Glossary

A

Access for Infants and Mothers (AIM)

As of July 2014, this program for pregnant women is under the management of the California Department of Health Care Services and is called the Medi-Cal Access Program. See the “Medi-Cal Access Program” entry below.

accountable care organization (ACO)

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.

actuarial value

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.

Advanced Premium Tax Credit (APTC)

Financial assistance eligible consumers may receive when enrolling in a Covered California health insurance plan, to assist them in paying their monthly premium costs. The amount of premium assistance an individual may receive is determined based on his or her income as a percentage of the federal poverty level. This tax credit may also be described as “premium assistance.” Tax credits are also available to small businesses with fewer than 25 full-time-equivalent employees to help offset the cost of providing coverage.

Affordable Care Act

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.

affordable coverage

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 a certain percentage of annual household income. Individuals offered employer-sponsored coverage that's affordable and provides minimum value are not eligible for premium assistance.

Alaska Natives

Indigenous peoples of Alaska. See “federally recognized tribe” below.

allowed amount

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.

ambulatory patient services

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.

annual household income

The total amount of income for a family in a calendar year. The modified adjusted gross income of the household used for tax purposes.

annual limit

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.

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B

benefit

Products and services covered under health insurance plans. Covered benefits and excluded services are defined in the insurance products’ explanations of coverage.

Bronze plan

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.

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C

carrier

A company that provides health insurance plans.

Certified Educator

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. More information is available at http://hbex.coveredca.com/outreach-n-edu/

Certified Enrollment Counselor, Certified Enrollment Entity

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.

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.

Certified Insurance Agent

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 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 Covered California for Small Business (CCSB). 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.

COBRA

A federal law (the Consolidated Omnibus Budget Reconciliation Act) 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.

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. 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.

Community Outreach Network

Uncompensated community partners providing outreach and education about Covered California in local communities.

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 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 worker

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

Covered California™ is the state marketplace established under the Patient Protection and Affordable Care Act that connects Californians to accessible, quality health coverage.

Covered California for Small Business (CCSB)

Covered California operates a specific program, Covered California for Small Business, which offers new health insurance choices to small businesses and their employees. The program is designed specifically for employers with 100 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.

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D

deductible

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.

dental coverage

Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays and fillings.

dental exclusive provider organization (DEPO)

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.

dental preferred provider organization (DPPO)

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.

dental health maintenance organization (DHMO)

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 (DHMOs) require referral to specialty dental providers. These products do not include coverage of services provided by dental care providers outside the dental plan.

dependent

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.

Dependent (for Shared Responsibility provision)

For purposes of the Employer Shared Responsibility provisions, a dependent is an employee’s child (including a child who has been legally adopted or placed for adoption) who has not reached the age of 26. Spouses are not considered dependents and neither are stepchildren or foster children. For more information see: https://www.irs.gov/Affordable-Care-Act/Employers/Employer-Shared-Responsibility-Provisions

dependent coverage

Insurance coverage for family members of the policyholder, such as spouses, children or partners.

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E

eligible immigration status

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.

emergency services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

ESRP – Employer Shared Responsibility provisions

Under the Affordable Care Act’s Employer Shared Responsibility provisions, ALEs must either offer minimum essential coverage that is “affordable” and that provides “minimum value” to their full-time employees (and their dependents), or potentially make an employer shared responsibility payment to the IRS. The Employer Shared Responsibility provisions are sometimes referred to as “the employer mandate” or “the pay or play provisions.” The vast majority of employers will fall below the ALE threshold number of employees and, therefore, will not be subject to the Employer Shared Responsibility provisions. For more information see: https://www.irs.gov/Affordable-Care-Act/Employers/Employer-Shared-Responsibility-Provisions.

Enhanced Silver plan

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 94 percent, 87 percent or 73 percent of expenses in total for covered benefits, with enrollees responsible for the rest.

essential health benefits

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.

exchange

See “health insurance marketplace.”

exclusive provider organization (EPO)

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.

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F

federal poverty level

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.

Program Eligibility by Federal Poverty Level (PDF)

federally recognized tribe

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.

formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

Full-Time Employees

For the purposes of the Employer Shared Responsibility provisions, a full-time employee for any calendar month is an employee who has on average at least 30 hours of service per week during the calendar month, or at least 130 hours of service during the calendar month. For more information see: https://www.irs.gov/Affordable-Care-Act/Employers/Identifying-Full-time-Employees

Full-Time Equivalent Employee - FTE

For purposes of determining whether the employer is an Applicable Large Employer (ALE), an employer determines its number of full-time-equivalent employees for a month in the steps that follow:

Combine the number of hours of service of all non-full-time employees (e.g. part-time employees, or those working fewer than 30 hours per week) for the month but do not include more than 120 hours of service per employee, and divide the total by 120. The resulting number is the number of full-time equivalent employees for a month. This figure should be combined with the number of full-time employees to get a total employment figure for a month. The employment figure for each calendar month will be used to determine the employer’s ALE status for the calendar year.

An ALE need not offer minimum essential coverage to its part-time employees to avoid an employer shared responsibility payment. A part-time employee’s receipt of the premium tax credit for purchasing coverage through the Marketplace cannot trigger an employer shared responsibility payment.

For more information see: https://www.irs.gov/Affordable-Care-Act/Employers/Determining-if-an-Employer-is-an-Applicable-Large-Employer

For more information see: https://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-Questions-and-Answers:-Determining-FTEs-and-Average-Annual-Wages

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G

Gold plan

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.

guaranteed issue

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.

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H

habilitative services/habilitation 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.

health care service plan (HCSP)

A health care service plan (HCSP) 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.

health coverage

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).

health disparities

Preventable differences in health status among different groups of people. These groups may be based on race, ethnicity, immigrant status, disability, sex or gender, sexual orientation, geography and income. Because the health status of a population is influenced by social factors such as geography, income and race/ethnicity, these factors affect the prevalence of disease and life expectancy.

health insurance

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

health insurance marketplaces

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.

health insurance plan

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.

health maintenance organization (HMO)

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.

health risk assessment

Sometimes called health assessment or health risk appraisal, health risk assessment is a tool, usually a questionnaire, used by a member to provide information about their health status and risk factors for disease. Members’ medical providers can use their completed health risk assessment to provide personalized feedback, including ways to reduce a member’s risk of disease.

hospitalization

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.

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I

independent practice association (IPA)

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.

inpatient care

Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

investment income

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.

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J

job-based health plan

Coverage that is offered to an employee (and often his or her family) by an employer.

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L

legal resident of California

A person who is lawfully present is determined in accordance with federal law. Click here to find out if you meet the requirements of being lawfully present.

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M

marketplace

See “health insurance marketplace.”

Medi-Cal

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 the Medi-Cal section of this website for more information.

Medi-Cal Access Program (MCAP)

California’s Medi-Cal Access Program (MCAP) for pregnant women (formerly known as the 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. This program is administered by the California Department of Health Care Services.

Medi-Cal dental managed care

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.

medically necessary

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.

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).

minimum coverage plan

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.

MEC - Minimum Essential Coverage

Coverage that under the regulations provides affordable minimum coverage and provides minimum value to its full-time employees (and their dependents).Minimum essential coverage designated by statute or regulations includes the following:

• Employer-sponsored coverage (including Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage and retiree coverage)
• Coverage purchased in the individual market, including a qualified health plan offered by the Health Insurance Marketplace (such as Covered California)
• Medicare Part A coverage and Medicare Advantage (MA) plans
• Most Medicaid coverage
• Children's Health Insurance Program (CHIP) coverage
• Certain types of veterans health coverage administered by the Veterans Administration
• TRICARE
• Coverage provided to Peace Corps volunteers
• Coverage under the Non-appropriated Fund Health Benefit Program
• Refugee Medical Assistance supported by the Administration for Children and Families
• Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014 (for later plan or policy years, sponsors of these programs may apply to HHS to be recognized as minimum essential coverage)
• State high risk pool coverage established on or before November 26, 2014 in any state

For more information, see: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/minimum-essential-coverage.html
and https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/ACA-Individual-Shared-Responsibility-Provision-Minimum-Essential-Coverage.

Minimum Value

An employer-sponsored plan provides minimum value if it covers at least 60 percent of the total allowed cost of benefits that are expected to be incurred under the plan. https://www.irs.gov/Affordable-Care-Act/Employers/Minimum-Value-and-Affordability

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N

Navigator

A Covered California Certified Enrollment Counselor who is affiliated with a Certified Enrollment Entity and registered in Covered California’s Navigator Program. Navigators facilitate enrollment into health insurance plans, provide referrals to exchanges and offer information that is culturally and linguistically appropriate for consumers. Additionally, they provide consumers information to raise awareness about exchange programs.

Navigator grantee

A Covered California Certified Enrollment Entity that was awarded grants to participate in the Navigator Program.

Navigator Program

A program established by federal law to provide fair and impartial information to consumers about enrollment into insurance plans through health benefit exchanges. Grant funds are awarded to Certified Enrollment Entities to perform outreach, education and enrollment assistance to consumers. The Covered California Navigator Program began in 2014 and is funded through Covered California operating funds.

network

The facilities, providers and suppliers with whom your health insurer or plan has contracted to provide health care services.

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O

Offer of Coverage

An employer makes an offer of coverage to an employee if it provides the employee an effective opportunity to enroll in the health coverage (or to decline that coverage) at least once for each plan year. An employer makes an offer of health coverage to an employee for the plan year if it continues the employee’s election of coverage from a prior year but provides the employee an effective opportunity to opt out of the health coverage.

If an employer provides health coverage to an employee but does not provide the employee an effective opportunity to decline the coverage, the employer is treated as having made an offer of health coverage to the employee only if that health coverage provides minimum value and does not require an employee contribution for the coverage for any calendar month of more than 9.56 percent in 2018 of a monthly amount determined as the mainland federal poverty line for a single individual for the applicable calendar year, divided by 12.

For more information: https://www.irs.gov/pub/irs-prior/i109495c–2015.pdf and https://www.irs.gov/pub/irs-drop/n-15-87.pdf

open enrollment

A designated period of time each year during which individuals or employees can enroll in a health insurance plan or make changes to their coverage. Open enrollment for Covered California takes place during the fall.

People who experience certain life events — such as getting married or losing previous health coverage — may be eligible for special enrollment outside of the open-enrollment period. See “special enrollment.” Medi-Cal enrollment occurs year round.

out-of-pocket costs

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.”

out-of-pocket limit

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.

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P

Patient Protection and Affordable Care Act

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

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.

Platinum plan

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.

policy

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.

pre-existing medical condition

Any illness or condition a patient has prior to obtaining insurance.

preferred provider

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.

pre-existing medical condition

Any illness or condition a patient has prior to obtaining insurance.

preferred provider organization (PPO)

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.

premium

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.

premium assistance

See “Advanced Premium Tax Credit.”

Premium Tax Credit - PTC

The premium tax credit, or PTC, is a refundable tax credit calculated with the filing of a Tax Return that helps eligible individuals and families with low or moderate income afford health insurance purchased through a Health Insurance Marketplace such as Covered California. To get this credit, the employee must meet certain requirements and file a tax return. For more information see: https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/The-Premium-Tax-Credit

preventive services/preventive care

Routine health care that includes screenings, checkups and patient counseling to prevent illnesses, disease or other health problems.

pricing region

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. 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.

primary care provider

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.

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Q

qualified health plan (QHP)

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.

qualifying life event

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).

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R

rehabilitative/rehabilitation services

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.

risk adjustment

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.

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S

Seasonal Worker

Seasonal workers are workers who perform labor or services on a seasonal basis as defined by the Secretary of Labor, and retail workers employed exclusively during holiday seasons. For this purpose, employers may apply a reasonable, good faith interpretation of the term “seasonal worker.” For more information see: https://www.irs.gov/Affordable-Care-Act/Employers/Determining-if-an-Employer-is-an-Applicable-Large-Employer

Service Center representative

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.

SHOP plan year

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).”

Silver plan

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.

Small Business Employers

Some of the provisions of the Affordable Care Act, or health care law, apply only to small employers, generally those with fewer than 50 full-time employees or equivalents. For more information: https://www.irs.gov/Affordable-Care-Act/Employers/Affordable-Care-Act-Tax-Provisions-for-Small-Employers

Small Business Health Options Program (SHOP)

(Rebranded as Covered California for Small Business) (CCSB)

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 100 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.

special enrollment

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.

subsidy

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.

summary of benefits and coverage (SBC)

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.

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T

tax credit

See “Advanced Premium Tax Credit.”

tax household

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.

tax penalty

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.

For more information about the tax penalty, visit The Tax Penalty for Remaining Uninsured.

team care

Also called team-based care, team care is based on a philosophy of professional and nonprofessional personnel who work together toward a common goal of providing quality, comprehensive care. The team members may include nurses, physician assistants, pharmacists, nutritionists, social workers, and care coordinators.

telehealth

Also called telemedicine, telehealth is the use of telecommunication and information technology that allows medical providers to evaluate, diagnose and treat patients in real time, at a distance. Telehealth includes applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications.

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U

urgent care

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.

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W

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.

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