A

The employer’s share and percentage of the Average Monthly Rate for each Coverage Type.

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.

When you renew your plan. Rates might change at that time.

A limit on the dollar amount that a health plan will pay for all covered services in a year.  If your plan has an annual benefit maximum, you will be responsible for all costs above that maximum.

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.

A limit on how much you are required to pay each year for covered services through deductibles, co-insurance and certain co-payments. Some costs or services may be exempt.

The employer’s share of the Average Monthly Rate for each Coverage Type.

A sum of the rates for all enrolled employees, by Coverage Type. It is used to set the Fixed Dollar Employee Contribution. Employers get a “list bill” based on actual rates, not the Average Monthly Rate.

 

B

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

Explains covered benefits, limits, and exclusions. (Also known as Certificate of Coverage, Evidence of Coverage, or Member Handbook.)

The limit or degree of your insurance coverage

The length of time when benefits will be paid for an accident, illness or hospital stay.

A licensed professional who helps businesses and individuals obtain a health plan.

 

C

Another term for an insurer or insurance company. 

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.

A number assigned to employers that participate in Health Connector insurance programs.

ConnectorCare plans are a set of plans that offer lower monthly premiums and lower out-of-pocket costs, because they are partially paid for by the state. If you qualify for a ConnectorCare plan, you will be able to get the most savings possible if you choose one of these plans when selecting your health insurance.

A binding agreement or promise.

Employer-sponsored insurance under which the employer and employee share in the cost.

Continues your coverage under a new policy once your policy has been canceled.

Prevents duplication of benefits within a group.  Limits benefits to 100% of covered expenses when there are multiple insurers or policies in place. Also sets the order in which the different carriers pay benefits.

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.

Type of policy: individual, two-person or family, for example. 2-Tier structures rate individual and family coverage.  3-Tier structures rate individual, two-person and family coverage.

A family size category that people can select for their health plan coverage. Health Connector plans have four:

  • Employee Only
  • Employee & Spouse
  • Employee & Child(ren)
  • Family

A family size category that people can select for their health plan coverage. Health Connector plans have four:

  • Self
  • Self & Spouse
  • Self & Child(ren)
  • Family

 

D

The amount that you will pay before your health or dental plan covers certain services. See also Annual Deductible

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

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

A physician who is a member of your health plan’s network or a doctor or specialist to whom you are referred according to the rules of your health plan. 

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

 

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 injury, symptom, or illness that requires immediate medical attention

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

The number of Eligible Employees who reside within the selected plan’s Extended Service Area.

The total monthly cost to the employer. It is based on the plan selected and the employer’s contribution toward the plan.

The date(s) when employees can apply for coverage under an employer’s insurance plan.

A set of health care service categories that must be covered by certain plans, starting in 2014.

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, 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 in the Health Insurance Marketplace, and all Medicaid state plans must cover these services by 2014.

Services that are not covered.

 

F

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.

The set monthly amount that will be paid by an employee who enrolls in the employer’s Benchmark Plan, displayed by coverage type

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

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

 

H

A doctor, hospital, 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.

Provides health services through member physicians to enrolled individuals and families within a particular geographic area.  Referrals to outside specialists are limited.   

A benefit package offered by an insurance company.

The period from admission into a hospital until discharge.

A period during which you are admitted to a hospital for treatment or recovery.  An inpatient stay usually involves an overnight stay in the hospital.  An inpatient stay ends when you are discharged.

 

I

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

 

L

Laboratory tests (such as blood work and urine tests) and imaging tests (such as x-ray, ultrasound, CT, MRI, etc.) that are done without a hospital admission.

The date when the applicant’s previous health insurance coverage ended

 

M

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.

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

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.

The number assigned to each subscriber in a company.

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.

 

N

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 percentage of the Average Monthly Rate for each Coverage Type contributed to by the Employer.

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.

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

 

O

The time when subscribers can select a new health plan from the options offered by the group (employer).

A designated period of time each year—usually a few months—during which insured individuals or employees can make changes in health insurance coverage.

The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For 2016, the Open Enrollment Period is November 1, 2015–January 31, 2016. 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 Medicaid or CHIP, at any time of the year.

Insurance plan feature and benefit information.

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.

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

 

P

A health care provider that is contracted with your health insurer to provide medical services.

A specific benefit package offered by an insurer.

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.

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 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 group of health care providers that is similar to an HMO.   Members may visit a provider outside of the PPO, but they may face higher out-of-pocket costs (deductibles, co-payments, lower reimbursement rates, etc.).  No doctor referral is required to see a specialist.

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

A premium tax credit is money that the federal government pays directly to your insurance company every month so that you have lower monthly premiums. If you qualify for premium tax credits, you may be able to use some of the tax credit towards the purchase of dental insurance as well.

Your tax credit is based on the income you and the people in your tax household expect to have during the year.

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.

A medical doctor who 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.

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.

 

R

Same as the coverage effective date, or the date when benefits are set to begin. It is the date used to lock in the amounts charged for a health insurance plan. The rates stay in place until the plan anniversary date 12 months later.

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.

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.

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 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.

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—these 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, etc. There is only a limited amount of time to report a triggering event and enroll in health coverage.

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

A medical doctor who is focused on a specific branch of medicine.  Surgeons, cardiologists, oncologists, and allergists are typical examples.

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.

 

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.

Type of policy individual, two-person or family, for example.

The total monthly cost to the employer. It is based on the plan selected and the employer’s contribution toward that plan.

The total monthly cost of a health insurance plan based on the list bill rates for all enrolled employees.

The total monthly cost of a health insurance plan based on the list bill rates for all enrolled employees.

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

 

U

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

A formal review of the services provided to a subscriber.  Can be performed before, during, or after the service.