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.
Aggregate Family Deductible
In a family plan with an aggregate deductible, an individual deductible is not embedded in the family deductible. Before medical bills can be covered, the entire amount of the deductible must be met. It can be met by one family member or by a combination of family members.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your health care provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Annual Household Income
The total income for a family in a calendar year.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. Caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.
A request for your health insurance company or the Marketplace to review a decision that denies a benefit or payment. If you don't agree with a decision made by the Marketplace, you may be able to file an appeal.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider, one that is participating in your insurance company’s provider network, may not balance bill you for covered services.
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.
The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.
Children’s Health Insurance Program (CHIP)
An insurance program jointly funded by states and the federal government that provides health insurance to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage. In Colorado, this program is called Child Health Plan Plus.
Chronic Disease Management
An integrated care approach to managing illness that includes screenings, checkups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease.
A request for payment that you or your health care provider submits to your health insurer after you receive items or services you think are covered.
The percentage of costs of a covered health care service you pay after you've paid your deductible. For example, your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible; you pay 20% of $100, or $20. The insurance company pays the rest. If you haven't meet your deductible; you pay the full allowed amount, $100.
A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.
A federal law that may allow you to temporarily keep health coverage after your employment ends, after you lose coverage as a dependent of the covered employee, or as a result of another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Colorado Young Adult (CYA) Plan
The Colorado Young Adult (CYA) Plan provides coverage for only high-cost services, such as medical catastrophe, or when medical costs exceed a very high deductible. This plan is available to individuals under age 30 at the beginning of the plan year, and may also be available for certain Coloradans with low incomes. The CYA plan is also referred to as a catastrophic plan, or catastrophic coverage, as defined by the Affordable Care Act.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.
The amount you must pay for health care services before your health insurance company will start paying benefits. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your deductible for covered health care services that are subject to the deductible. The deductible may not apply to all services.
A child or other individual for who a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a Premium Tax Credit to help cover the cost of coverage for themselves and their dependents.
A limit in a range of major life activities. This includes limits on activities such as seeing, hearing, and walking and on tasks such as thinking and working. Because different health insurance programs may have different disability standards, please check the program you’re interested in for its disability standards.
Embedded Family Deductible
In a family plan with an embedded deductible, the plan contains two components; an individual deductible and a family deductible. Both deductible components allow each member of the family plan the opportunity to have medical bills covered prior to the entire dollar amount of the family deductible being met. The individual deductible is embedded in the family deductible.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Essential Health Benefits
A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services.
Health care services that your health insurance or plan doesn’t pay for or cover.
Federal Poverty Level (FPL)
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 2017 Federal Poverty Level for an individual is $16,040 in yearly income and $32,718 for a family of four.
Fee for Service
A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.
Flexible Benefits Plan
A benefit program that offers employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage. Also known as a Cafeteria plan or IRS 125 Plan.
Flexible Spending Account (FSA)
An arrangement through an employer to pay for out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, 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.
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.
Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.
A list of drugs your insurance plan covers. A formulary may include how much you pay for each drug. If the plan uses “tiers,” the formulary may list which drugs are in which tiers. Formularies may include both generic drugs and brand-name drugs.
Grandfathered Health Plan
An individual health insurance policy purchased on or before March 23, 2010. These plans weren’t sold through the Marketplace, but by insurance companies, agents, or brokers. They may not include some rights and protections provided under the Affordable Care Act.
Plans may lose “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose whether it considers itself a grandfathered plan. (Note: If you’re in a group health plan, the date you joined may not reflect the date the plan was created. New employees and family members may be added to existing grandfathered group plans after March 23, 2010).
A complaint that you communicate to your health insurer or plan.
A requirement that health plans must allow you to sign up for coverage, regardless of health status, age, gender, or other factors that might predict how much you use health services. Guaranteed issue doesn’t limit how much you can be charged if you enroll.
A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Guaranteed renewal doesn’t limit how much you can be charged if you renew your coverage.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Maintenance Organization (HMO)
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.
Health Reimbursement Account (HRA)
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.
Health Savings Account (HSA)
A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP).
High-deductible plans usually have lower monthly premiums than plans with lower deductibles. By using the untaxed funds in an HSA to pay for expenses before you reach your deductible and other out-of-pocket costs like copayments, you reduce your overall health care costs.
HSA funds roll over year to year if you don't spend them. An HSA may earn interest.
You can open an HSA through your bank or other financial institution.
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
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 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.
Life Change Event
An event that makes an individual eligible to enroll or change their health insurance coverage outside of the Open Enrollment Period. Life Changes Events range from moving, to getting married or having a baby. A Life Change Event will give an individual a Special Enrollment Period to enroll or change their health insurance coverage.
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 services can be provided at home, in the community, in assisted living facilities or in nursing homes. Individuals may need long-term care at any age. Medicare and most health insurance plans don’t pay for long-term care.
A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program. Colorado’s Medicaid program is known as Health First Colorado (Colorado's Medicaid Program) and is operated by the Colorado Department of Healthcare Policy and Financing.
Medical Loss Ratio (MLR)
A basic financial measurement of how much of the premium is used to pay for medical care versus overhead. . If an insurer uses 80 cents out of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80%. A medical loss ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay for overhead expenses, such as administrative costs, salaries, marketing and agent commissions, and/or retaining some as profit. Federal law sets minimum medical loss ratios for different markets, as do some state laws.
A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare isn’t part of the Health Insurance Marketplace. If you have Medicare coverage you don’t have to make any changes. You’re considered covered under the health care law.
Health plans are organized by metal tiers, also known as "coverage levels". There are three metal tiers, Gold, Silver and Bronze. These tiers show how much of the cost of medical services is covered by the health insurance company and how much is paid for by the customer.
Gold plans are 80% health insurance company and 20% customer, Silver is 70% and 30% and Bronze is 60% and 40%. Bronze plans will generally have the lowest monthly premiums, while the customer will pay the most when receiving medical care and Gold plans will have the highest monthly premium, while the customer will pay the least when receiving medical care.
Minimum Essential Coverage
The type of coverage an individual needs to have to meet the individual responsibility requirement under federal law. This includes individual market policies, job-based coverage, Medicare, Health First Colorado (Colorado's Medicaid Program), CHIP, TRICARE and certain other coverage.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Open Enrollment Period
The period of time set up to allow you to choose from available plans, usually once a year.
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
A fixed amount you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs typically include deductibles, coinsurance and copayments for covered services plus all costs for services that aren’t covered.
Out-of-Pocket Limit (OOP)
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 does not include your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Plan Year/Policy Year
The 12-month period when a health plan provides coverage. 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. This can sometimes be called a ‘policy year.’
Point-of-Service (POS) Plan
A type of plan in which you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. POS plans may require you to get a referral from your primary care doctor in order to see a specialist.
A medical provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you’re allowed to see all preferred providers or if, instead, your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
The amount you pay for your insurance plan every month. You pay this even if you don't use health care services that month.
Routine health care that includes screenings, checkups, 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.
Qualified Health Plan
An insurance plan that is certified by Connect for Health Colorado, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.
A process in which state insurance departments to review rate increases before insurance companies can apply them to you. In Colorado, this is conducted by the Colorado Division of Insurance in the Department of Regulatory Agencies.
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 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 federal law, rescission is illegal except in cases of fraud or intentional misrepresentation of facts as prohibited by the terms of the plan or coverage.
Rider (exclusionary rider)
A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy.) In most states today, an exclusionary rider is an amendment, permitted in individual health insurance policies that permanently prohibits coverage for a health condition, body part or body system. Under federal law, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.
A type of plan used primarily by larger companies where the employer collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.
Special Enrollment Period
A time outside of the Open Enrollment Period during which you and your family have a right to sign up for health coverage. This can be allowed in the event of certain life events, such as marriage, the birth of a child, and loss of a job.
Summary of Benefits and Coverage (SBC)
An easy-to-understand, standardized form that summarizes the benefits and coverage available for each health plan. This information allows customers to make “apples-to-apples” comparisons when looking at different plans. A link to each plan’s SBC is available in the Marketplace when you’re comparing plans
UCR (Usual, Customary and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount for providers that are not contracted with the insurance company.
Health care or services provided by hospitals or health care providers that don’t get reimbursed. Often uncompensated care arises when people don’t have insurance and cannot afford to pay the cost of care.
Waiting Period (Job-based coverage)
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.
Well-baby and Well-child Visits
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.
A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings