Glossary of terms related to the Affordable Care Act

2013-07-27T20:00:00Z Glossary of terms related to the Affordable Care ActTimes Staff
July 27, 2013 8:00 pm  • 

Below is a partial list of terms you'll be hearing more often as the Affordable Care Act continues to roll out.

Accountable care organization

A group of health care providers who give coordinated care, 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.


An agent or broker is a person or business who can help you apply for help paying for coverage and enroll in a qualified health plan through the marketplace. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer's plans. Some brokers may be able to sell only plans from specific health insurers.

Certified applicant counselor

An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses and their employees as they look for health coverage options through the marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers.

Dental coverage

In the marketplace, dental coverage is available either as part of a comprehensive medical plan or by itself through a "stand-alone" dental plan.

Employer-shared responsibility payment

The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.

Employer or union retiree plans

Plans that provide health and/or drug coverage to former employees or members, and, in some cases, their families. These plans are offered to people through their (or a spouse's) former employer or employee organization. Many of these plans aren't legally required to meet many of the provisions of the Affordable Care Act, including providing coverage for children up to age 26.

Essential health benefits

A set of health care service categories that must be covered by certain plans, starting in 2014.

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside the Health Insurance Marketplace, 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.

Insurance policies must cover these benefits to be certified and offered in the health insurance marketplace, and all Medicaid state plans must cover these services by 2014.


Starting Jan. 1, 2014, if someone doesn't have a health plan that qualifies as minimum essential coverage, he or she may have to pay a fee that increases every year: from 1 percent of income (or $95 per adult, whichever is higher) in 2014 to 2.5 percent of income (or $695 per adult) in 2016. The fee for children is half the adult amount. The fee is paid on the 2014 federal income tax form, which is completed in 2015. People with very low incomes and others may be eligible for waivers.

Full-time employee

An employee who works an average of at least 30 hours per week (so part time would be less than 30 hours per week).

Grandfathered health plan

As used in connection with the Affordable Care Act: A group health plan that was created — or an individual health insurance policy that was purchased — on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

Hardship exemption

Under the Affordable Care Act, most people must pay a fee if they don't have health coverage that qualifies as "minimum essential coverage." One exception is based on showing that a "hardship" prevented them from becoming insured. More information will be available later in 2013.

Health insurance marketplace

A resource 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. The marketplace also provides 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 marketplace and information about other programs, including Medicaid and the Children’s Health Insurance Program, or CHIP. The marketplace encourages competition among private health plans and is accessible through websites, call centers and in-person assistance. In some states, the marketplace is run by the state. In others, it is run by the federal government.

Health plan categories

Plans in the marketplace are primarily separated into four health plan categories — Bronze, Silver, Gold or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you'll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60 percent (Bronze), 70 percent (Silver), 80 percent (Gold), and 90 percent (Platinum). This isn't the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.

Minimum value

A health plan meets this standard if it’s designed to pay at least 60 percent of the total cost of medical services for a standard population. Starting in 2014, individuals offered employer-sponsored coverage that provides minimum value and that’s affordable won’t be eligible for a premium tax credit.

Modified adjusted gross income

The figure used to determine eligibility for lower costs in the marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest or foreign income you have.

Medical loss ratio

A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers' medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80 percent. A medical loss ratio of 80 percent indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

Minimum essential coverage

The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.


An individual or organization that's trained and able to help consumers, small businesses and their employees as they look for health coverage options through the marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.


An official form of communication that informs individuals about the status of their applications, their eligibility for programs or other important information. Notices may be sent by the marketplace or by health insurers.

Open enrollment period

The period of time during which individuals who are eligible to enroll in a qualified health plan can enroll in a plan in the marketplace. For 2014, the open enrollment period is Oct. 1, 2013. to March 31, 2014. For 2015 and later years, the open enrollment period is Oct. 15 to Dec. 7 of the previous year. Individuals also may qualify for special enrollment periods outside open enrollment if they experience certain events.

Payment bundling

A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicate tests and treatments.

Premium tax credit

The Affordable Care Act provides a new tax credit to help you afford health coverage bought through the marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you're due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

Special enrollment period

A time outside the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other job-based health coverage.


Copyright 2014 All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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