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Affordable Care Act – The Affordable Care Act (ACA), or Obamacare, was signed into law on March 23, 2010, with the goals of increasing access to healthcare, improving affordability and improving quality.
Catastrophic Health Insurance – Health plans that meet all of the requirements relevant to other Qualified Health Plans, however, this insurance doesn’t cover any benefits except allowing for 3 primary care visits per year before the plan’s deductible is met.
COBRA – A federal law (the Consolidated Omnibus Budget Reconciliation Act) 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. 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.
Coinsurance – Your share of the costs of a covered health care service, calculated as a percentage (forexample, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductible you owe. For example, if the health insurance plan’s allowed amount for an office visit is $200, and you have met your deductible for the year, your coinsurance payment of 20 percent would be $40. The health plan pays the rest of the allowed amount.
Copayment – A fixed amount you pay for a covered health care service, usually when you receive the service.
Claim – A request for payment that you or your health care provider submits to your health insurer when you receive items or services you believe are covered under the terms of an insurance contract or policy.
Children’s Health Insurance Program (CHIP) – Insurance program jointly funded by state and federal government that provides health coverage to low-income children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage.
Deductible – The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. The deductible may not apply to all services.
Dependent – A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help with the cost of coverage for themselves and their dependents.Dependent Coverage – Insurance coverage for family members of the policyholder, such as children, spouses, or domestic partners.Disability – A limit in a variety of major life activities. This includes everyday actions like seeing, hearing, walking, and tasks like thinking and working. Different programs may have different definitions of disability standards.
Effective Date – The date on which coverage under an insurance policy starts.
Emergency Room Care – Emergency services you get in an emergency room.
Eligibility Assessment – In some states, the Marketplace isn’t responsible for the final decision on Medicaid eligibility. Instead, the Marketplace conducts an assessment and passes the application to the State Medicaid agency to handle a final eligibility determination.
Emergency Medical Services (EMS) – Emergency care provided by ambulance personnel such as first responders, paramedics, EMTs (emergency medical technicians), or other approved individuals.
Emergency Services – Assessment of an emergency medical condition and treatment to prevent the condition from getting worse.
Exclusive Provider Organization – A managed care plan that covers services only if you see doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Flexible Benefits Plan – Also known as a Cafeteria plan or IRS 125 Plan. A benefit program that offers employees a choice between various benefits including retirement plans, life insurance, health insurance, child care, vacations and cash. Generally, a common set of benefits may be required, but you can choose how your remaining benefit dollars are to be distributed for each type of benefit from the total amount promised by the employer. Some plans allow you to contribute more for additional coverage.
Free Health Insurance – You may qualify for free or low-cost care through Medicaid based on income and family size. The health care law provides states with additional federal funding to expand their Medicaid programs to cover adults under 65 who make up to 133% of the federal poverty level. Children (18 and under) are eligible up to that income level or higher in all states.
Government Health Insurance – Health care benefits administered by a government agency through insurance coverage that provides for the payments of benefits as a result of sickness or injury.
Grandfathered Plan – 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 exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain important changes that increase costs or reduce benefits to consumers.
Group Health Plan – Basically, a health plan offered by an employer or employee group that provides health coverage to qualified employees and their families.
Health Benefits – Medical care and services that are provided under a health insurance plan.
Health Coverage or Health Insurance – Legal privilege to payment or reimbursement for all or part of your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program.
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. Except in an emergency, it usually won’t cover out-of-network services you receive. An HMO may require you to live or work in its service area to be eligible for coverage.
Health Insurance – A contract that requires your health carrier to pay some or all of your health care costs in exchange for a premium.
Health Savings Account – A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds placed in the account aren’t subject to federal income tax when they are deposited. All funds must be used to pay for qualified medical services. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
High Deductible Health Insurance – Insurance that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement agreement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
Inpatient – An individual admitted to a health care facility to receive health care services
Individual Health Insurance – Health insurance purchased by an individual rather than a group plan purchased by an employer.
Long-term Care – Health 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. Services can be provided at home, in assisted living facilities or in nursing homes. Medicare and most health insurance plans don’t cover long-term care services.
Managed Care – A system of health care used by health plan companies to control the cost of providing health care by placing limits on physicians’ fees and by restricting the patient’s choice of physicians.
Maximum Out of Pocket Cost – The highest or total amount your health insurance company requires you to pay each year towards the cost of your health care.
Medicare Advantage – A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all 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.
Medicaid – Medicaid is a federal government program to help provide healthcare coverage for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. Among those covered by Medicaid are people over 65 and those with disabilities. Eachstate runs its own version of Medicaid, with slightly different rules and coverage.
Medicare – A federal health insurance program for people who are 65 or older, certain people younger than age 65 who have disabilities, and those who have permanent kidney failure. Theprogram helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.
Medicare Part D – A Medicare program that helps pay for prescription drugs for people with Medicare who join a plan that includes prescription drug coverage.
Network – A group of facilities, providers and suppliers your health carrier or plan has contracted with to provide health care services.
Obamacare – The Affordable Care Act (ACA), or Obamacare, was signed into law on March 23, 2010, with the goals of increasing access to healthcare, improving affordability and improving quality.
Outpatient – A patient who visits a health care facility for services and leaves without staying overnight.
Open Enrollment Period – The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For coverage starting in 2015, the proposed Open Enrollment period is November 15, 2014–February 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they are affected by certain events.
Out-of-Network Copayment – A set amount you pay for receiving covered health care services from providers who don’t contract with your health insurance or plan. Out-of-network copayments are generally higher than in-network copayments.
Out-of-Pocket Costs – Your expenses for medical care that aren’t reimbursed by insurance. These include copayments, coinsurance, and deductibles for covered services in addition to all costs for services that aren’t covered.
Participating Providers – Health care providers who are under contract with an insurer or HMO.
Point of Service (POS) Plans – A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that are affiliated with the plan’s network. In order to see a specialist, a POS plan requires you to get a referral from your primary care doctor.
Pre-existing Condition Insurance Plan – A 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 the Health Insurance Marketplace, and you can no longer be discriminated against based on a pre-existing condition.
Preferred Provider Organization (PPO) – A network of medical providers that contracts with an insurer to provide services at pre-negotiated fees. You pay less if you use providers that belong to the plan’s network, however, you are allowed to choose use doctors, hospitals, and providers outside of the network for an additional cost.
Prescription Drug Coverage – Health insurance or plan that helps pay for medications and prescription drugs.
Preventive Services – Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Policy Year – Benefits coverage under an individual health insurance plan over a 12-month period. This 12-month period may not be the same as the calendar year. (Note: In group health plans, this 12-month period is called a “plan year”).
Premium – The amount that you and/or your employer pay for health insurance, usually paid monthly, quarterly or yearly.
Prescription Drugs – Drugs and medications not sold over-the-counter; by law, they require a prescription.
Primary Care – Health services that cover a variety of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants.
They may also coordinate your care with specialists.
Physician Services – Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Platinum Health Plan – Plans in the Marketplace are primarily separated into 4 health plan categories Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plan will spend, on average, is 90%. You pay about 10%.
Pre-Existing Condition – A health problem you had before the date that new health coverage starts.
Preferred Provider – A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Primary Care Physician – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Qualified Health Plan – Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows set limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other criteria. A qualified health plan will have a certification by each Marketplace in which it is sold.
Referral – A written order from your primary care doctor for you to see a specialist or get certain medicalservices. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Social Security – A system that distributes financial benefits to retired or disabled people, their spouses, and their dependent children based on their reported earnings. While you work, you may pay taxes into the Social Security system. When you retire or become disabled, you, your spouse, and your dependent children may get monthly benefits that are based on your reported earnings. Your survivors may be able to collect Social Security benefits if you die.
Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.
Self-Insured Plan – Type of plan usually found 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.
Social Security Benefits – The amount you get from Social Security Disability, Retirement (including railroad retirement), or Survivor’s Benefits each month.
Small Business Health Options Program (SHOP) – A health plan that has been certified to meet the requirements of MNsure and may be offered through MNsure.
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.
Subsidized Coverage – Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.Specialist – A physician specialist 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 non-physician specialist is a provider who has more training in a specific area of health care.
Third Party Payer – Anyone paying for the health care who is not the patient (first party) or the caregiver (second party).
Underinsured – People with inadequate health insurance that does not cover all necessary medical care.
Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Worker’s Compensation – An insurance plan that employers are required to have to cover employees who get sick or injured on the job. 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.