre-tax basis to pay for qualified medical expenses if you have a high deductible health insurance plan.
High Deductible Health Plan (HDDP)
A High Deductible Health Plan (HDHP) is plan that requires higher deductibles than other plans. These 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.
Your insurance company has contracted with hospitals, providers and suppliers to provide services at a lower cost. You can find out if a provider is in-network using the online provider directory or by contacting your insurance company.
Medicaid is 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.
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 covers hospital insurance; Part B is medical insurance and Part D covers prescription drugs. Part C can supplement Part A, B and sometimes D.
Minimum Essential Coverage (MEC)
Minimum Essential Coverage (MEC) is 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, Children’s Health Insurance Program, TRICARE, and certain other coverage.
Modified Adjusted Gross Income (MAGI)
Modified Adjusted Gross Income (MAGI) is defined by the Internal Revenue Service (IRS). Calculations include determination of MAGI with respect to federal poverty level and other considerations such as pregnancy, children, children’s age, and whether the applicant is a caretaker for other dependents.
Open Enrollment Period
The period of time, usually from November 1 – January 15, when you can enroll or renew in qualified health plans (QHP) through Access Health CT. Open Enrollment Periods can differ between states and coverage types.
Out-of-pocket costs are expenses for medical care that are not reimbursed by your insurance company. These costs include deductibles, co-insurance, and co-payments for covered services plus all costs for services that are not covered.
The Maximum-Out-Of-Pocket (MOOP) also known as out-of-pocket limits, is the most you will pay during a policy period (usually a year) before your health plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or services your plan does not cover. Some health plans do not count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. For HUSKY Health Program (Medicaid/Children’s Health Insurance Program), the limit does include premiums.
Point-of-Service (POS) Plan
A Point-of-Service Plan (POS) type offers discounted services if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. POS plans may require you to get a referral from your primary care doctor in order to see a specialist.
Preferred Provider Organization (PPO) Plan
A Preferred Provider Organization plan (PPO) 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 usually use doctors, hospitals, and providers outside of the network for an additional cost.
The amount you pay for your health insurance plan to the insurance company every month.
Premium Tax Credit (PTC)
Premium Tax Credits (PTC) also called Advanced Premium Tax Credits (APTC) can be distributed monthly or when you file your taxes. Most customers receive APTC and it is sent directly to the insurance company from the federal government. To qualify for an APTC, you:
- Cannot be eligible for other affordable healthcare coverage through your employer or a government program, such as Medicaid
- Must be a Connecticut resident and a citizen or lawful resident of the United States, and not in prison (other than pending fi nal disposition of charges)
- Must enroll in coverage through Access Health CT
- Meet income requirements based on your Modified Adjusted Gross Income (MAGI)
These services include annual check-ups, immunizations, patient counseling, and screenings. Preventive services are an Essential Health Benefit and covered under plans offered through Access Health CT.
Primary Care Physician (PCP)
A doctor who provides, coordinates or helps a patient access a range of health care services.
Qualified Health Plan (QHP)
An insurance plan that is certified by Access Health CT, provides Essential Health Benefits, follows established limits on cost -sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meets other requirements.
Qualifying Life Event (QLE)
A Qualifying Life Event (QLE) is a change in your life — like losing health coverage, getting married, having a baby or moving to Connecticut— that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.
Special Enrollment Period (SEP)
A Special Enrollment Period (SEP) is a special window of time during the year when you can enroll in health insurance through Access Health CT. To get a Special Enrollment Period, you must prove that you have a Qualifying Life Event – and you will have 60 days from the date of that event begin your application process.
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.
A tiered network divides hospitals and doctors into groups, based on information about the quality of their care and the costs of their services. What you pay is based on the tier of the provider.
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