Glossary: Words You Should know
Application assistance: There will be people available in every state to help consumers understand their health coverage options and how to sign up for a plan through the Health Insurance Marketplace. In-person help will have many different names, but the important thing is that they are there to help you. They may be called navigators, in-person assisters (IPA), certified application counselors (CAC), or something else. No matter what they are called, they are there to provide unbiased assistance.
Catastrophic coverage: A health care plan that covers limited services, such as hospitalizations and emergency care. Catastrophic health plans are not comprehensive coverage; they generally require you to pay all of your medical costs up to a certain amount, usually several thousand dollars. These plans will be available to Americans under the age of 30 and to those with limited incomes.
Certified application counselors (CAC): There will be people and organizations in each state that can help you better understand and apply for the new options for health coverage. In-person help will be able to help you sign up and pick a plan that fits your needs and your budget. They do not sell insurance or get paid commissions. They provide unbiased information about the coverage options available through the Health Insurance Marketplace. [Also see: navigators, in-person assisters (IPA)]
Children’s Health Insurance Program (CHIP): An insurance program that provides free or low-cost health coverage to children from low-income families. The program is partially funded by both federal and state governments. In some states, pregnant women in families who earn too much to qualify for Medicaid, but can’t afford to purchase private health insurance coverage, are also allowed to enroll in CHIP.
COBRA: This is a federal law that allows some people who have employer-based health coverage to temporarily keep health coverage for themselves and their families after their job is terminated, from between 18 and 36 months after the job is terminated. Individuals and families with COBRA coverage generally have to pay for their entire premium, which for some, can be costly.
Coinsurance: The portion of health care costs that you are responsible for once you’ve paid your co-pay and have met your deductible (if you have one). Coinsurance is usually a percentage of the total medical bill. For example, if your bill is $100, and your coinsurance is 20%, you will pay $20 for your medical services if you have already met your deductible.
Comprehensive coverage: The health insurance plans offered through the Health Insurance Marketplace must include a basic set of benefits, including doctor visits, hospitalizations, maternity care, emergency room care, prescriptions, and more. See the full list of these essential benefits.
Coverage: also called “health coverage.” This refers to whether someone has health insurance. Different health insurance plans offer different types of coverage. For example, some health insurance plans offer dental and vision coverage, while others do not.
Co-pay: A fixed amount of money (for example, $15) that you may need to pay for a covered health care service, usually at the time of service. The amount can vary depending on your health insurance plan and the type of health care service — for example, doctor visits or emergency care.
Deductible: The amount of money that you may need to pay out-of-pocket before your health insurance plan begins to pay for health care services. For example, if your deductible is $50, your plan won’t pay for anything until you’ve paid the $50 deductible. Deductibles vary by health insurance plan and may not apply for every service.
Financial assistance: There may be ways for those with low or middle incomes to get help paying for their health insurance by signing up for a plan through the Health Insurance Marketplace. If you qualify for financial assistance, the government will pay a portion of your health insurance premiums directly to your health insurance company every month. This will lower the amount of money you have to pay for your health insurance premium every month.
Health insurance: Health insurance is a way to help you pay for your health care. It is a contract with an insurer that says they will help pay for your doctor visits if you get sick or injured. Having quality health insurance is coverage that helps you stay healthy, protects your wallet, and gives you peace of mind.
Health Insurance Marketplace (Exchange): The Health Insurance Marketplace (sometimes called an Exchange) is a new way to compare and purchase health insurance plans. Every state will have a Health Insurance Marketplace, though each state’s Marketplace will look different. But the important thing is that all plans available through the Marketplace will cover the care that you need. You will be able to choose from a selection of insurers and plans in easy-to-understand language, so you can compare the different types of coverage that are available to you.
Health insurance requirement: As part of the new health care law, most Americans will need to have health insurance. If you do not have health insurance, you may have to pay a fine. You won’t have to pay a fine if you have a very low income and coverage is unaffordable for you, or for other reasons including your religious beliefs. You can also apply for a waiver asking not to pay a fine if you aren’t automatically exempt.
In-network: A group of doctors, hospitals, and other health care providers that a health insurance plan has partnered with to provide care to the plan’s members. These providers are called “network providers” or “in-network providers.” You can find out if a provider is in-network by checking with your health insurance plan.
In-person assisters (IPAs): There are people and organizations in each state that can help you better understand and apply for health coverage through the Health Insurance Marketplace. These people will be able to help you sign up and pick a plan that fits your needs and your budget. They do not sell insurance or get paid commissions. They provide unbiased information about the coverage options available through the Health Insurance Marketplace. [Also see: navigators, certified application counselors (CAC)]
Medicaid: A state-run health insurance program for low-income families and children, pregnant women, people with disabilities, and in some states, other adults. Some states are still making decisions about whether to expand Medicaid. States can choose to expand Medicaid at any time. To see if your state has expanded Medicaid, check this map.
Navigators: There will be people and organizations in each state that can help you better understand and apply for the new options for health coverage. These people will be able to help you apply for and enroll in coverage that fits your needs and your budget. They do not sell insurance or get paid commissions. They provide unbiased information about the coverage options available through the Health Insurance Marketplace. [Also see: certified application counselors (CAC), in-person assisters (IPA)]
Open enrollment period: The period of time when you can sign up for health coverage through the Health Insurance Marketplace. The next open enrollment period is from November 15, 2014 to February 15, 2015.
Out-of-network: Doctors, hospitals, and other health care providers who have not partnered with your health insurance plan to provide care to the plan’s members. You may have to pay more for services from an out-of-network provider. Check with your health insurance plan to see if a provider is in-network or out-of-network.
Out-of-pocket maximum: The limit on your out-of-pocket costs during your policy period (which is usually one year). Once you pay this amount, your insurance must pay 100% of the covered services you receive. (Note: Premiums typically do not count toward your out-of-pocket maximum.)
Pre-existing conditions: A current or past medical condition, illness, or disability that — before the health reform law was passed — could cause a person to be denied or charged more for their health coverage. Beginning in 2014, people can no longer be turned down or charged more for their health coverage because of pre-existing conditions.
Premium tax credit: A type of financial help that you may qualify for that reduces your monthly payment (or premium) as soon as your coverage begins. For example, if your premium is $200, and you qualify for a $180 a month premium tax credit, you will pay $20 a month for your insurance plan. The amount of your premium tax credit is based on your estimated yearly income.
Provider: A person or place you go to to receive health care services. Examples include doctors, hospitals, pharmacies, and more. Check with your health insurance plan to find out if a provider is in-network or out-of-network.
Provider network: The group of doctors, hospitals, and other health care providers who have partnered with your health insurance plan to provide care to the plan’s members. Check with your health insurance plan to see if a provider is in your provider network.
Qualifying life event: A change in your life that can qualify you for a special enrollment period to enroll in a 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, or have a baby).
Special enrollment period: The next open enrollment period for the Health Insurance Marketplace is November 1st, 2015 through January 31st, 2016. Outside of this window, someone may qualify for a special enrollment period. This period lasts until 60 days after a qualifying life event, such as a job loss, birth, or divorce.
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