- Actuarial Value 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.
- Advanced Premium Tax Credit A tax credit designed to help pay for your monthly premium, when you take it in advance. Or you can wait and take the tax credit at the end of the year when you file your taxes. Whether or not you qualify for this financial help depends on factors including your family size and estimated annual household income for the year the insurance will be in effect. If your actual income does not match your estimate, you may owe or be owed money on your tax return.
- 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.
- Allowed Amount 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.
- Annual Limit 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.
- Appeal 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.
- Balance Billing 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. This only applies to out-of-network providers when your health insurance plan includes out-of-network benefits (which most of them do not). A preferred provider, one that is participating in your insurance company’s provider network, may not balance bill you for covered services.
- Benefits The healthcare items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents.
- Care Coordination The organization of your treatment across several healthcare providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.
- Child Health Plan Plus (CHP+) 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.
- 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 healthcare costs if you have a chronic disease by preventing or minimizing the effects of a disease.
- Claim A request for payment that you or your healthcare provider submits to your health insurer after you receive items or services you think are covered.
- COBRA 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.
- Coinsurance A percentage of costs for a covered healthcare service or medication you pay (30%, for example) AFTER you've met your deductible. Let’s say you’ve met your deductible: You pay 30% of a $100 service which is $30. The insurance company pays the rest (70%). The percentage amount varies depending on the level of plan.
- Colorado Option Plans Colorado Option plans were introduced because of the Standardized Health Benefit Plan Colorado Option (HB21-1232) law, which allowed the state to develop a standardized health insurance plan that private health insurance companies are required to offer in the individual and small group markets starting in 2023. Colorado Option plans cover all essential health benefits required by the Affordable Care Act (ACA), provide free ($0) primary care and mental health visits, and have a specific set of lower, fixed costs across all companies, allowing for easier shopping.
- Catastrophic Health Plan A health insurance plan with a low monthly premium and very high annual deductible designed to protect customers from worst-case situations like a serious injury or illness. This type of plan is available to individuals under age 30 at the beginning of the plan year, or those who qualify for a hardship exemption. Catastrophic plans are required to cover the same essential health benefits as other Marketplace plans, including certain preventive services at no cost when delivered by an in-network provider. They also cover at least three primary care visits during the plan year, but consumers pay all other medical costs until the annual deductible is met. Then the plan pays 100% for covered services for the rest of the plan year. Premium Tax Credits and Cost-Sharing Reductions may not be used with this type of plan.
- Copayment (or Copay) A fixed amount ($10, for example) you owe for a prescription or medical visit that is covered under your health plan, usually paid when you receive the service. For most plans, the copay phase of cost-sharing starts right away; the exception is Health Savings Account (HSA) plans for which you have to meet the deductible first. Copays do NOT count towards your deductible amount, but they DO count towards your out-of-pocket maximum.
- Cost-Sharing Health insurance is designed to share costs with you in two ways – copayments and coinsurance. When they apply depends on the deductible and out-of-pocket maximum.
- Cost-Sharing Reductions (CSR) Subsidies designed to lower the amount you pay when you receive care by reducing the out-of-pocket costs such as copays, deductibles and coinsurance for covered healthcare services, as well as the out-of-pocket maximum. Unlike Premium Tax Credits, which apply to all plans if you qualify, Cost-Sharing Reductions can only be used on Silver level plans. Whether or not you qualify for this financial help depends on factors including your family size and estimated annual household income for the year the insurance will be in effect.
- Coverage Levels A health insurance plan fits into one of four metal tiers or coverage levels: Bronze, Silver, Gold, and Platinum and are intended to help you narrow your options based on your budget and health need. The levels are based on how you and your insurance company will split costs for that plan and have nothing to do with quality of care. The lowest level, Bronze, will typically have the lowest premiums but the insurance company will pay the lowest percentage of costs when you receive care (60%, for example). The higher levels, Gold and Platinum, will typically have higher premiums, but the insurance company will pay a higher percentage of the costs when you receive care (80%, for example).
- Deductible Generally, the amount you have to spend on covered healthcare services and prescriptions out of pocket before your health insurance company starts to pay a percentage of your bills (coinsurance phase). Health plans can vary on what they count towards the deductible. Plans with lower premiums tend to have higher deductibles. All plans must provide many preventive services and screenings at no charge to you BEFORE you met the deductible. Plans may also offer other services with a copayment that do not apply to the deductible.
- Dependent 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.
- Disability 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.
- Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
- Essential Health Benefits All health insurance plans available through Connect for Health Colorado are required by federal law to include what are called essential health benefits. These include: ambulatory patient services; emergency services; hospitalization; pregnancy, maternity and newborn care; mental health and substance use disorder services including behavioral treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services (for free) and chronic disease management; and pediatric services, including dental and vision care. This doesn’t mean that all plans are the same. Some plans may oﬀer a higher level of service or additional services beyond the minimum required, or exclude other optional services that may be important to you. It's important to understand these differences when comparing plans.
- Excluded ServicesHealthcare services that your health insurance or plan doesn’t pay for or cover.
- Exclusive Provider Organization (EPO) EPO Plans are more flexible than HMO plans in that you are typically able to see a specialist without a referral. Though, some EPO plans require a referral to a specialist. Like HMO plans, EPO plans do NOT cover any out-of-network healthcare costs, except in an emergency.
- 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 2018 Federal Poverty Level for an individual is $16,147 in yearly income and $33,383 for a family of four.
- Fee for Service A method in which doctors and other healthcare 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.
- Formulary 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).
- Grievance A complaint that you communicate to your health insurer or plan.
- Guaranteed Issue 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.
- Guaranteed Renewal 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.
- Habilitation Services Healthcare 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.
- Health Insurance 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) HMOs often provide integrated care and focus on prevention and wellness. With HMO plans you must choose an in-network primary care physician (PCP), and then all of your care will be coordinated through that PCP to other in-network providers. So, if you need a specialist, such as a cardiologist (heart doctor), you’ll need a referral from your PCP first. Though, some HMO’s do not require a referral to see a specialist. HMOs do NOT cover any out-of-network healthcare costs, except in an emergency.
- 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 an HSA Plan (sometimes referred to as a High Deductible Health Plan or HDHP). These HSA plans don't share any of the medical costs until the deductible is met. They tend to have lower monthly premiums and higher 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 healthcare 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 Healthcare services a person receives at home.
- Hospice Services 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.
- Household The Marketplace generally considers your household to be you, your spouse if you’re married, and your tax dependents – those on your tax return, which may be different than those actually living in your house. Your eligibility for financial help is generally based on the income of all household members, even those who don’t need insurance. (Also referred to as "Tax Household.")
- In-Network The facilities, providers and suppliers such as doctors, hospitals and pharmacies your health insurance company or plan has contracted with to provide healthcare services. Also called "provider network" or "preferred providers." Most health insurance plans will only cover in-network providers and won't pay anything if you go out-of-network.
- 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.
- Long-Term Care 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.
- Marketplace Another way of referring to Connect for Health Colorado which is a Health Insurance Marketplace – a shopping and enrollment service for medical insurance created by the Affordable Care Act.
- Medicaid 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.
- Medicare 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.
- Metal Tiers A health insurance plan fits into one of four metal tiers or coverage levels: Bronze, Silver, Gold, and Platinum and are intended to help you narrow your options based on your budget and health need. The levels are based on how you and your insurance company will split costs for that plan and have nothing to do with quality of care. The lowest level, Bronze, will typically have the lowest premiums but the insurance company will pay the lowest percentage of costs when you receive care (60%, for example). The higher levels, Gold and Platinum, will typically have higher premiums, but the insurance company will pay a higher percentage of the costs when you receive care (80%, for example).
- 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.
- Modified Adjusted Gross Income The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and Child Health Plan Plus. MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest. For many people, MAGI is identical or very close to adjusted gross incomeMAGI doesn’t include Supplemental Security Income (SSI)MAGI does not appear as a line on your tax return.
- Network The facilities, providers and suppliers such as doctors, hospitals and pharmacies your health insurance company or plan has contracted with to provide healthcare services. Also called "provider network" or "preferred providers." Most health insurance plans will only cover in-network providers and won't pay anything if you go out-of-network.
- Open Enrollment Period The period of time set up to allow you to choose from available plans, usually once a year.
- Out-of-Network Any facilities, providers and suppliers such as doctors, hospitals and pharmacies that are NOT part of your health insurance company or plan's provider network (or considered in-network). Most health insurance plans won't pay anything if you go out-of-network.
- Out-of-Pocket Costs 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 Maximum/Limit The most you’d ever have to pay for covered services and prescriptions in a plan year. After you spend this amount on deductibles, copays and coinsurance, your health insurance company pays 100% of the costs of covered benefits for the rest of the year. Your monthly premium or anything you spend for services your plan doesn’t cover (out-of-network) do not count toward this limit. This limit resets each year.
- Plan Year/Policy Year The 12-month period in which a health plan provides coverage. For plans purchased through Connect for Health Colorado, the plan year is the same as a calendar year – January through December – even if you aren't enrolled for the entire calendar year.
- Point-of-Service (POS) Plan A type of plan in which you pay less if you use doctors, hospitals and other healthcare 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.
- Preferred Provider 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.
- Preferred Provider OrganizationA type of health insurance plan that covers care from in-network and out-of-network providers. You pay less if you use providers that belong to the plan's network. You can use providers outside of the network, but at a higher cost.
- Premium Think of this as your monthly bill – the amount you must pay the health insurance company, on-time each month or you may lose coverage. You pay this even if you don't use healthcare services that month. If you choose a plan with a lower premium, expect to pay more for prescriptions and healthcare services.
- Premium Tax Credit A tax credit designed to help pay for your monthly premium. You can take it in advance or you can wait and take the tax credit at the end of the year when you file your taxes. Whether or not you qualify for this financial help depends on factors including your family size and estimated annual household income for the year the insurance will be in effect. If your actual income does not match your estimate, you may owe or be owed money on your tax return.
- Preventive Services One of the Essential Health Benefits, all plans are required to cover many preventive services – check-ups, vaccinations, screenings for breast cancer, cholesterol, diabetes, and more – before you meet the deductible AND at no additional cost to you when delivered by a doctor or other provider in your plan's network.
- Primary Care 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.
- Rate Review 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.
- Rehabilitation Services Healthcare 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.
- Rescission 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.
- Self-Insured Plan 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.
- Small Business Tax Credit Small businesses that have fewer than 25 employees, pay average annual wages below $50,000 and pay at least half of employee health insurance premiums are eligible for a federal tax credit when they purchase health insurance through Connect for Health Colorado. This tax credit can be up to 50 percent (or 35 percent for nonprofits) to offset the cost of premiums for employees.
- 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 if you have a qualifying Life Change Event such as marriage, the birth of a child, and loss of coverage.
- Standardized Plans Another name to refer to Colorado Option plans, which have a specific set of lower, fixed costs (i.e., a standardized cost and benefit structure) across all companies, allowing for easier shopping.
- 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.
- Tax Credit An informal way to refer to the Premium Tax Credit for individuals and families or the Small Business Tax Credit.
- 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.
- Uncompensated Care Healthcare or services provided by hospitals or healthcare 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.
- Wellness Programs 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.