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Affordable Care Act glossary

• Affordable Care Act — 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. The unofficial name of the law is “Obamacare.” The law has three main goals, to: help more people have health insurance; reduce the cost of health care; and, improve how people get health care.

• Affordable Health Insurance — By law, large employers must offer their employees affordable health insurance. That means it should not cost more than 9.5 percent of a

• Benefits — 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.

• Claim — 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.

• Consumer Operated and Oriented Plan (CO-OP) — A Consumer operated and oriented plan is a non-profit, member run health insurance organization authorized and funded under the ACA CO-OP program to foster competition in a local insurance markets.

• Cost Sharing — 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.

• Creditable Coverage — Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); Healthy Montana Kids; a state health insurance high risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.

• Deductible — The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. For example, under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage.

• Employer Mandate — A federal requirement that companies with 50 or more workers pay a penalty to the government if one of their workers obtains taxpayer subsidized coverage through the law. Delayed one year to Jan. 1, 2015. Intended to keep companies from “dumping” employees into public coverage.

• Essential Health Benefits — Basic health benefits that most health insurance plans will have to cover starting in 2014. They include office visits, emergency services, hospitalization, rehab care, mental health and substance abuse treatment, prescriptions, lab tests, prevention, maternal and newborn care, and pediatric care.

• Federal Employees Health Benefits Program (FEHB) — Provides health insurance to employees of the U.S. Federal government and, under the ACA, to employees of Tribes, tribal organizations and urban Indian organizations.

• Grandfathered Health Plan — Under ACA, individuals are allowed to maintain their coverage as it existed on the date of ACA enactment (March 23, 2010). However, grandfathered health plans are subject to new ACA requirements.

• Health Insurance Marketplace — Online health insurance markets in each state where consumers can get private health insurance, subsidized by the government. They used to be called “exchanges,” but the feds decided that was too confusing and started calling them “marketplaces.” Still, some states stuck with the original name. Open enrollment starts Oct. 1, and the coverage takes effect Jan. 1, 2014. Fifteen states and Washington, D.C., are running their own marketplaces, according to a tally by The Associated Press. The Obama administration is taking the lead in 35 states, in some cases partnering with the state government. All the marketplaces can be accessed online through healthcare.gov. Small businesses will have their own marketplaces.

• Healthy Montana Kids — A Montana managed insurance program that provides health insurance to low-income children.

• Home and Community-Based Services (HCBS) — Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing. This care is covered when provided by care workers or, if your state permits it, by your family.

• Individual Mandate — A federal requirement that virtually everyone in the United States has health insurance, either through an employer, a government program or by buying his own plan. Effective Jan. 1, 2014. Exemptions for financial hardship and religious objections. Does not apply to immigrants living in the U.S. illegally. People who ignore the mandate will face fines from Internal Revenue Service.

• Indian Health Care Improvement Act — The Indian Health Care Improvement Act (IHCIA) is a key legal authority for the provision of health care to American Indians and Alaska Natives (AI/ANs). The IHCIA was originally enacted in 1976 to address the deplorable health conditions in Indian Country. As Congress states in the findings of IHCIA: “Federal health services to maintain and improve the health of the Indians are consonant with and required by the Federal government’s historical and unique legal relationship with, and resulting responsibility to, the American Indian people.” Along with the Snyder Act of 1921, the IHCIA forms the statutory basis for the delivery of health care to AI/ANs, by the Indian Health Service (IHS), an agency with the U.S. Department of Health and Human Services.

• 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, so Medicaid varies state by state and may have a different name in your state.

• Medicaid expansion — The health care law also expands the federal-state safety-net program to cover more low-income people. Medicaid is expected to account for about half the 25 million uninsured people who, the Congressional Budget Office estimates, eventually will gain coverage through the law. The federal government will pay the full cost of the new coverage from 2014-2016, then phase down to 90 percent. Twenty-four states plus Washington, D.C., have accepted the expansion, according to AP’s count. Eight states are still considering it. And 18 states including Montana have rejected it. Many adults below the poverty level will remain uninsured in the refusing states. A state can change its decision at any time, but the full federal payment for the expansion is only available through 2016.

• Medicare — A Federal health insurance program for people who are age 65 or 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 Advantage (Medicare Part C) — A type of Medicare health plan offered by a private company that contract with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

• Medicare Part D — A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

• Medicare Prescription Drug Donut Hole — Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

• Metal levels —The four levels of coverage — Bronze: 60-40, Silver: 70-30, Gold: 80-20, and Platinum: 90-10 — available through exchange plans, called bronze, silver, gold, and platinum. Bronze plans feature the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans have higher premiums and cover 90 percent of expected costs. The insured pick up the remaining premium percentage.

• Minimum Essential Coverage — The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.

• Navigators — People or agencies that can teach and/or assist a person about the health insurance plans available in the Health Insurance Marketplace.

• New Plan — As used in connection with the Affordable Care Act: A health plan that is not a grandfathered health plan and therefore subject to all of the reforms in the ACA. In the Health Insurance Marketplace, a plan that your family is purchasing for the first time will generally be a new plan. In the group health insurance market, a plan that your employer is offering for the first time will generally be a new plan. Please note that new employees and new family members may be added to existing grandfathered group plans – so a plan that is “new to you” and your family may still be a grandfathered plan. In both the individual and group markets, a plan that loses its grandfathered status will be considered a new plan. A plan loses its grandfathered status when it makes significant changes to the plan, such as reducing benefits or increasing cost-sharing for enrollees. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

• Nondiscrimination — A requirement that job-based coverage not discriminate based on health status. Coverage under job-based plans cannot be denied or restricted. You also can’t be charged more because of your health status. Job-based plans can restrict coverage based on other factors such as part-time employment that aren’t related to health status.

• Open Enrollment Period — The period of time set up to allow you to choose from available plans, usually once a year. American Indians and Alaska Native may enroll anytime during the year.

• Out-of-Pocket Costs — Your expenses for medical care that are not reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

• Out-of-Pocket Limit (OOP) — The maximum amount you will have to pay for covered services in a year. Generally, this includes the deductible, coinsurance, and copayments. This definition may vary from plan to plan. For example, in some plans the out-of-pocket limit doesn’t include cost sharing for all services, such as prescription drugs. Plans may have different out-of-pocket limits for different services. In Medicaid and HMK, the limit includes premiums.

• Pre-existing condition — An ongoing or past health problem. Currently insurers can use pre-existing conditions to deny or restrict coverage, or charge more. Those practices will be barred by federal law starting January 1, 2014, and insurers will have to accept all applicants.

• Prevention — Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

• Preventive Services — Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Learn more about preventive care and services.

• 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 — Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Health Insurance Marketplace in which it is sold.

• Skilled Nursing Facility Care — Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

• Special Health Care Need — The health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.

• Tax credits — Government health insurance subsidies for individuals will come in the form of tax credits. The money will be paid directly to the consumer’s health plan, to help cover premiums. The subsidies are on a sliding scale based on income. Each year, people will have to “true up” with the IRS to make sure they got the right amount. People who receive too generous a tax credit may owe money back to the government.

• Tax penalty — The fine levied on individuals who disregard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014 it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. Thereafter it’s adjusted for inflation.

• Value-Based Purchasing — Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.

• 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 Program — 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.

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