Glossary

Actuarial Value: A health plan's actuarial value is the percentage of total average costs for benefits that a plan covers. Starting in 2014, all health plans will have an actuarial value assigned to them” bronze, silver, gold or platinum. As the metal category increases in value, so does the percent of medical expenses that a health plan will cover. This means the platinum-level plans will cover the highest percentage of health care expenses. These expenses are usually incurred at the time of health care services" when you visit the doctor or the emergency room, for example. The health plans that cover the greatest percentage of health care expenses also typically have higher premium payments.

Affordable Care Act: The Federal Patient Protection and Affordable Care Act (PPACA), also commonly known as "Obamacare", was enacted in March 2010 with the intent of expanding access to high-quality affordable insurance and healthcare.  PPACA is aimed primarily at decreasing the number of uninsured Americansand reducing the overall costs of health care. It provides a number of mechanisms, including mandates, subsidies, and tax credits, to employers and individuals in order to increase the number of individuals covered by health insurance. PPACA requires insurance companies to cover all applicantsand offer the same ratesregardless of pre-existing conditionsor sex.

Allowed Amount:  the maximum amount on which payment by the insurance carrier is based for a covered health care service. If a health care provider (such as a doctor's office) charges more than the "allowed amount" the insured may have to pay the difference.

Appeal: A request to a health insurance carrier to review a decision or grievance.

Co-insurance: your portion of the costs of a covered health service (for example 20%) of the allowed amount for the service; you would pay 20% of the bill and the carrier would pay 80% of the allowed amount.

Co-payment:  A fixed amount (such as $35) you pay for a covered health service, usually at the time of service. The amount varies depending on the type of service as well as the type of health plan.

Deductible:  The amount you pay for health care services before your health insurance plan begins to pay.  For example, if you have a $2,000 deductible, your insurance carrier will not pay anything until you have paid $2,000 on covered health care services subject to the deductible. The deductible typically does not include any co-payments made.

In-network co-insurance: The percent of the "allowed amount" you pay for a covered health care service to the providers (such as a doctor office), for example you pay 20% and the carrier pays 80% of a bill after the deductible has been met.

Premium: The amount paid to an insurance carrier in exchange for health insurance. Premiums can usually be paid monthly, quarterly, or yearly.

 

Special Enrollment: The opportunity to enroll in an employer's health plan or a plan available through the "exchange" outside of the plan's specified enrollment period. This occurs when one experiences a life changing event such as (loss of a job, birth of a child, death of a spouse).

Subsidy: Beginning in 2014, subsidies and tax credits are designed to lower the cost of premiums and out-of-pocket expenses for health coverage for individuals and families who qualify.

Tax Credit: Starting in 2014 tax credits will be available to individuals and families to help consumers pay for health insurance premiums.