Glossary
Adjusted Gross Income Your total (or “gross”) income for the tax year, minus specific permissible adjustments, which include but are not limited to deductions for conventional IRA contributions, alimony paid, student loan interest, and more. Adjusted gross income can be found on line 37 of IRS Form 1040.
Affordable Care Act The ACA, or The Affordable Care act, is the name of a comprehensive health care reform law enacted in March of 2010. Goals of the law include, but are not limited to, making health care more affordable, expanding the Medicaid program to cover all adults with income below 138% FPL, and support innovative medical care delivery designed to generally lower the overall costs of health care.
Annual Wellness Exam This is an appointment, typically with your primary care physician, which can include a review of your medical history related to your health. This check up can also include education and counseling about preventive services
APTC Advanced premium tax credits, this is the subsidy in the form of a tax credit you can take in advance towards your monthly health insurance premium, available within the Covered California marketplace for certain individuals and households who qualify based on estimated income. If you have questions or concerns about whether or not you qualify for APTC, do not hesitate to contact us for free advice and clarification. Send us an email at info@corecolumbia.com, or call us at (206) 258-6820.
Balance Billing This is the difference between what the physician charges for a service and what the health plan pays for that service. If a physician were to charge $200 and the health plan covered $150, the member would be responsible for the remaining $50 payment. Balance billing varies from carrier to carrier, but typically only applies to plans with out of network coverage, such as PPOs.
Benefits Also referred to as covered services. These are health care services that are covered by your health plan, including but not limited to primary care physician visits, laboratory tests, and X-Rays.
Broker A broker is a licensed individual or agency, such as Core Columbia Insurance, that is certified to provide assistance with applying for enrollment in and/or financial assistance with a Covered CA plan.
Catastrophic Health Insurance Plan These are plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that do not include any coverage for benefits beyond three primary care visits per year before the plan’s deductible is met. These plans typically have a lower premium than other than QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance have the potential to be significantly higher. Individuals must be below 30 years of age or obtain a hardship exemption to be eligible for enrollment in a catastrophic health insurance plan.
CHIP Low-cost coverage extended by the state to children in families that earn too much money to qualify for MediCaid. In some states, pregnant women are covered.
COBRA A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you are responsible for paying 100% of the premiums, including the share the employer used to pay, plus a small administrative fee. If you have questions or concerns about whether or not COBRA coverage is in your best interest, do not hesitate to contact us for free advice and clarification. Send us an email at info@corecolumbia.com , or call us at (206) 258-6820.
Coinsurance This is a portion of the cost of a health service, calculated as a percentage, of a covered medical service. Coinsurance varies by service, carrier, and plan. If a medical appointment or service were $200, and a member had a 50% copayment, the health plan would pay $100, and the member would be responsible for paying $100.
Coordination of Benefits A system for deciding which plan needs to pay first when two or more health insurance plans are both responsible for paying the same medical claim.
CoPayment A copayment is a portion of the costs of a health service, usually calculated at a fixed rate. Copayments vary by service, carrier, and plan.If a member had a $100 copayment for a $1000 medical appointment or service, the member would only be responsible for paying $100, and the health plan would pay the rest.
Cost Sharing This is the amount the member would pay out of pocket for services covered by a health plan. Coinsurance, copayments, and deductibles are all types of cost sharing.
Cost Sharing Reduction Also referred to as CSR, this is a discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. For those who qualify, these additional savings are available when they enroll in Covered CA plans in the Silver tier.
Covered California Covered Ca is the state of California’s health care marketplace that provides individuals, families, and small business with low cost health insurance options.
Covered Services Also referred to as benefits. These are health care services that are covered by your health plan, including but not limited to primary care physician visits, laboratory tests, and X-Rays.
Deductible This is the amount members pay out of their own pocket for services before those services are covered by their health plan. For example, if a health plan has a medical deductible of $1000, the member will be responsible for all health care service payments until they reach a cumulative total of $1000. The deductible is always outlined clearly by the health plan, and does not apply to all services.
Dependents These are the children, spouses, or domestic partners of primary members. Emergency Room Care – Costs and coverage related to visits to and treatment in a hospital’s designated emergency room facility.
Excluded Services These are services that a health plan will not pay for or cover. Many excluded services are typically defined in a plan’s summary of benefits and coverage. If you have questions or concerns about whether or not a service is excluded or included by your existing or prospective plan, do not hesitate to contact us for free advice and clarification. Send us an email at info@corecolumbia.com , or call us toll free at 888-417-7624.
Formulary This is a list each health plan maintains of the prescription drugs that are covered under each plan. Some drugs are defined as always covered, while others may require prior authorization before they are covered.
FPL The Federal Poverty Level is a measure of income issued every year by the HHS that is used to determine eligibility for and enrollment in programs such as MediCaid, MediCal, CHIP, and Covered California.
Group Health Plan These are types of health plans, typically offered by an employer or employee organization, that gives health insurance coverage to employees or organization members and their families under a single policy.
HMO Also known as a health maintenance organization, an HMO is a type of health plan that typically places a limit on coverage for treatment from physicians who are not contracted with the health plan. HMOs typically do not cover out of network costs, except for emergency treatment. HMOs may require that you reside or work within their service area to be eligible, or require that enrollees receive prior authorization from a PCP before an appointment with a specialist is covered.
MediCaid A joint state and federal program to assist with medical costs and coverage of individuals and families who qualify based on income. MediCal – Coverage extended by the state of California to individuals and families whose income falls below 138% of the FPL.
MediCare Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). There are different parts of Medicare that help cover specific services, including but not limited to Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and Medicare
Part D (prescription drug coverage).
Medical Deductible This is the amount members pay out of their own pocket for specific medical services before those services are covered by their health plan. For example, if a health plan has a medical deductible of $1000, the member will be responsible for all health care service payments until they reach a cumulative total of $1000. The medical deductible is always outlined clearly by the health plan, and only applies to plan specific medical services.
Member Any individual who receives benefits under a health plan.
Minimum Essential Coverage – Any insurance plan that meets the Affordable Care Act requirement for having health coverage. For example, to avoid the 2018 penalty for not having insurance. you must have been enrolled in a plan that qualifies as minimum essential coverage (sometimes called “qualifying health coverage”). Examples of plans that qualify include: Marketplace plans; job-based plans; Medicare; and Medicaid & CHIP.
Modified Adjusted Gross Income (MAGI) The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children’s Health Insurance Program (CHIP). MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.
Network Your network is the group of physicians, hospitals and medical groups, specialists, and other types of providers that the health plan is contracted with to provide health care services.
Obamacare An unofficial name often used for the Affordable Care Act (ACA).
Open Enrollment A period of the year when consumers do not require a qualifying life event to enroll in a health plan.
Out-of-Pocket Maximum Each year, each health plan sets a maximum limit on what members responsible for paying for out of pocket cost on non-premium health care spending such as copayments and deductibles. This amount is defined by you health plan each year. Pharmacy and over the counter spending is typically not factored into this amount, and some plans have separate out of pocket maximums for prescription drugs.
Pharmacy Deductible This is the amount members pay out of their own pocket for specific prescription drugs before those services are covered by their health plan. For example, if a health plan has a pharmacy deductible of $1000, the member will be responsible for all prescription drug payments until they reach a cumulative total of $1000. The pharmacy deductible is always outlined clearly by the health plan, and only applies to plan specific prescription drugs.
Pre-existing Conditions A health problem, such as cancer, arthritis, or heart disease, that you may have been diagnosed with or treated for prior to the effective date of your new health coverage. Health insurance carriers are prohibited from increasing premiums or out of pocket costs because of pre-existing conditions, or refusing to cover treatment for pre-existing conditions.
Premium This is the amount paid to the health insurance carrier each month to maintain enrollment and coverage in a plan.
Preventative Care This is defined as routine health care, such as check ups or screenings to prevent diseases or illnesses.
Primary Care Physician (PCP) This is the doctor who is a first point of contact for providing health care services for patients.
PPO Also known as a preferred provider organization, this type of health plan contracts directly with entities such as hospital groups and physicians, to create a network of participating providers. PPO plans typically charge enrollees less money for appointments and services with providers that belong to the plan’s network, and more for using providers outside of the network.
Qualifying Life Event A QLE, or qualifying life event, is any change in your situation, such as having a baby or losing your employer sponsored coverage, that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period. If you have questions or concerns about whether or not your situation is a qualifying life event, do not hesitate to contact us for free advice and clarification. Send us an email at info@corecolumbia.com , or or call us at (206) 258-6820.
Special Enrollment Period – This is defined as the portion of the year outside of the annual open enrollment period (when anyone eligible for a health plan can apply for health insurance). To qualify for applying for a health plan during the special enrollment period, families and individuals need to have had certain qualifying life events, such as having a baby, moving outside of your plan’s coverage area, or losing employer sponsored coverage. If you have questions or concerns about whether or not your situation is a qualifying life event, do not hesitate to contact us for free advice and clarification. Send us an email at info@corecolumbia.com , or call us at (206) 258-6820.
Specialist A doctor who specializes in a certain area of medicine and/or treats certain types of symptoms and conditions is considered by most health plans to be a specialist.
Subscriber Most carriers define the subscriber as the name of the main individual listed on the health plan. Travel Health Insurance – temporary health insurance plans for health insurance coverage outside the continental US for US residents who have current ACA compliant US only policies. Core Columbia Insurance offers travel health insurance policies for many different durations, from a few days, to many months.
Tax Household A tax household is a term for a group consisting of the taxpayer(s) and anyone who is currently being claimed as a dependent, such as a spouse or a child, on a single federal income tax return.
Urgent Care Defined as care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.