HAP

GLOSSARY OF TERMS

  • Actuarial Value
    The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
  • Affiliated Provider
    An Affiliated Provider is a licensed corporation, partnership or individual with which HAP has contracted to provide licensed health care services to members. Affiliated Provider includes, but is not limited to, hospitals, physicians, and ancillary providers of health care services.
  • Affordable Coverage
    Employer coverage is considered affordable - as it relates to the Advanced Premium Tax Credit (APTC) - if the employee's share of the annual premium for individual coverage is no greater than 9.5% of annual household income. Individuals offered employer-sponsored coverage that's affordable and provides minimum value won't be eligible for an APTC.
  • Benefits
    The services your health plan covers, such as doctor visits, routine physicals, hospitalization, mental health services and prescription drugs.
  • Catastrophic Plan
    Catastrophic health plans cover all of the Essential Health Benefits (EHB) as defined by the ACA and cover up to three primary care visits per year with no cost-sharing.  All other services (except preventive services) are subject to the deductible. To qualify for a catastrophic plan, you must be under 30 years old or get a "hardship exemption" from the Health Insurance Marketplace.
  • Coinsurance
    The percentage of charges for certain covered services that you pay after your deductible has been met. Some health plans do not have coinsurance.
  • Consumer-driven Health Plan (CDHP)
    A consumer-driven health plan (CDHP) consists of a tax-advantaged funding structure paired with a health plan. These plans encourage members to use their health care benefits judiciously, while giving them the freedom to decide where their allocated dollars go. A variety of HAP's HMO, PPO or EPO products and can be paired with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA).
  • Copay
    A set amount you pay each time for a covered service, or the purchase of medications or other medical supplies. The copay amount can vary by the type of covered health care service. Copays do not count toward the deductible. You will continue to pay copays after you have met your deductible, until reaching your out-of-pocket limit.
  • Cost-Sharing
    The amount you pay for covered services, medications and medical supplies. These expenses are also known as out-of-pocket costs. They do not include your monthly premium (i.e. the amount you pay each month for health insurance). Your cost-sharing responsibilities reset at the beginning of the next benefit period (which is January 1 in most cases).
  • Cost-Sharing Reduction
    A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copays. You may be able to get this reduction if you buy coverage through the Health Insurance Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. If you're a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.
  • Deductible
    The amount you owe for certain covered medical services before your health plan begins to pay for them. There are per person deductible amounts and family deductible amounts.
  • Emergency
    Care necessary to screen and stabilize someone in cases where a person with no medical training, acting reasonably, believes that an emergency medical condition exists.  
  • Employer-Sponsored
    Employee health care benefits that are paid for by the employer, in the form of premium payments, health savings account funding or other applicable items. Also known as job-based insurance.
  • Employer Shared Responsibility
    The Affordable Care Act requires certain employers with at least 50 full-time employees (including full-time equivalents) to offer health insurance coverage that meets certain minimum standards to their full-time employees (and their dependents) or make a tax payment called the Employer Shared Responsibility Payment.
  • Essential Health Benefits (EHBs)
    A set of health care service categories that must be covered by Qualified Health Plans, under the Affordable Care Act. EHBs 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.
  • Exclusive Provider Organization (EPO)
    EPO plans offer the freedom of a PPO, without the out-of-network benefits. Members can see any doctor within the EPO network, without a referral and without choosing a personal care physician.
  • Federal Poverty Level (FPL)
    A measure of income level issued each year by the Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits.
  • Flexible Spending Account (FSA)
    An employer-sponsored benefit program offered to help employees save pre-tax dollars to pay for qualified medical or dependent care expenses.. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA.. Your employer's plan sets a limit on the amount you can put into an FSA each year.
  • 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.
  • Generic Drug
    A generic drug has the same active ingredients as the original brand-name drug, but it may use different inactive ingredients (such as fillers) that may affect the color or shape of the drug. In other respects, the drug is clinically the same. Generic drugs usually cost 30 to 60 percent less than the corresponding brand-name drugs, and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
  • Grandfathered Health Plan
    As used in connection with the Affordable Care Act (ACA): 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 ACA. 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.
  • Health Insurance Marketplace (Marketplace)
    A health insurance sales channel where individuals and families 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. In some states, the Marketplace is run by the state. In others it is run by the federal government. While Michigan is considered a "partnership state", it uses a federally-facilitated marketplace - the Health Insurance Marketplace.
  • Health Insurance Premiums
    The amount you pay each month for health insurance.
  • Health Reimbursement Arrangement (HRA)
    Employer-funded group health plans from which employees are reimbursed for specific qualified medical expenses up to a fixed dollar amount per year. The employer funds and owns the account. Health Reimbursement Arrangements are sometimes called Health Reimbursement Accounts.
  • Health Savings Account (HSA)
    An individually owned bank account that can be used to pay for qualified medical expenses such as copays, coinsurance, deductibles, vision and dental services and more. HSAs can only be used with a Qualified High Deductible Health Plan. The funds contributed to the account aren't subject to federal income tax at the time of deposit and roll over from year to year.  
  • HMO (Health Maintenance Organization)
    A form of health coverage that emphasizes preventive care. With an HMO, care is coordinated through a Primary Care Physician and, in some cases, referrals are needed for specialty care or services. Out of network coverage is not available except for emergency and urgent care services.
  • Household Income
    Your household income is your modified adjusted gross income (MAGI) (joint MAGI if you're married), plus the MAGI of your dependents who make enough money to have to file a tax return. MAGI is generally your adjusted gross income plus any tax-exempt Social Security benefits (except for Supplemental Security Income (SSI), which is not counted), tax-exempt interest, and tax-exempt foreign income.
  • Individual Shared Responsibility Payment
    If you and your family members have gaps in qualifying health coverage of three months or more during the year, you may be subject to a tax penalty when you file your income tax return. This is also referred to as the "individual mandate".
  • Lifetime Limit
    A cap on the total lifetime benefits you may get from your insurance company. After a lifetime limit is reached, the health plan will no longer pay for covered services. Under the Affordable Care Act, insurance companies cannot set a dollar limit on what they spend on Essential Health Benefits for your care during the entire time you're enrolled in that plan.
  • Maximum Allowable Charge
    The maximum amount HAP will pay for a covered service under the terms of the policy.
  • Medicaid
    A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities and, in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid will vary from state to state.
  • Minimum Essential Coverage
    The type of health coverage an individual needs to have in order to meet the Individual Shared Responsibility requirement under the Affordable Care Act. This includes individual policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
  • 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 standard populations. Individuals offered employer-sponsored coverage that provides minimum value and that is affordable are not eligible for an Advance Premium Tax Credit.
  • Navigator
    An individual or group that is specially trained to help consumers, small businesses, and their employees as they look for health coverage options through the Health Insurance Marketplace, including completing eligibility and enrollment forms. Navigators are required to be unbiased (they cannot favor one plan over another). Their services are free to consumers.
  • NCQA (National Committee for Quality Assurance)
    An independent, nonprofit organization that leads the effort to assess, measure and report on the quality of care provided by the nation's health plans. The NCQA seal is a widely recognized symbol of quality and a reliable indicator than an organization is well-managed and delivers high quality care and service.
  • Out-of-Pocket Costs
    The amount you pay for services, medications and medical supplies. This includes copays, deductibles and coinsurance for covered services, as well as all costs for services that are not covered. 
  • Out-of-Pocket Limit
    The most you pay for covered services during a benefit period (usually a calendar year) before HAP begins to pay 100 percent of the allowed amount. All copays, coinsurance and deductible amounts count toward your out-of-pocket limit. The out-of-pocket limit never includes your monthly premium or non-covered services.
  • Patient Protection and Affordable Care Act (PPACA) or Affordable Care Act (ACA)
    The federal health care reform law enacted in March 2010.
  • Personal Care Physician (PCP)
    An affiliated physician who has agreed to coordinate the medical care of HAP members. A personal care physician may practice in the area of family practice, internal medicine or pediatrics.
  • Preferred Provider Organization (PPO)
    In a PPO, members seek care from providers either in-network or out-of-network, without referrals. Generally speaking, receiving care out-of-network incurs higher out-of-pocket costs. In addition, members are covered for emergency and urgent care wherever they go - worldwide.
  • Premium
    The amount you pay each month for health insurance.
  • Preventive Care
    Health care services intended to prevent a medical condition from occurring, or to detect the onset of a condition early so that it can be more effectively treated. Preventive care includes regular medical check-ups, screening tests, vaccinations, and the encouragement of a healthy lifestyle.
  • Prior Authorization
    To be sure certain drugs or medical services are used correctly and only when truly necessary, your plan may require a "prior authorization". This means you or your doctor need to get approval from your plan before a particular drug or service will be covered.
  • Private Exchange
    A sales channel where an employer or group of employers can work with specific insurers to offer employees coverage. Often these follow a defined contribution model as opposed to a defined benefit model. Private exchanges provide employees with more personal choice to purchase HAP plans that are not available through the Health Insurance Marketplace.
  • SHOP Marketplace
    The Small Business Health Options Program (SHOP) Marketplace is a new sales channel for small employers. The SHOP Marketplace is currently open to employers with 50 or fewer full-time-equivalent employees.
  • Step Therapy
    A type of prior authorization for some prescription medications. In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, we will then cover Drug B.
  • Subsidy (Advanced Premium Tax Credit)
    If you buy coverage through the Health Insurance Marketplace, you may be eligible for cost savings based on your family size and how much your family earns. The Affordable Care Act provides a tax credit called the Advance Premium Tax Credit (also called a subsidy) to help lower the cost of health coverage purchased through the Marketplace.
  • Pharmacy Cost Sharing Tiers
    Some health plans place prescription drugs in their formulary into different "tiers". Your drug copay will vary, depending on the tier. For example, one approach to tiers is the following:
    • Tier 1: Generic drugs
    • Tier 2: Preferred brand drugs
    • Tier 3: Non-preferred brand drugs
    • Tier 4: Specialty drugs
  • Qualified Health Plan (QHP)
    Qualified Health Plans are Affordable Care Act-compliant plans that cover Essential Health Benefits and follow established limits on cost-sharing. All QHPs, whether they are purchased through the Health Insurance Marketplace or directly from an insurance company, are grouped in different metal levels - Platinum, Gold, Silver, Bronze - based on actuarial value, or the percentage of health care costs the plan covers.
  • Tax Penalty
    The Affordable Care Act requires most Americans to have health insurance. People without health insurance will face a tax penalty, or Individual Shared Responsibility payment when they file their annual tax return. Under certain circumstances, you won't have to make the individual responsibility payment. This is called an "exemption".
  • Wellness Program
    A program intended to improve and promote health and fitness that's usually offered through the workplace, although insurance plans can offer them directly to their enrollees. The program allows employers or plans to offer premium discounts, cash rewards, gym memberships, and other incentives to participants. Some examples of wellness programs include: programs to help individuals stop smoking, diabetes management programs, weight loss programs, and preventive health screenings.
  • Urgent Care
    Care for an urgent medical condition that is not life threatening, but may require prompt attention. Sprained ankles, most burns, and minor wounds requiring stitches are typical examples of urgent conditions.