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Health Care Form Glossary

A
Adverse Selection
In health care, a tendency for only the most ill to sign up for health insurance. When insurers are not able to charge sick people more or exclude preexisting conditions, premiums increase for all consumers over time. This may cause fewer healthy people to get insurance and increase the impacts adverse selection.
A
Affordable Care Act (ACA)
The comprehensive health care reform law enacted in March 2010. Also known as “Obamacare.”
A
Affordable Coverage
With regard to employer sponsored insurance, an individual employee's premium contribution (for self-only coverage) cannot exceed 9.5% of his or her household income.
C
Capitation
An alternate method of paying for health care where providers receive a set payment for each person assigned to them, instead of payment per service provided. Payments can be adjusted based on demographics, expected costs of the members, or other factors.  
C
Case Management
The process of medical providers working together to provide high quality care. Case management (sometimes called “care management”) is generally used for patients with high health care needs. Case managers may be doctors, nurses, social workers, or other health care professionals.
C
Children’s Health Insurance Program (CHIP)
Insurance program funded by both state and federal government that provides health insurance to low-income children and, in some states, pregnant women.
C
Co-insurance
The percentage of charges you pay when you receive a covered service. Your health insurance pays the rest.
C
Co-payment
A fixed dollar amount you pay when you receive certain covered services or prescriptions. Your health insurance pays the rest of the fee.
C
Consolidated Omnibus Budget Reconciliation Act (COBRA)
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is 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. With COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
C
Cost-sharing
The percentage, or “share,” of fees that you pay for covered services. Cost-sharing can include deductibles, co-payments and co-insurance.
C
Health Insurance (also referred to as “coverage” or “plan”)
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium you pay or your employer pays to the insurance company.
D
Deductible
The amount you pay for covered services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan will not begin to pay for services until you have  paid $1,000 for qualified services.
D
Dependent
A family member, such as your spouse, child or partner, who is covered under your health insurance plan.
D
Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a gap in coverage called a "donut hole."  After you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs for your prescriptions until you reach a yearly limit. Then, your drug plan resumes helping you pay for covered prescriptions.
E
Essential Health Benefits
Health benefits, items and services that must be covered by individual and small group health plans beginning in 2014. These essential health benefits must include items and services within at least the following 10 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.
F
Federal Poverty Level
A level of income defined each year by the Department of Health and Human Services. A family’s income compared to the Federal Poverty Level is used to determine eligibility for Medicaid, health insurance tax credits, and other programs and benefits.
F
Flexible Spending Account (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses, such as insurance co-payments and deductibles, and qualified prescription drugs, insulin and medical devices. You don’t have to pay taxes on this money, and employers may permit employees to carryover up to $500 of unspent funds to the next year.
G
Grandfathered Plan
A group health plan that was created — or an individual health insurance policy that was purchased — on or before March 23, 2010 and that has made only small changes since. These plans do not have to meet many of the requirements of the Affordable Care Act.
G
Guaranteed Issue
A requirement that health plans permit you to enroll regardless of your health status, age, gender or other factors.
H
Habilitative Services
Health care services, such as physical, speech or occupational therapy, that help people of all ages maintain or improve their functioning for daily living.
H
Health Care Reform
A term used to describe both the health policy changes put in place by the federal Affordable Care Act of March 2010 and any state laws passed to implement the Act.
H
Health Information Technology
Systems and technologies that allow medical providers to gather, share, and store medical information electronically. This process improves the efficiency of health care.
H
Health Insurance (also referred to as “coverage” or “plan”)
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium you pay or your employer pays to the insurance company.
H
Health Insurance Marketplace (also called Health Insurance Exchange)
Web-based “insurance mall” where individuals and small businesses can research, compare and enroll in health plans. Visitors can also learn if they are eligible for free or discounted plans, tax credits or other financial help.
H
Health Savings Account (HSA)
A Health Savings Account (HSA)  is  a medical savings account for people enrolled in a high-deductible health insurance plan. HSA funds are not subject to federal income tax at the time of deposit and they roll over year to year.  
H
Health Status
A term that includes factors such as a person’s medical conditions, medical history, past use of insurance and health care services and genetic information, among others.
H
High Deductible Health Plan
A type of health insurance plan that has higher deductibles than traditional plans. These plans can be combined with a health savings account to help participants pay the deductible on a pre-tax basis.
L
Large Employer
In general, the Affordable Care Act defines a “large business” as one with more than 50 full-time equivalent employees.
L
Long-Term Care
Services provided over a long period of time to those who can no longer care for themselves. These include both medical and non-medical services, and can be provided at home, in an assisted living facility, or in a nursing home. Medicare and most health insurance does not cover long-term care.
M
Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a gap in coverage called a "donut hole."  After you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs for your prescriptions until you reach a yearly limit. Then, your drug plan resumes helping you pay for covered prescriptions.
M
Managed Care
A type of health care that aims to control health care costs and improve the quality of care that patients receive. A managed care organization may require consumers to use only in-network providers and receive authorization for advanced treatment.
M
Medicaid
An insurance program for low-income families and individuals. Medicaid is funded by both state and federal governments and managed by the states.
M
Medicare
An insurance program run by the federal government for people age 65 and older and individuals with disabilities.
M
Minimum Value
Insurance that covers at least 60% of costs for a standard population.
M
Modified Adjusted Gross Income (MAGI)
A definition of income created by the Affordable Care Act (ACA) to evaluate eligibility for insurance tax credits and Medicaid. The calculation takes into account family size and income from all family members.
N
Network
All the hospitals, doctors, facilities, service providers and suppliers who are under contract with your insurance company to provide health care services to you.
O
Obamacare
Term used to reference the Affordable Care Act (ACA) and health care reform.
O
Open Enrollment Period
The period of time, usually once a year, when you are allowed to enroll in a new health plan.
O
Out-of-network
All the hospitals, doctors, facilities, service providers and suppliers who are not under contract with your insurance company. If you receive services out-of-network, you may have to pay for some or all of the costs yourself.
O
Out-of-pocket Expenses
These are payments you make—in addition to premium payments—to cover part or all of the costs for health care services. This includes co-payments, co-insurance and deductible payments.
P
Health Insurance (also referred to as “coverage” or “plan”)
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium you pay or your employer pays to the insurance company.
P
Play or Pay
Term used to describe the requirement that employers offer their employees’ affordable health care coverage beginning in 2015 or pay a penalty to the government. In general, this applies to businesses with more than 50 full-time equivalent employees.
P
Pre-existing Conditions
Medical conditions, such as diabetes, asthma or cancer, that people have before or when they enroll in a new health insurance policy.
P
Premium
The fee that is paid to your health insurance company or plan. You and/or your employer will usually pay it monthly, quarterly or yearly.
P
Preventive Services
Screenings, lab tests, “well exams” and patient counseling that help you prevent or delay illnesses, disease and other health problems.
R
Reinsurance
Insurance that protects insurers from very high claims. It usually involves a third party who guarantees payment for claims above a certain level. Reinsurance stabilizes the insurance market by making insurers more financially secure.
S
Subsidy
Financial assistance the government will give to eligible individual and families in the form of an advance tax credit, to help them buy health insurance coverage.
S
Summary of Benefits and Coverage
A plain-language summary of what an insurance plan covers—and does not cover. The Affordable Care Act requires insurance companies to provide this to members and prospective members during open enrollment or upon request.
T
Tax Credit
A tax credit is a reduction in the amount of tax a person or family owes. It can be given as a refund when taxes are filed, or given in advance, such as to help pay for health insurance purchased through the Marketplace.
T
Transitional Policy Fix
Permits states and insurers to grant individuals the ability to re-enroll or renew health insurance plans that were cancelled, which could extend the life of non-ACA compliant health plans through as late as September 30, 2017.
W
Well-baby and Well-child Visits
Routine doctor visits that occur during a child’s first years of life and annual visits until age 21. These visits include physical exams, measurements, vision and hearing screenings and oral health risk assessments.