Health Care Dictionary

Advance premium tax credit

A tax credit that can help you lower the cost of your plan in the Health Insurance Marketplace. These tax credits can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you are due, you will get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

Affordable Care Act (ACA), also known as Obamacare

A law passed in 2010 that made many changes in how Americans get health insurance. It created a website, the Health Insurance Marketplace, as a new way to buy health insurance.

Affordable and minimum value coverage

Employers who offer insurance may be subject to penalties if the coverage they offer is not considered affordable or does not provide a minimum level of coverage. To be considered affordable coverage, a worker’s share of premiums should be less than 9.5% of their pay. For example, if a worker is paid $35,000 a year, his or her share of premiums for individual coverage should be less than $3,325 for the year.For coverage to meet the minimum value requirement, it should have an actuarial value of 60%. For example, if a covered health service costs $100, the health plan would pay $60 and the worker would be responsible for paying $40.

Annual limit

An annual limit is the maximum amount of money a health insurance plan will pay for covered benefits in a year. It is important to know that the ACA bans annual limits – a dollar limit on what an insurer will spend for your covered benefits. The exceptions are on health care services that are not considered essential health benefits and grandfathered individual health insurance policies.

Appeal

An appeal is when you ask your health insurance company to review and change a decision it has already made. For example, you may ask your insurance company to pay for a treatment it already said it will not cover.

Balance billing

Balance billing is when a doctor or health care provider charges you for services your health plan did not cover. For example, if your doctor charges you a $100 and your health plan pays $70, your doctor can bill you the $30 difference.

Benefits

Benefits are the health care services and items covered under a health insurance plan. Benefits vary based on your specific health insurance plan. Under the health law, essential health benefits are a set of benefits new health plans sold to individuals and families must cover.

Benefit year

The benefit year is the 12-month period in which the health care costs your insurance covers count toward your annual deductible. It runs January 1 through December 31 each year. Any changes to your health plan benefits or rates will start on January 1.

Brand name prescription drug

This is a medicine sold under a specific name by the company that makes it. Your doctor may prescribe a brand name drug and the pharmacy may give you a generic version of this medicine. Generic medicines are often cheaper than brand name medicines.

Bronze health plan

A bronze health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Bronze plans usually have lower monthly costs, but higher out-of-pockets. They usually cover about 60 percent of your health plan costs. You would have to pay the other 40 percent.

Catastrophic coverage or plan

An insurance plan in the Health Insurance Marketplace that offers limited coverage for health care services. This plan is only available to adults under age 30 or adults who get a hardship waiver. Rules for qualifying for Catastrophic coverage are shown at www.healthcare.gov.

Certificate of coverage

Tells you the period of time you will be covered by your health plan. It acts as a contract, spelling out your Health Insurance Marketplace plan benefits and provides useful information regarding costs and care.

Certified application counselor (CAC)

People who provide free help to consumers enrolling in the Health Insurance Marketplace. CACs work at local community organizations, hospitals or health centers.

Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP) is public health insurance for children. CHIP covers children in families who may not have access to other health insurance coverage and have family income above the Medicaid eligibility level. In Missouri, this program is called MO HealthNet.

Chronic (disease)

A chronic disease is an illness that lasts a long time. Doctors can treat chronic diseases but cannot cure them.

CMS

CMS stands for Centers of Medicare & Medicaid Services. It is the government agency in charge of Medicare, Medicaid and Children’s Health Insurance Program (CHIP).

Coinsurance

Your share of the cost for health care services, after you have paid your deductible amount each year. For example, if you go for a doctor visit that costs $100, your share may be $20 and your insurance plan’s share may be the remaining $80.

COBRA coverage

If you lose your job, you can temporarily keep your employee health insurance – but you must pay all of the monthly premiums yourself, including the share the employer used to pay.

Co-payment/Co-pay

A fixed amount you may pay at the time you receive a health care service – for example, you may pay $15 when you go for a doctor visit.

Cost sharing

Cost sharing is what you pay for health services out of your own pocket. Most health insurance plans have some type of cost sharing. Deductibles, coinsurance and co-pays are all types of cost sharing. Health insurance premiums are generally not considered part of cost sharing.

Cost-sharing reduction

Money the government pays to help cover out-of-pocket health care costs for people who qualify. People who qualify, in general, are those who enroll in a Marketplace Silver plan and have a yearly income that is from 100 percent to 250 percent of the Federal Poverty Level (FPL). Other rules for qualifying for cost-sharing reductions are shown at www.healthcare.gov.

Deductible

The amount you must pay for your covered health care services each year – for example, $1,000 – before your insurance plan will begin sharing the cost with you (see “coinsurance”).

Dependent

A child or other person who you claim on your taxes for a personal exemption tax deduction.

Emergency care

Health care services you get in the emergency room (ER) at a hospital.

Employer shared responsibility payment (ESRP)

The Affordable Care Act requires some employers with 50 or more full-time employees (or equivalents) to offer health coverage that meets certain standards or pay a tax called the Employee Shared Responsibility Payment.

Employer-sponsored insurance plan

Insurance you get through your job. Employers that offer an insurance plan pay part of their employees’ monthly premiums.

Essential Health Benefits

The 10 kinds of health care services most insurance plans must now cover, including care to help prevent disease, care for children, emergency care, prescription drugs, and more. Learn more about essential benefits here.

Excluded services

Health care services that are not covered and not paid for by your insurance plan.

Exclusive provider organization (EPO)

A type of health insurance plan that only pays for in-network health care services or for out-of-network care in an emergency.

Explanation of benefits

A written explanation from your insurance company about a claim for payment they have gotten from you or your health care provider. The EOB shows how much money the insurance company paid and how much money you must pay (if any) for the covered health care service or item. The EOB is not a bill. If you owe any money, you will get a bill from your health care provider.

Federal poverty level (FPL)

A measurement of how much a person or family needs to earn so they can pay for food, clothing, housing and other necessary things. The government decides what the FPL is for each year. For example, in 2017 the FPL was set at $12,060 for one person and $24,600 for a family of 4 people.

Federally-qualified heath center (FQHC)

A type of clinic that offers primary care services even if you cannot pay for them. The price you are charged is based on how much you can pay. FQHCs are funded by the federal government.

Federally recognized tribe

A federally recognized tribe is any Indian or Alaska Native tribe, band, nation, pueblo, village or community recognized by the federal government.

Flexible spending account (FSA)

An account you can set up through your job to pay for out-of-pocket health care costs like prescriptions or copays. You decide how much of your pay check you want put into the account each month. The money is taken from your check before tax and you do not have to pay taxes when you use it. You do not get money in your FSA account back at the end of your plan year, even if you do not spend it.

Formulary

A list of the prescription medicines or drugs that are covered under your insurance plan. Most plans use a formulary that groups the drugs into tiers, or levels, to control costs. Your plan may pay less for the drugs in some tiers.

Full-time employee

A person who works an average of 30 hours a week is considered a full-time employee.

Full-time equivalent (FTE) employees

Rules in the health reform law count the number of workers a business has as full-time equivalent employees or FTEs. This may not be the same as the total number of employees a business has. FTEs are the combination of all full-time workers and part-time workers added together. Generally, if you have two part-time employees, they would count as one FTE.

Gold health plan

A gold health plan is one of four types of health plans you can buy in the Health Insurance Marketplace. Gold plans usually have higher monthly costs, but lower out-of-pockets. They usually cover about 80 percent of your health plan costs. You would have to pay the other 20 percent.

Generic prescription medicine

A generic prescription is a medicine sold without a brand name. Generic medicines usually cost less than brand name medicines but work the same way. The order from your doctor may say the brand name drug and note that it is okay to fill the prescription with a generic form of the medicine.

Grace period

The extra time you have to pay your health plan premium after its due date without losing your coverage. Grace periods vary by plan, but usually last 30 or 31 days. Check with your health plan company to find out the length of your grace period.

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 bought, on or before March 23, 2010. Grandfathered plans do not have to meet the new standards required under the Affordable Care Act.

Group Health Plan

A group health plan is one offered by your job or an employer organization that provides health coverage to you and your family.

Habilitative/habilitation services

Services that help you keep, learn, or improve skills and functioning for daily living. For example, these services might include therapy for a child not walking or talking at the expected age.

Health insurance

Health insurance is coverage through a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. A health insurer can be a health insurance company, an employer, or a union. Public health insurance programs like Medicare and Medicaid are similar, where the federal or state government pays some or all of your health care costs.

Health insurance literacy

Health insurance literacy is the ability to understand health insurance information to make decisions about your coverage.

Health literacy

Health literacy is the ability to understand and use health care information to make health decisions.

Health maintenance organization (HMO)

Health literacy is the ability to understand and use health care information to make health decisions.

Health plan categories

Missouri Marketplace health plans are divided into four plan categories: Bronze, Silver, Gold, or Platinum. Plan categories are based on how you and the insurance company will share costs. Bronze and silver plan will generally have lower monthly costs, but higher out-of-pockets. Silver and platinum plans usually cost more each month, but have lower out-of-pocket costs.

Health savings account (HSA)

A savings account available to people who enroll in a high deductible health plan. The money you put into the account can only be used to pay for qualified medical expenses, such as doctor visits or medicines. The advantage to you is that the money you put into the account is not subject to federal income tax.

High deductible health plan (HDHP)

An insurance plan that has a higher deductible than most insurance plans – for example, $3,000.

HIPAA (Health Insurance Portability and Accountability Act)

The Privacy Rule, a Federal law, that gives you rights over your health information and sets rules and limits on who can look at and receive your health information. When you go to a doctor’s office or other health provider, you may need to read about HIPAA and sign a statement saying you understand it.

Household income

Household income is the total income of all individuals who live in a single household, place or residence at the same time.

Individual responsibility payment/Penalty/Fine

A penalty that most Americans have to pay with their 2014-2018 Federal income tax if they do not have health insurance for at least 9 months during a calendar year. The penalty amount is based on the number of months you go without health insurance. Some people may not have to pay a penalty – for example, those who make a low income or are a member of a special group. More information is shown at www.irs.gov.

In-network providers

Health care providers, including doctors, hospitals and other suppliers, who contract with your insurance plan to give health care services to you at a lower cost. In-network providers are also called “preferred” providers.

Inpatient care

Health care services that require you to stay overnight in a hospital or other health care facility. Care that does not require an overnight stay is called “outpatient” care.

Insurance card

A wallet-sized card with information about your health plan, such as your name and policy number. It proves you have health coverage. You will need to show your health insurance card when you visit the doctor, hospital, emergency room or other places to get health care services.

Insurance claim

A request for payment that you or your health care provider send to your health insurance company when you visit a doctor, hospital or pharmacy.

Lifetime limit

A limit on the total lifetime benefit payments some insurance companies will pay for a person’s health care – for example, $1 million. An insurance company may also limit benefit payments for a specific type of health care, such as organ transplants or certain types of surgery. After the insurance company has reached the lifetime limit on your benefit payments, it will no longer pay any money for your health care benefits.
Short-term, limited duration plans may have lifetime limits. Under the Affordable Care Act, most Qualified Health Plans cannot use lifetime limits on most benefits.

Managed care

Managed care is a system in which people get most or all of their Medicaid services from an organization under contract with the state. Managed care companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state.

Medicare

A government health insurance program for Americans who are age 65 or older, certain younger people with disabilities, and people who have end-stage renal disease (kidney failure).

Medicare Part D donut hole

The donut hole is a gap in Medicare prescription coverage, where the plan does not cover medication costs until you have spent a certain amount out of pocket. Once you reach the out-of-pocket limit, the plan will help pay for covered medicines again. Under the health law, the donut hole is being phased out as discounts for brand name and generic prescription drugs are introduced and other adjustments are made. In 2020 the coverage gap will close.

Medicaid

A government health insurance program for Americans who have low incomes or disabilities. In Missouri, this program is called “MO HealthNet” for adults, and “MO HealthNet for Kids” for children up to age 19.

Medicaid expansion

Under the Affordable Care Act, the federal government offered money to help each state pay for and expand Medicaid coverage to more people.

Medicaid gap

Medicaid gap is also known as the coverage gap. People in the Medicaid gap earn an income that is too high for them to get Medicaid, but too low for them to receive a Marketplace tax credit.

Minimum essential coverage

Minimum essential coverage is the type of coverage a person has to have in order 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.

Missouri Health Insurance Marketplace

An online marketplace where you can buy a Qualified Health Plan (Bronze, Silver and Gold in Missouri) or Catastrophic coverage from private insurance companies.

Navigator

People in communities throughout Missouri who are certified to provide free help to consumers enrolling in the Health Insurance Marketplace.

Obamacare

See Affordable Care Act.

Open enrollment period

Open enrollment is a time period, usually a few months, when you can choose or change your health insurance plan. Open enrollment often happens in the fall with changes to the coverage starting in January. If you have a major life change, like getting married, having a baby, or losing your job, you may be able to change your health insurance outside of the open enrollment period. The Open Enrollment Period for 2019 health coverage is Nov. 1 through Dec. 15, 2018. However, if you experience a major life change before or after open enrollment, you may qualify for a Special Enrollment Period to enroll in Marketplace coverage. Some job-based health insurance plans have an open enrollment period where you can add family members who may have been covered by a different insurance plan the year before. Medicare also has an open enrollment period.

Out-of-network provider

Health care providers, including doctors, hospitals and other suppliers, who have not contracted with your insurance plan. Out-of-network providers are also called “non-preferred” providers.

Out-of-pocket

Money that you pay for health care services yourself, out of your own pocket. These costs include deductibles, copayments and coinsurance. They do not include monthly premiums.

Out-of-pocket maximum

A limit on your out-of-pocket costs – for example, $5,000. After you have reached your out-of-pocket maximum, your insurance company will pay 100 percent of your covered essential health benefits.

Outpatient care

Health care services that do not require you to stay overnight in a hospital or other health care facility. Care that requires an overnight stay is called “inpatient” care.

Over-the-counter (OTC)

Over-the-counter are medicines you can buy without a prescription from a health care provider.

Part-time employee

A person who works less than an average of 30 hours a week is considered a part-time employee.

Pre-existing condition

Any health problem you have before a new health insurance plan begins is considered a pre-existing condition. Some common examples are asthma, diabetes, and heart disease.

Preferred provider organization (PPO)

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 doctors and hospitals that belong to your plan’s network. You can use doctors, hospitals, and providers outside of your network, but you will pay more to see them.

Premium

A premium is the cost of your health insurance. Premiums may be paid by you, your employer, or both. It is usually paid monthly or every three months. Or, it can be paid all at once for the whole year.

Premium tax credit

Money the government pays to help cover monthly premium payments for people who qualify. People who qualify, in general, are those who enroll in a Marketplace plan and have a yearly income that is between 100 percent and 400 percent of the Federal Poverty Level (FPL). Other rules for qualifying for tax credits are shown at www.healthcare.gov. To see how much you could save, use the calculator.

Prescription drug

Medications that are prescribed, or ordered, by your doctor or other health care provider. Medications that you can buy without a prescription, like Tylenol, are called “over-the-counter” medications.

Preventive care

Routine health care that includes screenings, check-ups, and patient counseling to help prevent illnesses, disease, or other health problems. Many preventive care services are covered at no cost under the Affordable Care Act.

Primary care provider

A doctor who gives care for common health problems and for preventing illness. He or she can help you get access to special care services if you need them.

Private health insurance company

A private health insurance company is a business that offers health insurance plans that are not owned by the government. Health insurance companies can be nonprofit or for-profit businesses.

Provider

A medical professional, hospital or other medical facility that provides health care services.

Qualifying life event

A change in your life that can make you eligible for a Special Enrollment Period to enroll in a Marketplace health insurance plan. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, have a baby, move from another state or become a U.S. citizen).

SHOP (Small Business Health Options Program)

A health insurance program for small businesses (50 or fewer full-time equivalent employees) that want to offer health or dental insurance to their employees.

Short-term, limited duration (STLD) health insurance plans

Plans that provide coverage for a limited amount of time – up to 3 years at most. They do not have to follow the rules of the Affordable Care Act (ACA), so these plans may not cover pre-existing conditions or all 10 essential health benefits, and may put limits on how much they’ll pay for covered health care.

Silver health plan

A silver health plan is one of the four types of health plans you can buy in the Health Insurance Marketplace. Silver plans usually have lower monthly costs, but higher out-of-pockets. They generally cover 70 percent of your health plan costs. You would have to pay the other 30 percent.

Sliding scale

Sliding scales are used to set prices or costs based on your ability to pay. For example, premium tax credits in the Missouri Health Insurance Marketplace are based on a sliding scale. That means the tax credit is larger for people with lower incomes and smaller for people with higher incomes.

Small business

Under the Affordable Care Act, a small business is a for-profit or nonprofit business with 50 or fewer full-time equivalent employees.

Small business tax credit

This is a tax credit meant to help very small businesses who offer health coverage to their workers. The tax credit gives businesses back a portion of what they pay for employees’ health insurance premiums. Small nonprofit organizations can use this tax credit too. Learn more or see if you qualify.

Special enrollment period

A period of time outside of Open Enrollment when some people can enroll in an insurance plan, or change their insurance plan, in the Marketplace. In general, you may get a Special Enrollment Period when you have a qualifying life event.

Special care doctor, also called a specialist

A doctor who gives health care for a specific medical problem – for example, a foot doctor or heart doctor. A doctor who gives care for common illnesses or injuries is called a primary care doctor.

Summary of benefits and coverage (SBC)

A written summary that lets you compare the costs and benefits of different health plans. When you enroll in a health insurance plan, your insurance company will send you an SBC for your plan.

Tax credit

Money the government pays to help cover monthly premium payments for people who qualify. People who qualify, in general, are those who enroll in a Marketplace plan and have a yearly income that is between 100 percent and 400 percent of the Federal Poverty Level (FPL). Other rules for qualifying for tax credits are shown at www.healthcare.gov.

Urgent care

Urgent care is care for an illness, injury or condition that needs to be treated quickly, but does not require emergency room care.

Wellness programs

Programs intended to improve and promote health and fitness that are usually offered through your job. Wellness programs allow your job to offer you discounts, gym memberships, cash rewards or other perks for participating. Examples of wellness programs include programs to help you stop smoking, loss weight or get health screenings.