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When you are choosing your health insurance plan, the last thing you need is to be faced by words or terms you don't fully understand. We've put this guide together to help clear things up a bit. (Your plan's summary of benefits and coverage will also give you an explanation of how the terms apply.)
Advanced Premium Tax Credits (APTC)
Sometimes known as APTC, “advance payments of the premium tax credit,” or premium tax credit. These tax credits can be used to lower monthly premium costs. If you qualify, you may choose how much to apply to your premiums each month, up to a maximum amount. MNsure sends your tax credit directly to your insurance company. If at the end of the year you have received more APTC than you’re due, you may have to pay money back when you file your federal income tax return. If you’ve taken less than you qualify for, you’ll get the difference back.
Affordable Care Act
On March 23, 2010, president Obama signed the Affordable Care Act, a comprehensive health care reform law that expands Medicaid coverage to millions of low-income Americans. 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.
One key feature of the law is that affordable health insurance exchanges or marketplaces (like MNsure) would be set up in every state. They will allow residents to compare health plans, get their questions answered, find out if they qualify for tax credits or health programs, and enroll in a health plan.
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 provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Annual Household Income
For most taxpayers, the household modified adjusted gross income (MAGI) is the same as adjusted gross income (AGI) which can be found on Line 4 on a Form 1040EZ, Line 21 on a Form 1040A, or Line 37 on a Form 1040.
Taxpayers who receive non-taxable Social Security benefits, earn income living abroad, or earn non-exempt interest should add back that income to AGI to calculate MAGI. For more information, search for "modified AGI" on IRS.gov.
Medical Assistance eligibility will be determined excluding the following types of income: scholarships, awards, or fellowship grants used for education purposes and not for living expenses, and certain American Indian and Alaska Native income derived from distributions, payments, ownership interests, real property usage rights, and student financial assistance.
Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. PPACA prohibits annual limits for essential benefits for plan years beginning after Sept. 23, 2010.
A request for a fair review of a decision or action, to see if an error was made.
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 may not balance bill you for covered services.
Broker (insurance agent)
Brokers are trained and licensed professionals who provide free face-to-face enrollment help and advice for selecting private insurance plans.
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, or those who qualify for a hardship exemption. If you’re 30 or older and want to enroll in a catastrophic plan, you must claim a hardship exemption to qualify. You can apply for an exemption from HealthCare.gov. These exemptions are not issued by MNsure. Eligible individuals will receive an exemption certificate number (ECN) from HealthCare.gov. Each member of your household who qualifies for the exemption will get their own ECN. You’ll need your ECN when you enroll in a catastrophic plan.
COBRA stands for Consolidated Omnibus Budget Reconciliation Act. This federal law provides many workers with the right to continue coverage in a group health plan from their employer for limited periods of time (typically up to 18 months) under certain circumstances, such as voluntary or involuntary job loss. The entire cost of the plan premiums usually must be paid by the worker.
MNsure can provide a lower-cost alternative to COBRA.
The U.S. Department of Labor has more information about COBRA.
Co-insurance is your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. For example, if your plan's co-insurance is 20%, you’ll pay 20% of the cost of covered services until you reach your out-of-pocket maximum. Generally, you'll start to pay co-insurance after you have paid your health plan’s deductible.
Complications of Pregnancy
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren't complications of pregnancy.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Cost-Sharing Reductions (CSR)
Reductions included in specific silver level plans; only available to applicants that are determined eligible for this subsidy. CSR is reflected in the out-of-pocket costs, for example deductible, co-insurance or co-pays that enrollees in these plans pay, not in a reduction of premiums. Specific questions about cost-sharing reduction plans should be directed to the health insurance company offering the plan. American Indian/Alaskan Native cost-sharing reductions are available in all metal levels: bronze, silver, gold and platinum.
Covered Drug List
A covered drug list, also referred to as a formulary, is a list of prescription drugs covered through your health plan. The drugs covered can vary from plan to plan.
The amount you must pay out-of-pocket for health care for services covered by your health insurance or plan before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won't pay anything until you've met your $1000 deductible for covered health care services subject to the deductible. Not all health care services count toward the deductible.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
A notice sent by MNsure to let a MNsure consumer know the decision about whether the consumer qualifies (is eligible) for a MNsure program.
Emergency Medical Condition
A condition where there is an immediate need for health services. This happens when a person's life or health or ability to get, keep, or regain maximum function is in serious danger.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency Room Care
Emergency services you get in an emergency room.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Employer-Sponsored Insurance (ESI)
Insurance coverage under a group health plan (including self-insured plans), such as coverage provided by an employer to an employee and their dependents including some health reimbursement arrangements (HRAs), retirement benefits, or COBRA.
Essential Health Benefits (EHB)
Under the Affordable Care Act (ACA), health plans must cover ten benefit categories called essential health benefits offered in the individual and small group markets, both inside and outside of health insurance exchanges. Medical Assistance (Medicaid) plans must also cover these services by 2014. A description of the essential health benefits categories can be found on HealthCare.gov.
Health care services that your health insurance or plan doesn't pay for or cover.
A formulary, also known as a covered drug list, is a list of prescription drugs covered through your health plan. The drugs covered can vary from plan to plan.
A stated dissatisfaction or complaint that is not the same as an appeal.
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 Insurance Marketplace
A resource where individuals, families and small businesses can learn about their health coverage options, compare health insurance plans based on cost, benefits, and other important features; choose a plan; and enroll in coverage. The marketplace encourages competition among private health plans, and is accessible through websites, call centers and in-person assistance.
Health Maintenance Organization (HMO)
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor's visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
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.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
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 (for example, $15) 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.
An organized way to manage costs, use, and quality of the health care system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).
Medicaid or Medical Assistance
A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women), and disabled people. The program is called Medical Assistance in Minnesota.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
MinnesotaCare is a subsidized health care coverage program for lower income Minnesotans who do not have access to affordable health care coverage and are not eligible for Medical Assistance. Enrollees pay a monthly premium, determined by a sliding-fee scale based on family size and income.
Minimum Essential Coverage (MEC)
Any insurance plan that meets the Affordable Care Act requirement for having health coverage. Some consumer protections depend on whether someone has minimum essential coverage. For example, certain special enrollment periods to enroll in coverage outside of the annual open enrollment period are only available to individuals who had and lost minimum essential coverage.
Modified Adjusted Gross Income (MAGI)
See entry above for Annual Household Income.
Navigators are trained staff from local, trusted community organizations who provide free help with filling out an application and enrolling in coverage. They have specialized experience with Medical Assistance and Minnesota Care enrollment.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.
Open Enrollment Period
The annual period when eligible individuals can enroll in a private health insurance plan or renew or make changes to a current plan.
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 (for example, $30) 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.
Costs like your co-pay or deductible. This amount does not include your premium or services that are not covered by your plan. Keep in mind there is an annual limit on your out-of-pocket costs.
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 limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Health care services a licensed medical physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinates.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Point-of-Service Plan (POS)
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar co-payment (say $10 for a doctor's visit), or to an out-of-network provider and pay a deductible and/or co-insurance charge.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn't a promise your health insurance or plan will cover the cost.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your plan to see if you can see all preferred providers or if your health insurance plan has a "tiered" network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also "participating" providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Preferred Provider Organization (PPO)
A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Drugs and medications that by law require a prescription.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Routine health care that includes screenings, check-ups and patient counseling to prevent illnesses, disease or other health problems.
Primary Care Physician
A doctor (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A doctor (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
A doctor (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
A provider network is a list of health care providers and facilities that an insurance plan contracts with to provide care to its members. These providers are typically referred to as "in-network providers."
Qualified Health Plan
Qualified health plans are commercial health insurance plans (private health insurance plans) offered by insurance companies on the MNsure marketplace. All qualified health plans offer the same core set of benefits, including preventive services, mental health and substance abuse services, emergency services, prescription drugs and hospitalization and follow established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts). Each qualified health plan has been reviewed by state regulators and approved to be sold on MNsure.
Qualifying Life Event
A change in your life that can make you eligible for a special enrollment period to enroll in health coverage outside the annual open enrollment period. Examples of qualifying life events are: moving to a new area; certain changes in your income; and changes in your family size (for example, if you marry, divorce or have a baby).
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
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.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Special enrollment period (SEP)
A period of time when you can enroll in a private health plan or change to another private plan if you experience a qualifying life event.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Summary of Benefits (SBC)
A document provided by insurance companies explaining in plain language the benefits and coverage of a health plan. All SBCs are formatted the same and cover the same key features. This makes it easy for consumers to compare plans side by side. SBCs are available to consumers as they shop and compare plans on MNsure.
Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.
UCR (Usual, Customary, 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.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.