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.
A term used to describe an employer-offered insurance plan where an employee’s share of the premium (for his/her own coverage, not dependents’) is no more than a certain percentage of the employee’s annual household income. The percentage is set by the IRS each year. If your employer offers affordable coverage that provides minimum value, you can’t get a tax credit to help pay for your premiums.
A request to your health insurance company to change a decision it has made about your coverage. For example, you may file an appeal if the company cancels your coverage or decides to not pay health care services you think should be covered.
People (see “Certified Application Counselors” and “Navigators”) who provide free help to consumers enrolling in the Health Insurance Marketplace.
Benefit year or coverage year
A year of health insurance coverage. For example, a plan starting January 1 will end December 31. At the end of the benefit year, you re-enroll and begin paying out-of-pocket costs to meet your plan deductible again.
The health care services or items, such as medicines or medical equipment, your health insurance plan covers.
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% of your health plan costs. You would have to pay the other 40%.
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 for a life situation that kept you from getting health insurance, for example, recent death of a close family member.
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 (CACs)
People who provide free help to consumers enrolling in the Health Insurance Marketplace. CACs work at local community organizations, hospitals, or health centers.
CHIP (Children’s Health Insurance Program)
A program funded by the state and federal government to provide health coverage to children (and, in some states, pregnant women) in families who earn too much money to qualify for Medicaid but cannot afford to buy health insurance. In Missouri, CHIP is part of the MO HealthNet for Kid’s program.
Claim or 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.
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.
Your share of the cost for health care services after you have paid your deductible each year (see “Deductible”). Once you reach your deductible, the insurance plan will start sharing the cost of health care with you. 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.
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.
Money the government pays to help cover out-of-pocket health care costs for people who qualify. People qualify based on their yearly income and enrolling in a Marketplace Silver plan. Find other rules about qualifying for cost-sharing reductions at healthcare.gov.
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.
The amount you must pay out of your own pocket for your covered health care services each year – for example, $1,000. Once you reach your deductible, your insurance plan will begin sharing the cost with you (see “Coinsurance”).
A child or other person who you claim on your taxes for a personal exemption tax deduction.
Insurance that helps pay for basic or preventive dental services, such as teeth cleaning, x-rays, and fillings.
Levels or categories of drugs preferred by your insurance company. Drugs are divided into tiers based on their cost. For example, Tier 1 often includes generic drugs that have the lowest cost, Tier 2 often includes preferred brand-name drugs that cost more, and Tier 3 often includes nonpreferred brand-name drugs that have the highest cost.
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 a share 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.
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 (EOB)
A written explanation your insurance company sends to you after you get a health care service. 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. You can find the current FPL here.
Federally qualified heath center (FQHC)
Community health centers or clinics that provide low-cost health care in areas that don’t have enough doctors to serve the people living there.
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.
Formulary or drug 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.
A person who works an average of 30 hours a week is considered a full-time employee.
Full-time equivalent (FTE) employee
A full-time employee or a combination of part-time employees whose hours add up to full time. The Affordable Care Act has a formula to calculate how many FTE employees a business has.
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% of your health plan costs. You would have to pay the other 20%.
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.
A period that begins after an insured person does not pay his or her insurance premium. For plans in the Marketplace, your benefits will reduce or stop after 30 days of a grace period, and your coverage will be cancelled after 90 days, unless you begin paying your premium again.
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.
A complaint that you communicate to your health insurance company if it won’t pay for covered medical services or specialists or takes any other action that you believe hinders your ability to get quality health care. Learn more at: http://insurance.mo.gov/consumers/complaints/index.php.
Group Health Plan
A health insurance plan offered by an employer or an employee organization that provides health coverage to employees.
Habilitative or habilitation services
Health care that helps you keep, learn, or improve skills and ability to function for daily living. Some examples are speech therapy and physical therapy.
Circumstances that make it hard for a person to purchase health insurance coverage. Examples are homelessness, domestic violence, or bankruptcy.
Health insurance helps you pay for medical care and can protect you from high health care costs, like emergency room visits or hospital stays. Having health insurance gives you access to preventive care and provides a safety net when unexpected medical emergencies happen. Health insurance coverage is a contract with a health insurer.
Health Insurance Marketplace
Health maintenance organization (HMO)
Health plan categories
Health savings account (HSA)
High deductible health plan
HIPAA, Health Insurance Portability and Accountability Act
Medicare Part D donut hole
Minimum value coverage
Missouri Health Insurance Marketplace (also called Marketplace)
Open enrollment period
Out-of-pocket costs, also known as cost sharing
A limit on your out-of-pocket costs – for example, $5,000. After you have reached your out-of-pocket maximum for the year, your insurance company will pay 100% of your covered essential health benefits. Out-of-pocket maximum costs differ from plan to plan.
For example, your deductible may or may not count toward your out-of-pocket maximum. Check the Summary of Benefits and Coverage (SBC) for your insurance plan to see which out-of-pocket costs count toward your out-of-pocket maximum.
Pre-authorization or pre-certification
Preferred provider organization (PPO)
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% and 400% of the Federal Poverty Level (FPL). Other rules for qualifying for tax credits are shown at healthcare.gov. To see how much you could save, use the tax credit estimator.
Premium tax credits help make health care more affordable by lowering the cost you pay for your health insurance plan each month, which is called your premium. Premium tax credits can be taken now or later.
Primary care doctor
Primary care visit
Private health insurance company
Qualified Health Plan
Qualifying life event
SHOP (Small Business Health Options Program)
Short-term, limited duration (STLD) health insurance plans
Small business tax credit
Special Enrollment Period
Special care doctor or specialist
Summary of Benefits and Coverage (SBC)