Health Insurance Concepts and ACA Regulations

Vocabulary flashcards covering core concepts of health insurance, managed care models, government healthcare programs, and Affordable Care Act (ACA) provisions from the lecture.

Cost Sharing

Funds, other than the premium, paid by the insured person for the costs of health care in order to limit the insurance company's liability for small claims and keep premiums low.

Premium

The payment made by the insured person, their employer, or both, which provides the insurer with a pool of money to pay claims and cover benefits.

Copayment (Copay)

A fixed dollar amount an insured person pays for specific covered services at the time provided, charged at a lower amount when the provider contracts with the insurer.

Deductible

The amount an insured person pays for covered expenses in each plan year before the insurance company begins making payments.

Coinsurance

A form of cost sharing where, after the deductible is met, the insurance company pays a calculated percentage of total covered medical expenses (e.g., $90/10$, $80/20$, $70/30$, $60/40$).

Out-of-pocket Maximum

The highest amount an individual or family (2 or more people in the same plan) can pay during one policy period before the health plan pays $100\%$ for covered essential health benefits.

Lifetime / Annual Limits

Dollar caps insurance companies may impose on non-essential health benefits or specific benefits (such as a $200,000$ lifetime cap on organ transplants or 1 gastric bypass per year).

Medically Necessary

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or symptoms, meeting accepted standards of medicine.

Inpatient Care

Care provided after a person is formally admitted to a hospital, skilled nursing facility, or licensed/approved medical institution before being medically discharged.

Outpatient Care

Care provided when a doctor does not write an order to admit an individual as a patient in a hospital or medical facility (e.g., emergency room, clinic, observation, outpatient surgery).

Healthcare Provider

A person or facility that is trained and licensed to give health care.

Medical Supplier

A person or business that provides medical items or services, such as wheelchairs or walkers.

Traditional Health Plans (Fee-for-Service Plans)

Health plans offering the broadest level of choice regarding care without needing referrals for specialists, provider pre-certifications, or utilization reviews.

Managed Care Plans

Plans that contract with healthcare providers and facilities to offer medical services and treatment at lower costs while managing quality of care.

Preferred Provider Organization (PPO)

An organization of medical providers delivering medical treatment/services to enrollees based on a fee schedule and managed medical care guidelines.

Health Maintenance Organization (HMO)

An organization of medical providers employed or contracted by the insurer to provide health care to members, requiring selection of a primary care physician (PCP).

Capitation Fee

A specific fee paid to a provider per member under an HMO plan, regardless of the number or types of visits made by members.

Point of Service Organization (POS)

A combination of HMO and PPO where enrollees must choose a primary care physician but can seek out-of-network treatment.

Exclusive Provider Organization (EPO)

A PPO-like plan that does not allow the use of out-of-network providers without prior approval from the EPO.

High Deductible Health Plans (HDHPs)

Health plans with higher deductible and minimum deductible requirements set by the federal government and subject to annual changes.

Health Savings Accounts (HSAs)

Accounts that coordinate with high deductible health plans to allow individuals to pay for qualified out-of-pocket expenses with pre-tax dollars.

Individual Coverage Health Reimbursement Arrangement (ICHRA)

An arrangement allowing consumers to choose their own qualified health plans on or off the exchange instead of enrolling in traditional employer-sponsored coverage.

Medicare

A federal health plan primarily providing benefits to individuals $65$ and older, certain disabled persons, and persons suffering from kidney failure or ALS.

Medicaid

A program financed by federal and state governments to provide health care for low-income, disabled, elderly, or child Americans unable to pay for care.

Categorically Needy

Medicaid-eligible individuals who meet a certain threshold of the Federal Poverty Level (FPL), including low-income families, qualified pregnant women, children, and SSI recipients.

Medically Needy

Individuals whose income is too high for standard Medicaid but who have significant health needs and qualify through a spending down program.

Children's Health Insurance Program (CHIP)

A program (known in Nevada as Nevada Check Up) providing coverage for children from birth through age $18$ in households earning up to $200\%$ of the FPL.

Dual-eligibility

A status under the ACA where Medicare beneficiaries of any age with income less than a specified percentage of the FPL can enroll in Medicaid to cover uncovered expenses.

Employer Shared Responsibility Provisions

ACA requirement that Applicable Large Employers (ALEs) offer full-time employees affordable minimum essential coverage providing minimum value or pay a penalty.

Essential Health Benefits (EHBs)

A required comprehensive package of 10 categories of health care services for health plans in individual and small group markets.

Mental Health Parity and Addiction Equity Act (MHPAEA)

ACA provision requiring group plans with over $50$ employees to ensure mental health/substance use disorder financial requirements and treatment limits are no more restrictive than medical benefits.

Pre-existing Condition

Any physical or mental condition for which a person sought or received medical advice, treatment, care, or diagnosis prior to health plan enrollment.

Advance Premium Tax Credit (APTC)

A tax credit based on estimated household income for the upcoming year designed to lower monthly health insurance premiums for eligible individuals.

Rate Review

Requirement for insurance companies to publicly explain any rate increase of $15\%$ or more before charging the higher premium.

Medical Loss Ratio (MLR)

An ACA requirement, also known as the $80/20$ rule, regulating how insurers allocate funds between medical care and administrative costs.

Modified Adjusted Gross Income (MAGI)

The income methodology used to determine eligibility for Medicaid, CHIP, and insurance marketplace savings.

Summary of Benefits and Coverage (SBC)

A straightforward document detailing a plan's benefits, services, cost-sharing provisions, exceptions, and exclusions.

Agent

A trained insurance professional who helps applicants enroll in health insurance plans for an insurer.

Broker

A trained insurance professional certified by CMS who can enroll applicants in plans inside or outside the exchange.

Federal Poverty Level (FPL)

A standard measurement of income used to determine individual eligibility for specific state and federal benefits and programs.

Nevada Health Link Exchange

A state-based resource in Nevada for individuals, families, and small businesses to learn about, compare, and enroll in health insurance plans.

Minimum Essential Coverage (MEC)

Any health insurance plan that satisfies the Affordable Care Act requirement for having health coverage.

Minimum Value

A coverage standard met when a health plan pays at least $60\%$ of total medical costs for a standard population and offers substantial physician and inpatient hospital coverage.

Qualified Health Plan (QHP)

A health plan certified by the Silver State Health Insurance Exchange of Nevada to cover the 10 essential health benefits and adhere to cost-sharing limits.

Special Enrollment Period (SEP)

A time frame outside open enrollment (usually $60$ days before or after a qualifying life event) permitting sign-up for a QHP through the exchange.

Qualifying Life Event (QLE)

A significant life change (such as loss of coverage, household change, or residence change) that grants eligibility for a Special Enrollment Period.

Applicable Large Employers (ALEs)

Employers with $50$ or more full-time or full-time equivalent employees who are subject to employer shared responsibility provisions.

Full-time Employee (ACA definition)

An employee working $30$ hours or more per week, $120$ days or more per year, or $130$ hours in a calendar month.