A group of coordinated health care providers which delivers care to a group of patients. The ACO is structured to be accountable to the patients and the third-party payer for the quality, appropriateness and efficiency of the heath care provided.
A dollar limit placed upon the claims an insurer will pay over the course of a plan year. The Patient Protection and Affordable Care Act (PPACA) prohibits annual limits for essential benefits for plan years after September 23, 2010.
TopYour share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A fixed amount 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.
TopThe amount of expenses that must be paid out of pocket for health care services before an insurer will pay any expenses. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
A set of health care service categories that must be covered by certain plans, starting January 1, 2014. The Affordable Care Act ensures that ALL health plans offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Identifies plans that are found in a public exchange; these plans include all mandatory essential benefits.
A tax advantage medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit and they can roll over into the next year if they are not spent.
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor's visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor's visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
A component to the Patient Protection and Affordable Care Act, signed into law March 2010, and effective January 1, 2014. It states that all United States citizens and legal residents are required to buy health insurance or pay a penalty.
A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women), and disabled people.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
The maximum amount you can pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover. Some plans do not count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar copayment (say $10 for a doctor's visit), or to an out-of-network provider and pay a deductible and/or coinsurance charge.
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 managed care organization of providers - medical doctors, hospitals, and other health care entities - who have negotiated contracts with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients. Patients have financial incentives to select providers within the PPO network.
The estimated monthly cost of an insurance policy. The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the public exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
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).
Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.
The Affordable Care Act (ACA) establishes a system of tax credits to help consumers pay for the health coverage plans they are required to purchase by law. This tax credit helps contribute to the monthly cost or premium for the health plan coverage.
Premium tax credits are ONLY available for coverage purchased in a public Marketplace.
Premium tax credits will be available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line that are not eligible for Medicaid because of their immigration status.
In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children's Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer.
However, there are exceptions in cases when the employer plan is unaffordable, if the plan fails to provide a minimum level of coverage, or if a plan does not meet the standards for minimum value. If you are required to pay for than 9.5% of your income for coverage for a single person under your employer’s health plan, you could qualify for premium tax credits. You could also qualify for premium tax credits, if your annual deductible is higher than $6,350 per person.
When you apply for a premium tax credit during Open Enrollment, you will not necessarily know exactly what your 2014 income will be, so you will apply based on your best estimate of your 2014 income. When you file your 2014 tax return, due April 15, 2015, the IRS will compare you actual 2014 income to the amount of premium tax credit you claimed in advance. If your actual income is greater than your estimated income, you may be required to pay back some or all of the difference. If you did not receive all of the premium tax credit you are entitled to during the year, you can claim the difference when you file your 2014 tax return.
If your income changes during the year, you can modify the amount of premium tax credit accordingly. You can report any changes to a public Marketplace to raise or reduce the amount of premium tax credit you receive.
Your premium tax credit is calculated based on geographic location, household income, number of adults and children in the household, and the second lowest costing Silver plan available in your area.
To calculate your estimated premium tax credit, use our Premium Tax Credit Calculator located on the right-hand side of this page.
If you have questions or require further explanation, please contact your Agent for assistance.
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