California’s Access for Infants and Mothers (AIM) program provides low-cost, comprehensive health coverage for middle-income pregnant women who do not have health insurance, who are not eligible for Medi-Cal or Medicare Part A and Part B, and who are less than 30 weeks pregnant. The program is administered by the Managed Risk Medical Insurance Board.
A group of health care providers who give coordinated care and chronic disease management and thereby improve the quality of care patients get. The organization’s payment is tied to achieving health care quality goals and outcomes that result in cost savings.
A health insurance plan’s actuarial value is the percentage of total average costs for benefits that a plan covers. All Covered California health insurance plans 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 covers. This means the Platinum plans 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 insurance plans that cover the greatest percentage of health care expenses also usually have higher premium payments.
Enacted in March 2010, the federal Patient Protection and Affordable Care Act (Affordable Care Act), occasionally referred to as “Obamacare,” provides the framework, policies, regulations and guidelines for implementation of comprehensive health care reform by the states. The Affordable Care Act expands access to quality, affordable insurance and health care.
Employer coverage is considered affordable — as it relates to premium assistance from the federal government (also known as the Advanced Premium Tax Credit [APTC]) — if the employee’s share of the annual premium for self-only coverage is no greater than 9.5 percent of annual household income. Individuals offered employer-sponsored coverage that’s affordable and provides minimum value are not eligible for premium assistance.
Indigenous peoples of Alaska. See “federally recognized tribe.”
The amount a health insurance plan and health care provider have agreed on as reimbursement for a service by contract. For example, the provider agrees to accept a set dollar amount as full payment for an office visit.
Medical care provided without need of admission to a health care facility. This includes a range of medical procedures and treatments such as blood tests, X-rays, vaccinations and even monthly well-baby checkups by pediatricians.
The total amount of income for a family in a calendar year. The modified adjusted gross income of the household used for tax purposes.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services, such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.
Products and services covered under health insurance plans. Covered benefits and excluded services are defined in the insurance products’ explanations of coverage.
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.
Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.
A company that provides health insurance plans.
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 coverage, you pay 100 percent of the premiums, including the share the employer used to pay, plus a small administrative fee.
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. You pay coinsurance plus any deductible you owe. For example, if the health insurance plan’s allowed amount 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 the allowed amount.
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.
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. Cost-sharing in Medicaid and Children’s Health Insurance Program also includes premiums.
County eligibility workers are county employees who are already trained to provide assistance in facilitating enrollment in Medi-Cal and the Children’s Health Insurance Program (CHIP). They are vital in ensuring a “no wrong door” approach to implementing the Patient Protection and Affordable Care Act in California. Covered California expects counties to certify about 10,000 county eligibility workers in all 58 counties. County eligibility workers are authorized to provide enrollment assistance.
Covered California™ is the state marketplace established under the Patient Protection and Affordable Care Act that connects Californians to accessible, quality health coverage.
A Covered California Certified Educator is an individual who works for an organization supported through Covered California’s Outreach and Education Program. Certified Educators disseminate clear, accurate and consistent messages about Covered California that eliminate barriers, increase interest in Covered California programs and Medi-Cal and motivate consumers to enroll in coverage. Certified Educators must attend a two-and-a-half-day initial training through Covered California and pass an exam to become certified through Covered California. Certified Educators cannot provide enrollment assistance (i.e., they cannot help consumers fill out their application for insurance) and thereby are prohibited from handling payment information on behalf of a consumer. Certified Educators have already been selected for 2013 and 2014. More information is available at http://hbex.coveredca.com/educators/.
A Covered California Certified Enrollment Counselor is an individual who provides in-person assistance to consumers in the individual marketplace. These counselors help consumers apply for coverage and facilitate enrollment. They must complete a three-day Covered California-approved training, undergo a background check and pass an exam to obtain certification. In order to maintain one’s certification, one must pass an exam annually. Covered California’s Certified Enrollment Counselors were previously referred to as “assisters.”
Certified Enrollment Counselors are always affiliated with a Covered California Certified Enrollment Entity, which is paid $58 for each successful enrollment completed by the Certified Enrollment Counselor.
Certified Enrollment Counselors are prohibited from handling payment information on behalf of a consumer. Unlike Certified Insurance Agents, they cannot advise consumers about which plan is best for them.
Insurance agents wishing to work with Covered California must possess a valid license through the California Department of Insurance and must complete Covered California’s Certified Insurance Agent training and certification program. Covered California’s training and certification for insurance agents began in September 2013.
Covered California Certified Insurance Agents assist consumers in receiving eligibility determinations. Agents also work one on one with consumers to help them complete the Covered California application and select and enroll in a health insurance plan in either Covered California’s individual market or through its Small Business Health Options Program (SHOP) marketplace. Unlike Certified Enrollment Counselors, Certified Insurance Agents may collect premiums for consumers who are enrolled electronically, but they are prohibited from collecting any premium payments on behalf of consumers who complete the paper application. Certified Insurance Agents provide impartial information about a consumer’s plan choices, and they can offer advice about which particular plan may best meet a consumer’s needs.
Covered California Service Center representatives work in one of Covered California’s regional Service Centers. Service Center representatives are trained employees who guide Californians through their individual health coverage options in the marketplace and help them determine whether they qualify for federal financial assistance to cover some of the costs.
The amount you owe for health care services your health insurance plan covers before your plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you have met your deductible for covered health care services. The deductible may not apply to all services.
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays and fillings.
A dental exclusive provider organization (DEPO) works like a dental preferred provider organization (DPPO) but does not provide coverage for services provided by dentists outside the network of participating providers.
A type of dental plan product that delivers dental services to members through a network of contracted dental care providers and includes limited coverage of out-of-network services.
A type of dental plan product that delivers dental services by requiring assignment to a primary dental care provider who is paid a per-patient fee for providing all required dental services to the enrollee unless specialty care is needed. Dental health maintenance organizations (DMHOs) require referral to specialty dental providers. These products do not include coverage of services provided by dental care providers outside the dental plan.
A child or other individual for whom a parent, relative or other person may claim a personal exemption tax deduction. Under the Patient Protection and Affordable Care Act, individuals may be able to get premium assistance to help cover the cost of coverage for themselves and their dependents.
Insurance coverage for family members of the policyholder, such as spouses, children or partners.
An immigration status that’s considered eligible for getting health coverage through Covered California. View a list of individuals with “lawfully present” status for eligibility and enrollment purposes in the individual market.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
In some cases, individuals may qualify for an Enhanced Silver plan. This means, based on their income, that when an individual chooses a Silver plan, they have out-of-pocket savings through lower co-pays, co-insurance and deductibles.
Individuals in these categories get the out-of-pocket savings benefit of a Gold or Platinum plan for a Silver plan price. With an Enhanced Silver plan, on average, the plan pays 93 percent, 87 percent or 73 percent of expenses in total for covered benefits, with enrollees responsible for the rest.
Health care service categories that must be covered by all 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; behavioral health treatment; prescription drugs; rehabilitation 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 (Medi-Cal in California) must cover these services by 2014.
See “health insurance marketplace.”
An exclusive provider organization (EPO) is a type of health care doctor and hospital network that offers a full array of covered benefits from a single network. Covered benefits are not paid for services rendered by a doctor or hospital that is not part of the network, except in the case of emergency or plan-approved care outside the network.
A measure of income level issued annually by the U.S. Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits. In California, for example, Medi-Cal is available to those making up to 138 percent of the federal poverty level, which was $15,856 annually or $32,499 for a family of four in 2013.
For more information, visit www.CoveredCA.com/shopandcompare/#incomeGuidelines.
To see a chart with more information on federal poverty levels (http://aspe.hhs.gov/poverty/13poverty.cfm), please visit the U.S. Department of Health and Human Services (http://aspe.hhs.gov)’ website.
Any American Indian or Alaska Native tribe, band, nation, pueblo, village or community that the U.S. Department of the Interior acknowledges to exist as an American Indian tribe.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
An employee who works an average of at least 30 hours per week (so, part-time would be less than 30 hours per week).
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.
Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.
A requirement that health insurance plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services.
Health care services that help you 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 outpatient settings.
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company; a group health plan offered in connection with employment; or a government program like Medicare, Medicaid (Medi-Cal in California) or the Children’s Health Insurance Program (CHIP).
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Under the Patient Protection and Affordable Care Act, these are resources where individuals, families and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits and other important features; choose a plan; and enroll in coverage. Marketplaces also provide information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the marketplaces, and information about other programs, including Medicaid (Medi-Cal in California) and the Children’s Health Insurance Program (CHIP). Marketplaces encourage competition among private health plans and are accessible through websites, call centers and in-person assistance. In some states, such as California, the marketplace is run by the state. In others, it is run by the federal government.
See “health insurance.”
Health insurance plans sold through Covered California, the state’s marketplace for the federal Patient Protection and Affordable Care Act, provide essential health benefits, follow established limits on cost-sharing (such as for deductibles, copayments and out-of-pocket maximum amounts) and meet other requirements of the federal health care law.
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the health maintenance organization (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 area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
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.
An independent practice association (IPA) is a legal entity organized and directed by physicians in private practice to negotiate contracts with health insurance issuers on their behalf.
Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
The income you get from an investment, like interest you get from a bank or dividends you get from a stock you own.
For more information, see the Internal Revenue Service’s Publication 550.
Coverage that is offered to an employee (and often his or her family) by an employer.
A person who is lawfully present is determined in accordance with federal law. You can find out if you meet the requirements of being lawfully present by reviewing this document.
See “health insurance marketplace.”
California’s Medicaid health care program. This program provides free medical services for children and adults with limited income and resources. Your local county welfare/social services department manages Medi-Cal eligibility determinations. Visit https://www.coveredca.com/faqs/Medi-Cal/ for more information.
Medi-Cal’s dental managed care program provides a comprehensive approach to dental health care. This program combines clinical services and administrative procedures to provide timely access to primary care and other necessary services in a cost-effective manner. It is only available in Sacramento and Los Angeles counties. In Sacramento, a beneficiary must choose between one of three plans, and in Los Angeles, a beneficiary may choose one of three plans, or may elect to remain in fee-for-service Denti-Cal. See http://www.denti-cal.ca.gov for more information.
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.
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).
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. In addition to these categories, Covered California offers a “minimum coverage plan,” also known as a “catastrophic plan,” which helps protect a person from financial disaster in the event of a serious and expensive medical emergency. Minimum coverage plans are designed to cover excessive medical bills that occur above the limit that you would be able to manage financially. Covered California offers minimum coverage to those up to age 30 or those individuals who prove they are without affordable coverage options or are experiencing financial hardship.
Navigators, established by federal law, are similar to Covered California Certified Enrollment Counselors. Both provide fair and impartial information to consumers about enrollment into insurance plans through health benefit exchanges. They facilitate enrollment into the health insurance plans, provide referrals to exchanges and offer information that is culturally and linguistically appropriate. Additionally, navigators provide consumer education information to raise awareness about exchange programs. The Covered California Navigator Program begins in 2015 and will be funded though Covered California operating funds.
The facilities, providers and suppliers with whom your health insurer or plan has contracted to provide health care services.
A designated period of time each year — usually a few months — during which insured individuals or employees can make changes in health insurance coverage.
An out-of-pocket expense is a nonreimbursable expense paid by a patient. This could include any medical benefits that a plan doesn’t consider “covered services.”
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance plan doesn’t cover. Some health insurance plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit. In Medicaid and Children’s Health Insurance Program, the limit includes premiums.
Enacted in March 2010, the federal Patient Protection and Affordable Care Act (Affordable Care Act), occasionally referred to as “Obamacare,” provides the framework, policies, regulations and guidelines for implementation of comprehensive health care reform by the states. The Affordable Care Act expands access to quality affordable insurance and health care.
Plan-based enrollers are representatives who work directly for one of the health insurance companies that offers individual health insurance through Covered California. Plan-based enrollers undergo similar training, background checks and exam requirements as Certified Enrollment Counselors. Plan-based enrollers do not engage in door-to-door solicitation, but they may call their current or former health insurance companies’ enrollees or individuals who have expressed interest in coverage. Plan-based enrollers are authorized to provide enrollment assistance. Like Certified Insurance Agents, plan-based enrollers may accept premium payments on behalf of the health insurance company for which they work.
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.
Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.
The contract (agreement) between the person buying health insurance and the company providing it, describing specific health care services that are covered, any coverage limitations and any out-of-pocket costs (copays) that might be required.
Any illness or condition a patient has prior to obtaining insurance.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or 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.
A type of health insurance plan that contracts with participating doctors and hospitals to create a network. You pay less if you use doctors and hospitals that belong to the plan’s network. You can use doctors, hospitals and others outside the network for an additional cost.
The amount that must be paid for your health insurance or plan. You or your employer, or both, usually pay it monthly, quarterly or yearly.
One of the largest subsidy programs for health insurance, to help consumers pay health insurance premiums. Tax credits are also available to small businesses with fewer than 25 full-time-equivalent employees to help offset the cost of providing coverage.
Routine health care that includes screenings, checkups and patient counseling to prevent illnesses, disease or other health problems.
There are 19 pricing regions in California. For health plans that consumers can get through Covered California, either with or without premium assistance, the plans available and their prices vary by region. The easiest way to find the pricing region you live in is to use our Shop and Compare Tool online at https://www.coveredca.com/shopandcompare/#calculator. After entering your home ZIP code, the Shop and Compare Tool will show you your pricing region. You may also call our Service Center for assistance.
A physician (medical doctor [M.D.] or doctor of osteopathic medicine [D.O.]), 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.
An insurance product that is certified by a 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 has a certification by each marketplace in which it is sold. All Covered California health insurance plans are qualified health plans.
A change in your life that can make you eligible for a special enrollment period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income and changes in your family size (for example, if you marry, divorce or have a baby).
Health care services that help you keep, get back or improve skills and functioning for daily living that have been lost or impaired because you were 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 outpatient settings.
A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs.
In Covered California’s Small Business Health Options Program, this is a 12-month period beginning with the employer’s effective date of coverage. Also see “Small Business Health Options Program (SHOP).”
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health plan covers compared with what you are expected to pay in co-pays and deductibles. On average, Platinum-level plans cover 90 percent of health care costs, and you pay 10 percent; Gold plans cover 80 percent, while you pay 20 percent; Silver plans cover 70 percent, while you pay 30 percent; and Bronze plans cover 60 percent, while you pay 40 percent.
Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.
Covered California operates a specific program, the Small Business Health Options Program (SHOP), that offers new health insurance choices to small businesses and their employees. The program is designed specifically for employers with 50 and fewer eligible employees to give them unprecedented opportunities to offer a variety of health insurance plans to their employees. Through Covered California, employers and their employees can choose the plans that fit their needs and their budgets.
The opportunity for people who experience a life-changing event, such as the loss of a job, death of a spouse or birth of a child, to sign up immediately in a health plan, even if it is outside of the plan’s specified enrollment period.
Cost-sharing subsidies and premium assistance reduce the cost of premiums and out-of-pocket expenses for health coverage that qualifying individuals and families purchase through Covered California.
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits and other features that may be important to you. You’ll get a summary of benefits and coverage (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
The taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse or dependents.
There are penalties for individuals who choose not to get affordable insurance. These penalties are part of the federal law and will be collected by the Internal Revenue Service as part of individual tax filing for 2014. There are no penalties for small employers (fewer than 50 full-time-equivalent employees), but starting in 2015 large employers may be subject to a penalty if they do not offer affordable coverage to their employees.
In 2014, an individual who does not maintain minimum health coverage will face a penalty of $95 or 1 percent of income, whichever is greater. In 2014, a family will be charged a penalty of $95 per uncovered adult and $47.50 per uncovered child (up to $285 for a family) or 1 percent of the family’s income, whichever is greater.
For 2015, the penalty increases to $325 per adult and $162.50 per child (up to $975 for a family) or 2 percent of family income, whichever is greater.
For 2016, the penalty is $695 per adult and $374.50 per child (up to $2,085 for a family) or 2.5 percent of family income, whichever is greater.
However, some individuals may be exempt from paying a penalty, including:
- People who would have to pay more than 8 percent of their income for health insurance.
- People with incomes below the threshold required for filing taxes (in 2013, $9,750 for a single person and $27,100 for a married couple with two children).
- People who qualify for religious exemptions.
- Undocumented immigrants.
- Incarcerated individuals.
- Members of federally recognized American Indian tribes and Alaska Natives.
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.
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.
