Glossary from Covered California Website
Actuarial Value
A Health Plans 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 overall 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 point of receiving health care services-when you vist the doctor or the emergency room, for example. The health plans that cover the greatest percentage of health care expenses also have higher premium expenses.
Coinsurance
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service, is called coinsurance. You pay coinsurance plus any deductible you may owe. For example, if the health insurance plan's allowed for an office visit is $100 and you have met your deductible for the year, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of allowed amount. The allowed amount is the amount the provider has agreed to accept for the care provided.
Copayment
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
The share of costs for covered services 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 noncovered services. Cost-sharing in Medicaid and Children's Health Insurance Program also includes premiums.
EPO (Exclusive Provider Organization)
Exclusive Provider Organization is a type of health care provider network product that offers a full array of covered benefits from a single provider network. Covered benefits are not paid for services rendered by a provider who is not part of the provider network except in the case of emergency or plan-approved care outside of the provider network.
Essential Health Benefits
Health care service categories that must be covered by certain plans, starting in 2014. These service categories include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, behanioral health treatment, prescription drugs, rehabilitative and habilitation services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including dental and vision care. Insurance policies must cover these benefits in order to be certified and offered in the marketplace, and all Medicaid state plans must cover these services by 2014.
Federal Poverty Level
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. In 2012, the federal poverty level for an individual was $11,490 per year and $23,550 for a family of four. To see a chart with more information on federal poverty levels, please visit this link.
Health Insurance
A contract that requires your health insurer to pay some or all of your health care costs for covered services in exchange for a premium.
HMO (Health Maintenance Organization)
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 areas to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Out-of-Pocket Limit
The most you pay during a policy period (usually a calendar 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. In Medicaid and CHIP, the limit includes premiums.
PPO (Preferred Provider Organization)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay(s) it monthly, quarterly or yearly.
Qualified Health Plan
An insurance product that is certified by the California Health Benefit Exchange, 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 exchange in which it is sold.
Subsidy
Starting in 2014, cost-sharing subsidies and tax credits will lower the cost of premiums and out-of-pocket expenses for health coverage that qualifies families and individuals to purchase through Covered California.
Tax Credit
One of the largest federal subsidy programs for health insurance, starting in 2014, to help consumers pay health insurance premiums. Tax credits are available exclusively for insurance purchased through Covered California will also be available to small businesses with no more than 25 full-time equivalent employees to help offset the cost of providing coverage..
