Glossary

Glossary 2017-10-18T20:12:13+00:00

A

A tax credit that can help you afford coverage bought through the Health Connector Marketplace. Sometimes known as APTC, “advance payments of the premium tax credit,” or premium tax credit.

Unlike tax credits you claim when you file your taxes, 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’re due, you’ll 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.

The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.

The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Employer coverage is considered affordable – as it relates to the premium tax credit – if the employee’s share of the annual premium for the lowest priced self-only plan is no greater than 9.56% of annual household income in 2018. People offered employer-sponsored coverage that’s affordable and provides minimum value aren’t eligible for a premium tax credit. Use the job-based insurance affordability calculator

Money you get from a spouse with whom you no longer live, or a former spouse, if paid to you as part of a divorce agreement, separation agreement or a court order. Payments designated in the agreement or order as child support or as a non-taxable property settlement aren’t alimony.

Care you receive without being admitted to a hospital – for example, at a clinic, physician’s office or same-day surgery center. This is considered an essential health benefit that all plans inside the Health Connector Marketplace must include.

A facility that is focused on providing same-day surgical care, including diagnostic and preventive procedures.

A request for your health insurer or plan to review a decision or a grievance again.

When you apply for health coverage through the Marketplace, you’re required to agree (or “attest”) to the truth of the information provided by signing the application.

Someone who you choose to act on your behalf with the Health Connector, like a family member or other trusted person.  Some authorized representatives may have legal authority to act on your behalf. To assign an Authorized representative, you will need to fill out an Authorized Representative Designation Form. See the form now →

B

Basic dental care includes restorative care, including fillings and simple tooth extractions.

Basic dental care includes restorative care, including fillings and simple tooth extractions. Benefits for children are considered an essential health benefit and are covered in all dental plans available through the Health Connector.

These are services that are specific to the repair and reconstruction of natural teeth, such as extractions and fillings.

The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents.  In Medicaid (MassHealth) or Children’s Health Insurance Program (CHIP), covered benefits and excluded services are defined in state program rules.

Booklet provided by a health or dental insurer that explains covered benefits, limits, and exclusions. (Also known as Certificate of Coverage, Evidence of Coverage, or Member Handbook.)

A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.

A broker (or agent) is a person or business who can help you apply for help paying for coverage and enroll in a Qualified Health Plan (QHP) through the Health Connector. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer’s plans. Some brokers may only be able to sell plans from specific health insurers.

Massachusetts Health Connector health insurance plans are sold in four levels of coverage:

  • Bronze,
  • Silver,
  • Gold, and
  • Platinum.

As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.

Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Or, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. Metal categories do not indicate the quality of health care that you will receive.

 

C

If you incurred a debt from a loan or from buying something on credit a portion of the amount you owe is discharged or forgiven (“canceled”), the amount of the forgiven debt is generally counted as income to you.

A capital gain is the amount you get from selling property, like stock or a house.  For example, if you buy stock for $1,000 and sell it for $1,250, you have capital gain of $250.  You don’t need to include a capital gain if it’s from the sale of your main home you owned for at least 5 years (and the profit is less than $250,000).

Another term for an insurer or insurance company. 

Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don’t cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, co-payments, and co-insurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a federal “hardship exemption” because the Marketplace determined that you’re unable to afford health coverage.

An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Health Connector, including helping them complete eligibility and enrollment applications. Their services are free to consumers.

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Allows some workers to continue coverage from a former employer’s health insurance plan for a limited time.

A way of meeting your share of health costs under some health insurance plans.  Co-insurance is based on a percentage of the cost of a service.  Example: a plan may say that you pay 35% of the cost of a service.  If a medical test costs $100, you would pay $35 for that test.

The amount you must pay for prescriptions and medical services combined before your health plan will cover them.  Plans that do not have a combined deductible have separate deductible amounts for prescriptions from other medical services.

A program that provides reduced premiums for individuals who earn less than 300% of the Federal Poverty Level and who also qualify for the federal Advance Premium Tax Credit.

A flat amount that you must pay for medical service, usually at the time the service is delivered.

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and co-payments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

Cost sharing is the amount of money you pay when you get medical care. These costs may include co-pays and annual deductibles, and sometimes co-insurance. If you qualify for cost sharing reductions, your out-of-pocket costs will be lower when you get care.

Money that’s due to you as the result of a lawsuit. This money may be taxable. Examples of lawsuit proceeds that aren’t taxable are amounts awarded to you for personal physical injury or sickness and an amount you get as compensation for damages to your property if the payment is less than the amount you paid for the property.  Payments to compensate you for lost wages or punitive damages awards are examples of taxable court awards.

 

D

The amount that you or your family member(s) must pay before the health plan will pay for covered services.  Not all covered services are subject to the annual deductible. The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Dental check ups include preventative care, including cleanings and X-rays. Benefits for children are considered an essential health benefit and are covered in all dental plans available through the Health Connector.

Benefits that help pay for the cost of visits to a dentist for basic or preventative services, like teeth cleaning, X-rays, and fillings.  Through the Health Connector, dental coverage is available either as part of a comprehensive medical plan, or by itself through a “stand-alone” dental plan.

The amount you must pay for pediatric dental essential health benefits (EHB) before the health plan will cover them.

Legal spouse or children by birth, adoption, or legal guardianship who are eligible for benefits under your insurance policy.

Insurance coverage for family members of the policyholder, such as spouses, children or partners.

A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working.  Because different programs may have different disability standards, please check the program you are interested in for its disability standards.  The list of activities mentioned above isn’t exhaustive.  A legal definition of disability can be found here: http://www.ada.gov/pubs/ada.htm.  For the purposed EEOC ADA Amendments Act regulations and related resources see: http://www.gpo.gov/fdsys/pkg/FR-2009-09-23/html/E9-22840.htm 

A payment made by a for-profit corporation to it’s shareholders.  This payment is a portion of the corporate earnings and may be paid a certain number of times each year (such as each quarter).

A flat amount that you must pay for a covered doctor’s visit – usually at the time the services is delivered.

Two people of the same or opposite sex who live together and share a domestic life, but aren’t married or joined by a civil union.

The 8-digit number assigned to an employer by the Massachusetts Division of Unemployment Assistance for the purposes of Unemployment Insurance.

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

 

E

An employee who is permitted to enroll in a Health Connector plan. An eligible employee

  • is full-time with a normal work week of 30 or more hours
  • lives within an extended service area of one or more Health Connector plans available.

An eligible employee is not:

  • working on a temporary basis, on a term of 12 consecutive weeks or less
  • working on a seasonal basis, as determined by the Department of Unemployment Assistance
  • retired from the company
  • a member of the company’s board of directors or trustees, unless he or she is a full-time employee as defined above.

Disabled employees who are not actively working are eligible for coverage if they are considered permanent employees by the employer and the employer is required by law to cover them.

The date on which insurance benefits begin.

An immigration status that’s considered eligible for getting health coverage through the Marketplace. Immigrants with the following statuses qualify to use the Marketplace: Lawful Permanent Resident (LPR/Green Card holder); Asylee; Refugee; Cuban/Haitian Entrant; Paroled into the US; Conditional Entrant Granted before 1980; Battered Spouse, Child and Parent; Victim of Trafficking and his/her Spouse, Child, Sibling or Parent; Granted Withholding of Deportation or Withholding of Removal, under the Immigration laws or under the Convention against Torture (CAT); Individual with Non-immigrant Status (includes worker visas, student visas, and citizens of Micronesia, the Marshall Islands and Palau); Temporary Protected Status (TPS); Deferred Enforced Departure (DED); Deferred Action Status (Deferred Action for Childhood Arrivals (DACA) is not an eligible immigration status for applying for health insurance); Lawful Temporary Resident; Administrative order staying removal issued by the Department of Homeland Security; Member of a federally-recognized Indian tribe or American Indian Born in Canada; Resident of American Samoa. Applicants for any of these statuses qualify to use the Marketplace: Temporary Protected Status and Employment Authorization; Special Immigrant Juvenile Status; Victim of Trafficking Visa; Adjustment to LPR Status; Asylum (Applicants for asylum are eligible for Marketplace coverage only if they’ve been granted employment authorization or are under the age of 14 and have had an application pending for at least 180 days); Withholding of Deportation, or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT). People with the following statuses and who have employment authorization qualify for the Marketplace: Registry Applicants; Order of Supervision; Applicant for Cancellation of Removal or Suspension of Deportation; Applicant for Legalization under IRCA; Legalization under the LIFE Act. The rules for eligible immigration status may be different in each insurance affordability program.

A flat amount that you must pay for a covered Emergency Room visit – usually at the time the service is delivered.

Medical services you receive in an emergency.

Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families. These plans are offered to people through their (or a spouse’s) former employer or employee organization. Many of these plans aren’t legally required to meet many of the provisions of the Affordable Care Act, including providing coverage for children up to age 26.

The Affordable Care Act requires certain employers with at least 50 full time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.

Individuals who are trained and certified by the Health Connector to help you understand and apply for health coverage.

A set of health care service categories that are required to be covered by certain plans.

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Connector, offer a comprehensive package of items and services, known as essential health benefits. 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.

Insurance policies must cover these benefits in order to be certified and offered through the Health Connector.

An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.

Services that are not covered.

A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn’t yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The plan must accept this decision.

 

F

Any Indian or Alaska Native tribe, Alaska Native Claims Settlement Act (ANCSA) Corporation (regional or village), band, nation, pueblo, village, Rancheria, or community that the Department of the Interior acknowledges to exist as an Indian tribe.

Current list of federally recognized tribes can be found on the Bureau of Indian Affairs website.

A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year. (new paragraph) There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year. (Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.)

The list of prescription medications that are covered by your insurance benefits.

Under the Affordable Care Act (ACA), an full-time employee is an employee who works an average of at least 30 hours per week (so part-time would be less than 30 hours per week).

 

G

A prescription drug that has the same active-ingredient formula as a brand-name drug. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs. Generic drugs are usually the least expensive.

Massachusetts Health Connector health insurance plans are sold in four levels of coverage:

  • Bronze,
  • Silver,
  • Gold, and
  • Platinum.

As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.

Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Or, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. Metal categories do not indicate the quality of health care that you will receive.

Under the Affordable Care Act, this is 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 significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

Related content: https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/

A complaint that you communicate to your health insurance plan.

Provides coverage for a group of persons (usually employees of a company) under one master contract.

A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services.

A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums.

 

H

A doctor, hospital, pharmacy, community health center, skilled nursing facility, or other entity that delivers health care services.

The Health Connector plans are grouped in metallic tiers to make it even easier for shoppers to compare:

  • Platinum plans have the highest premiums but the lowest co-pays and deductibles.
  • Gold and Silver plans have lower premiums, but higher co-pays and deductibles.
  • Bronze plans have the lowest premiums but the highest co-pays and deductibles.

Legal entitlement to payment or reimbursement for 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 like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. In Massachusetts, the Health Connector is the Marketplace under the Affordable Care Act.

The Health Connector also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Health Connector, and information about other programs, including MassHealth. The Health Connector encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance.

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Plans offered through the Health Connector 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 plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service. Metal coverage levels only refer to cost sharing. The metal category does not determine the quality of your medical care. What to consider when choosing a plan category:

  • If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.
  • If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Silver or Bronze plan. These plans cost you less per month, but pay less of your costs when you need care. Catastrophic plans provide limited coverage for individuals under 30 or older individuals who qualify because of a financial hardship.
  • If you qualify to save on out-of-pocket costs: Silver plans may offer the best value. You may qualify for lower out-of-pocket costs based on your household size and income. If you do, you can get these out-of-pocket savings only if you enroll in a Silver plan. If you make this choice you’ll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium.
  • If you’re under 30 or have a hardship exemption and want low monthly premiums, you may want to choose a Catastrophic plan designed to protect you from worst-case scenarios, like serious accidents or diseases.

Of course, it’s impossible to predict all your health care needs for the year ahead. Pick a plan that fits your budget and meets your and your family’s expected needs.

Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.

A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.

A plan 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 arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

 

I

The number an insurer assigns to a subscriber and his or her dependents.

In network providers contract with health insurance plans to provide care at a lower rate. If you go to an in network care provider, your out-of-pocket costs will be lower.

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

Health care that you get when you’re admitted as an in-patient to a health care facility, like a hospital or skilled nursing facility.

Services that are provided in a hospital by a physician during a hospital stay.

The charge for the use of borrowed money.

Interest you get from a bank or dividends from a stock you own are examples of investment income, which you should tell us about if you apply for help paying for health coverage.

The income you get from an investment, like interest you get from a bank or dividends you get from a stock you own.

For more information, see IRS Publication 550.

Individuals who work for health plans but who are trained and certified by the Health Connector to help you understand and apply for health coverage. You do not have to buy coverage from that company to receive help, but you may if you wish.

 

L

Laboratory services include diagnostic tests and services that help care providers understand a condition. These may include blood tests, x-rays, or MRIs.

A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

The number of times you can have a certain service during the benefit year. After the limit quantity is met, costs related to this certain service will be out of pocket.

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. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

 

M

Major dental care includes crowns, bridges, and dentures for children under age 19.

These include major dental services to restore a patient’s teeth that have been damaged, decayed or lost such as crowns, bridges, dentures, and oral surgery.

A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. In Massachusetts, the Health Connector is the Marketplace under the Affordable Care Act.

The Health Connector also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Health Connector, and information about other programs, including MassHealth. The Health Connector encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance.

The Massachusetts Medicaid program. (See Medicaid, below.)

The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

A program offered by both the state and federal governments to provide health insurance for low-income individuals and families that meet the eligibility requirements. Medicaid policies for eligibility, services, and payment differ from state to state.

A federal program of health care coverage for the elderly, disabled and persons with end-stage renal disease.
Medicare Part A: Compulsory insurance that provides specified in-hospital and related benefits.
Medicare Part B: Voluntary program to provide additional insurance to cover certain medical services and supplies not covered under Medicare Part A.
Medicare Supplement Policy: Provides coverage to fill in the gaps in Medicare coverage.
Medicare Part D: Voluntary program that provides prescription drug benefits.

Benefits for covered mental health and substance abuse services, whether provided in an inpatient or outpatient setting.

Continues health benefits to employees of small businesses with 2-19 employees. Employees can elect to take COBRA benefits when they leave employment permanently or for a defined period (leave of absence), or other qualifying event.  Employers must notify employees of this right within 14 days of the qualifying event. Once notified, employees have 60 days to elect or decline that coverage. The period of these benefits varies based on the qualifying event. The employee remains on employer’s records and enrolled in the employer’s group benefits.

Minimum Creditable Coverage (MCC) is the package of essential benefits you need to be considered insured and avoid tax penalties in Massachusetts. Health insurers licensed in Massachusetts must let consumers know if their plans meet these standards. Look for a notice on the front of your plan documents. All plans sold in the Health Exchange are Minimum Creditable Coverage. Learn more about MCC

The type of coverage an individual needs to have 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. To avoid the penalty for being uncovered you must have insurance that qualifies as minimum essential coverage.

Health plans that qualify as minimum essential coverage

If you’re covered by any of the following types of plans, you’re considered covered under the health care law and don’t have to pay a penalty:

  • Any Marketplace plan, or any individual insurance plan you already have
  • Any employer plan (including COBRA plans, with or without “grandfathered” status)
  • Retiree health plans
  • Medicare
  • Medicaid
  • The Children’s Health Insurance Program (CHIP)
  • TRICARE (for current service members and military retirees, their families, and survivors)
  • Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spine Bifida Health Care Benefits Program)
  • Peace Corps Volunteer plans
  • Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014

Other plans may qualify. Ask your health coverage provider.

Health plans that don’t count as coverage

Some products that help pay for medical services don’t qualify as minimum essential coverage. If you have only this kind of product, you may have to pay the fee. Examples include:

  • Coverage only for vision care or dental care
  • Workers’ compensation
  • Coverage only for a specific disease or condition
  • Plans that offer only discounts on medical services

A health plan meets this standard if it’s designed to pay at least 60% of the total cost of medical services for a standard population. Individuals offered employer-sponsored coverage that provides minimum value and that’s affordable are not eligible for a premium tax credit through the Health Connector.

The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. Use the MAGI calculator and learn more

A Multi-State Plan is a private health insurance plan sold through the Marketplace under a contract between the U.S. Office of Personnel Management (OPM) and an insurance company. OPM is the federal agency that administers health insurance plans for federal employees, retirees, and their families.

Multi-State Plans must include essential health benefits, and generally must cover any additional benefits required by state law. Enrollees in Multi-State Plans are eligible for the same income-based savings as enrollees in other Marketplace plans.

Important: Some Multi-State Plan options offer in-network care out of state, but not all do. Please carefully review the plan’s materials and provider directory to see if providers outside the state or service area are included in the network. Services provided by health care providers outside of a plan’s network usually cost more than services delivered by in-network providers.

 

N

An individual or organization that’s trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.

The National Committee for Quality Assurance (NCQA) is a private non-profit dedicated to improving health care quality. NCQA accredits and certifies health care organizations and recognizes physicians in key clinical areas.

The amount by which your total long-term capital gain for the year is more than your short-term capital loss for the year.

For more information, visit this topic on the IRS website.

The amount someone pays you to use your property, after you subtract the expenses you have for the property. For more information, see IRS Publication 17, chapter 9.

The health care providers that serve the members of a health plan. There are often rules and costs associated with going out-of-network for health services.

A health plan that contracts with doctors, hospitals, pharmacies, and other health care providers to provide members of the plan with services and supplies at a discounted price.

Doctors, hospitals and other health care professionals participating in the selected plan.

A non-preferred brand drug typically has alternative generic or preferred brand drug. They are usually more expensive than preferred drugs or generic drugs.

An official form of communication that informs individuals about the status of their applications, their eligibility for programs, or other important information. Notices may be sent by the Marketplace or by health insurers.

 

O

  1. The time when subscribers can select a new health plan from the options offered by the group (employer).
  2. A designated period of time each year—usually several weeks—during which insured individuals or employees can make changes in health insurance coverage.

Marketplace 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 Health Connector Marketplace. For 2018, the Massachusetts Open Enrollment Period is November 1, 2017–January 23, 2018.

Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event).

You can submit an application for health coverage outside of the Marketplace, or apply for MassHealth (Medicaid), or CHIP, at any time of the year.

Orthodontia procedures, that includes braces that are used to straighten teeth, for children under 19 years of age.

Any visit to your doctor’s office that is not for a routine medical office visit.  (For this definition, routine office visits include annual adult physicals, routine gynecologic examinations, and well child check-ups.)

A fixed dollar amount (for example, $30) you pay for covered health care services from providers who don’t contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network copayments.

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services plus all costs for services that aren’t covered.

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count your co-payments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.

A fee charged for services provided in a hospital-based outpatient clinic or location.

Surgery that does not require an overnight stay in a hospital.

 

P

See Affordable Care Act (ACA) above.

A payment or series of payments made to you after you retire from work. Generally, the amount of your income from a pension or retirement account distribution depends on the type of pension or retirement account, how much you contributed to the pension or retirement account, and whether you were already taxed on the amounts you contributed.

For additional information, see IRS Publication 575.

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).

The day 12 months after a plan went into effect. It is the date when a plan must be renewed for continued coverage. Rates and contribution amounts are recalculated for the anniversary date at renewal time.

An outline of the benefits and services covered by a health insurance plan. It typically describes any deductibles, co-payments, or out-of-pocket costs for services, including any caps on those expenses.

Massachusetts Health Connector health insurance plans are sold in four levels of coverage:

  • Bronze,
  • Silver,
  • Gold, and
  • Platinum.

As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.

Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Or, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. Metal categories do not indicate the quality of health care that you will receive.

Specialized care to help restore functions of the body such as walking and the use of arms and legs.

Allows you to get services where you need them, either within the HMO or, perhaps at some cost, from a provider outside of the HMO.

The terms, conditions, benefits and obligations of a contract of insurance.

A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer. (Note: In group health plans, this 12-month period is called a “plan year”).

A review of your need for a hospital stay before admission.

A medical condition that has been discovered or treated within a set period before the effective date of an insurance policy/plan.

A prescription drug that your plan will cover more of the cost of than a non-preferred brand drug. The copayments for preferred brand drugs are usually higher than generic drugs, but less expensive than non-preferred brand drugs.

Preferred drugs are medications that have been approved as effective and low-cost. Preferred drugs are usually less expensive. If you require a drug that is not on the preferred drug list, it may cost more or your health plan may not cover it.

A 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 providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

The price of health plan membership.  The amount you pay to an insurer to receive insurance coverage under a contract.

A flat amount that you must pay for a covered prescription – usually at the time the prescription is dispensed.

Medications for which a pharmacist must have a physician’s authorization to dispense.

Generic, Preferred Brand Name and Non-Preferred Brand Name are the typical prescription tiers established by some health plans.  Health plans often set the lowest co-pays for the Generic tier and the highest co-pays for the Non-Preferred Brand Name tier.

Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

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. This doctor coordinates a patient’s care over time and makes referrals to specialists. General internists, family practitioners, pediatricians, and obstetrician/gynecologists are the types of doctors that commonly serve as PCPs.

A physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

The set amount of days before an employee can qualify for employer-sponsored insurance.

A group of medical providers who have agreed to serve a health plan or a medical facility’s members or patients.

  • In-Network:  You are in-network when you select a provider that has contracted with your health plan.
  • Out-of-Network:  You are out-of-network when you choose a provider that is not contracted with your health plan.

 

Q

An insurance product that is certified by a Marketplace, provides Essential Health Benefits, follows established limits on cost-sharing (like deductibles, co-payments and out-of-pocket maximum amounts) and meets other requirements. A Qualified Health Plan will have a certification by each marketplace in which it is sold.

A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. 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) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.

 

R

When a medical provider recommends another provider to a patient.  The most common type of referral is from a primary care physician to a specialist.

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

The return of insurance benefits after a policy has lapsed, usually once the subscriber has paid any past-due premiums and produced evidence that they are insurable.

The amount someone pays you to use your property, after you subtract the expenses you have for the property. Royalty income includes any payments you get from a patent, a copyright, or some natural resource that you own.

For more information, see IRS Pub 17, ch. 9, pg. 67-74.

The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.

A payment or series of payments made to you after you retire from work. Generally, the amount of your income from a pension or retirement account distribution depends on the type of pension or retirement account, how much you contributed to the pension or retirement account, and whether you were already taxed on the amounts you contributed. A qualified distribution from a designated Roth account isn’t required to be included in your income.

For additional information, see IRS Pub 575.

Routine dental services include diagnostic and preventative care, such as cleaning and x-rays for adults age 19 and older.

A periodic visit with a medical professional (doctor, nurse practitioner, etc.). Examples include yearly adult physical exams or well child check-ups.

A periodic eye examination.  It may include an examination to determine if you need eye glasses and a screening to detect common vision problems.

 

S

The net income you earn from your own trade or business. For example, any net income (profit) you earn from goods you sell or services you provide to others counts as self-employment income.

Self-employment income could also come from a distributive share from a partnership.

The geographic zone where a health plan offers benefits.  A health plan may have multiple service areas and may offer different health plan products in each service area.

Massachusetts Health Connector health insurance plans are sold in four levels of coverage:

  • Bronze,
  • Silver,
  • Gold, and
  • Platinum.

As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.

Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Or, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. Metal categories do not indicate the quality of health care that you will receive.

Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

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.

The amount you get from Social Security Disability, Retirement (including Railroad retirement), or Survivor’s Benefits each month.

Social Security benefits based on your record (if you should die) that are paid to your:

  • Widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22
  • Children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22; and
  • Parents if you provided at least one-half of their support.

An ex-spouse could also be eligible for a widow/widower’s benefit on your record. A special one-time lump sum payment of $255 may be made to your spouse or minor children.

A business where one individual owns and controls the entire company.

There are special circumstances that allow someone to purchase health insurance coverage outside of the Open Enrollment Period during what are called Special Enrollment Periods. A Special Enrollment Period is a time period outside of open enrollment that allows someone to enroll in a health insurance plan or change plans. A person can only access a Special Enrollment Period when they experience a triggering event like the birth or adoption of a child, marriage or divorce, or a change in employment, and other qualifying life events. There is only a limited amount of time to report a triggering event and enroll in health coverage.

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. Surgeons, cardiologists, oncologists, and allergists are a few examples.

A visit to a health care professional who focuses on a specific condition, illness, or part of the human body.  Some health plans require a referral from a primary care physician in order for you to see a specialist.

The person responsible for making premium payments or whose employment makes him or her eligible for membership in an HMO or other health plan.

Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

 

T

The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents.

A report to the insurer that adds to, adjusts, or terminates a subscriber’s coverage.

A health care program for active-duty and retired uniformed services members and their families.

A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.

 

U

The process by which an insurance company decides whether, and on what basis, to accept an application for insurance.

A center that provides care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.

W

The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.

Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.

An insurance plan that employers are required to have to cover employees who get sick or injured on the job.

Z

A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is at or below 300% of the federal poverty level. People enrolled in this type of plan:

  • Do not pay co-payments, deductibles, or coinsurance when getting care from an Indian health care provider or when getting essential health benefits through a Marketplace plan
  • Do not need a referral from an Indian health care provider when getting essential health benefits through a Marketplace plan
  • Can get zero costs sharing with a plan at any metal level on the Marketplace