A

Advanced Premium Tax Credit (APTC)

A federal subsidy that will pay a portion of an individual’s or family’s health insurance premium. To be eligible for the APTC, you must be lawfully present in the United States, a current tax filer with the IRS and earn between 100% and 400% of the Federal Poverty Level (FPL).

B

Benchmark Plan

The Benchmark plan is the plan selected in the state that sets the bar for benefits, services and prescriptions for every plan offered under the Affordable Care Act. Every plan that you will be able to select from will have the benefits provided by the benchmark plan, at a minimum.

C

Certified Application Counselors (CACs)

CACs will also be able to help people enroll in QHPs. They will be certified the same way as Navigators and Enrollment Assisters. Like Enrollment Assisters, they will be able to sit down with people, one-on-one, to personally help them enroll.

Coinsurance

Coinsurance is usually a percentage that you (the insured) must pay. A common coinsurance split is 80/20, meaning that the insurance company pays 80% of your medical bills and you pay 20%. For example, if you went to the ER, and your bill was $1,000, you would pay $200 and your insurance company would pay $800. Coinsurance usually does not apply until you (the insured) have met your deductible, which varies based on your insurance plan.

Copayment

A copayment (also referred to as a “copay”) is a fixed amount of money that you (the insured) must pay at the time a medical service is provided (when you visit the doctor, for example, the front desk will ask you to pay your copayment). Copayments are usually required for basic doctor visits and prescription medications. Copayment amounts will be outlined in your insurance plan language so you will know what your copayments are before you enroll.

Cost Sharing Reductions (CSRs)

A subsidy that is applied to reduce the out-of-pocket cost for individuals and families who make less than 250% of the Federal Poverty Level.

D

Deductible

A deductible is the amount of money that you (the insured) would need to pay before you can use any benefits from your health insurance plan. For example, if a person has a $1,000 deductible, that person will have to pay $1,000 for medical care before their insurance company pays anything. The deductible is an annual amount, something that you need to pay every year.

There are certain things, such as doctor’s visits and prescriptions, that will be available before you meet the deductible. For example, that same person would not need to pay $1,000 for medical care or services before their insurance started paying for their prescription. Your deductible amount and what is exempt from the deductible will be outlined in your insurance plan language so you will know what your annual deductible is before you enroll.

E

Enrollment Assister

Enrollment Assisters are individuals who have been trained and certified to help enroll uninsured and under-insured individuals in QHPs. They will be able to sit down with people, one-on-one, to personally help them through the entire enrollment process.

Essential Health Benefits

Essential Health Benefits are certain benefits that all QHPs must provide. The essential health benefits generally include things like:

  • ambulance services and care
  • emergency service
  • hospitalization
  • maternity and newborn care
  • mental health and substance abuse disorder treatment
  • prescription drugs
  • rehabilitation and habilitation services and devices
  • lab services
  • preventive and wellness services and chronic disease support
  • pediatric services, including dental and vision

F

Federal Poverty Level (FPL)

The Federal Poverty Level is a level of household income, set by the U.S. government, to help determine which individuals and families in the United States are living “in poverty.” This figure is commonly used to determine eligibility for certain assistance programs.

Full-Time Equivalent (FTE)

A full-time equivalent is a unit of measurement for labor that represents the total number of hours worked, by one or more employees, that equates to the hours worked by a full-time employee (2,080 hours a year). So, for example, if you have two part time employees, each working 20 hours a week, together they represent one FTE.

H

Household Income

For purposes of the premium tax credit, your household income is your modified adjusted gross income (MAGI) plus that of every other individual in your family for whom you can properly claim a personal exemption deduction and who is required to file a federal income tax return. Modified adjusted gross income (MAGI) is the adjusted gross income on your federal income tax return plus any excluded foreign income, nontaxable Social Security benefits (including tier 1 railroad retirement benefits), and tax-exempt interest received or accrued during the taxable year. It does not include Supplemental Security Income (SSI).

I

Individual Mandate

A requirement by law that certain people purchase or otherwise obtain a good or service. In this case, it means that people must have health insurance coverage. The U.S. law now says that, under the Affordable Care Act, individuals must have health insurance.

M

Minimum Essential Coverage (MEC)

An employer sponsored or privately purchased health insurance plan that covers the 10 Essential Health Benefits and meets a minimum actuarial value of at least 60%. This includes privately purchased or employer-sponsored plans, Medicare and Medicaid.

N

Navigator

Navigators are individuals, public organizations, or private entities that have been trained and certified to provide outreach and education to various communities regarding the specifics of securing health insurance under the Affordable Care Act. They are responsible for outreach, education and enrollment of uninsured and underinsured populations. They are charged with educating people on a variety of topics, including program eligibility, how and why to purchase, and health insurance terms. They will also be able to help people enroll in a health insurance plan.

O

Out-of-Pocket Cost

For health insurance, the term out-of-pocket cost(s) refers to money you (the insured) pay out of your own pocket for medical care you’ve received.

P

Premium

The premium is the amount you (the insured) will pay for your insurance plan. The premium, like many bills, is typically a monthly payment.

Provider Network

A provider network is a group of providers (a group of hospitals, doctor, X-ray centers, outpatient survey centers, therapist and labs, for example) that agree to accept certain insurance policies and plans. Every insurance plan offered typically lists its provider network members, so you will know what doctors and hospitals are covered before you enroll.

Q

Qualified Health Plan (QHP)

A QHP is a health insurance plan that is certified as providing essential health benefits and follow established limits on cost sharing (such as deductibles and co-payments).

Qualifying Life Event (QLE)

You may qualify for a special enrollment period (enrollment outside of the open enrollment period) if you have recently experienced a Qualifying Life Event. These include, but are not limited to marriage, birth or adoption of a child, divorce, moving to a new service area, or loss of other coverage. You must request coverage and send in documentation of the event no later than 60 days from the event date.

T

Total Tax Household Size

You may count yourself, your spouse (if applicable) and any dependents that you are allowed to claim on your tax return. Individuals living in your household who may not be claimed on your taxes may not be included in this number.