Glossary

Glossary 2017-06-01T14:23:22+00:00

A

Sometimes known as APTC, “advance payments of the premium tax credit,” or premium tax credit.

A federal tax credit that can help you afford coverage bought through the Massachusetts Health Connector Marketplace. 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 9.5% of annual household income. People offered employer-sponsored coverage that’s affordable and provides minimum value aren’t eligible for a premium tax credit.

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 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 →

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.

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

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 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.