FAQ and Glossary

FREQUENTLY ASKED QUESTIONS

What if I have been declined for insurance before?

It is best to discuss this with one of our agents, for Health Insurance, that is not a problem, however, your agent will advise you when applying for Life Insurance or Disability Insurance.

What if I am on ongoing medication?

It is best to discuss this with one of our agents when you are applying for Health Insurance, you’ll want to make sure that your current medication is on the drug formulary of the Health Plan you choose.

What if I had a recent illness or injury?

It is best to discuss this with one of our agents when you are applying for Health Insurance, you’ll want to make sure that your current doctor, facility or doctor’s group is in the network. You’ll want to share if there will be ongoing treatment, possible physical therapy or surgeries. The more information your agent knows about your situation and future needs will better equip your agent to make an informed recommendation.

Does every plan cover maternity?

All of the individual ACA plans written with effective dates of January 1, 2014 and later are required to have maternity benefits; however, those plans written prior to January 1, 2014 may cover maternity if you selected that option at an additional premium. Typically, all group health plans treat pregnancy as any other illness, having the charges incurred apply to the deductible and out of pocket maximum. It is best to discuss this with one of our agents to better serve your needs.

Will my policy bind me to an annual contract?

No, not at all, however, it is best to discuss your options with one of our agents, as there can be rippling ramifications that you may not be aware of that could affect you financially and medically. Remember there are penalties for not having credible coverage for you and your family. Additionally, there are only certain times during the year that you can enroll in a health plan unless you experience a qualifying event that grants you a Special Enrollment Period.

When can I enroll for Medicare Advantage and Medicare Prescription Drug Plans?

During certain times each year (yearly enrollment periods for Part C & Part D). Each year, you have a chance to make changes to your Medicare Advantage or Medicare prescription drug coverage for the following year. There are 2 separate enrollment periods each year.

Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage.
What can I do?

• Change from Original Medicare to a Medicare Advantage Plan.
• Change from a Medicare Advantage Plan back to Original Medicare.
• Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
• Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
• Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage.
• Join a Medicare Prescription Drug Plan.
• Switch from one Medicare drug plan to another Medicare drug plan.
• Drop your Medicare prescription drug coverage completely.

When? October 15–December 7

Medicare Advantage Dis-enrollment Period.
What can I do:

• If you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare.
• If you switch to Original Medicare during this period, you’ll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.

What can’t I do?

• Switch from Original Medicare to a Medicare Advantage Plan.
• Switch from one Medicare Advantage Plan to another.
• Switch from one Medicare Prescription Drug Plan to another.
• Join, switch, or drop a Medicare Medical Savings Account (MSA) Plan.

When? January 1–February 14

GLOSSARY/DEFINITIONS

Affordable Care Act
The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Agent
An agent or broker is a person or business who can help you apply for help paying for coverage and enroll you in a Qualified Health Plan (QHP) 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 agents and brokers may only be able to sell plans from specific health insurers.

Allowed Amount
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference

Benefits
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.

Benefit Year
A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.

Brand-Name Prescription Drug
Drugs developed, manufactured, and marketed with a brand name by a pharmaceutical company. Brand name drugs are typically more expensive that generic drugs.

Broker
An insurance salesperson that searches for quotes and plan options for individual clients.

Carrier
A company that provides insurance plans

Case Management
A management system in which case managers monitor patients’ health care, to improve quality, reduce cost, and ensure the patient receives appropriate care.

Claim
A request to an insurance company for payment of a service received.

COBRA
A Federal law 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 (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

Co-insurance
Your 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 coinsurance 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 coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Co-payment
A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.

Creditable Coverage
Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high risk pool. If you have prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage.

Deductible
The amount you owe for covered health care services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Dependents
Any person directly financially relying on insured. Usually includes spouse and unmarried children.

Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

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

Effective Date
The date when insurance coverage begins.

Exclusions
Any medical or health care services not covered by an insurance plan.

Family and Medical Leave Act (FMLA)
A Federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.

Fiduciary
Any person who has control over plan assets, or discretionary authority or control over plan administration, or gives investment advice.

Fee For Service (FFS) Plan
Also known as traditional ‘indemnity’ coverage, FFS plans reimburse policyholders for the care they receive, as long as it’s covered, from any health care provider.

Flexible Spending Account (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year. There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year. (Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements.)

Formulary
The list of all covered prescription drugs.

Generic Drug
Duplicates of brand-name drugs made after the patent expires of the company who developed the drug. Typically, generic drugs are much less expensive than brand-name drugs. And they’re just as safe and effective.

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. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

Group Insurance
Health insurance coverage offered for employees of a business.

Guaranteed Issue
Law, varying by state, requiring all insurance applicants to be accepted regardless of health condition, health history, age, or any other factor.

Health Insurance Quote
Health plan options provided by an automated quoting service, an agent, or an insurance company.

Health Savings Account (HSA)
A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.

High Deductible Health Plan (HDHP)
A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

HIPAA (Health Insurance Portability and Accountability Act)
Legislation that allows people to change jobs and be accepted into their new company’s group health insurance plan regardless of pre-existing conditions or health history.

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.

Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.

Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

In-Network Care Providers
Any health care professional that agrees with a health plan to discount their medical services in exchange for patient referrals.

In-Network Co-insurance
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

In-Network Co-payment
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Individual Health Insurance
A health plan purchased by an individual from an insurance company, not through an employer. Individual coverage can include your spouse and dependent children.

Individual Retirement Account (IRA)
An account to save money for retirement. Funds from an IRA can be moved to a Health Savings Account (HSA).

Inpatient Care
Care in which patients must stay overnight in a medical facility.

Insurability
The factors that determine if an applicant will be accepted into a health plan, including age, health history, and current health conditions.

Limitations
A specified limit on the benefits paid for a certain medical cost.

Long-Term Care
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

Major Medical Insurance
Insurance that provides coverage for major and catastrophic medical care.

Managed Care
A type of health insurance that creates an agreement with a ‘network’ of doctors, hospitals, and other care providers. The health plan provides patient referrals in exchange for discounted medical services.

Maximum Dollar Limit
The maximum dollar amount of benefits and claims that an insurance company will pay in a certain period of time.

Maximum Lifetime Benefit
The maximum dollar amount of benefits and claims an insurance company will pay in the insured’s lifetime.

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 varies state by state and may have a different name in your state.

Medically Necessary
Health care services or supplies needed to 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).

Medicare Advantage (Medicare Part C)
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part D
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Supplement (Medigap) Insurance Plans
Extra insurance coverage purchased through private insurance companies to cover some of the health care costs regular Medicare does not.

Minimum Essential Coverage (MEC)
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.

Mutual Insurance Company
Insurance companies that have no public stock and are owned by the wholly by the policyholders.

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

Non-Preferred Provider
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Obamacare
An informal name sometimes used to refer to the health coverage plans available through the Health Insurance Marketplace. Obamacare often also refers to the Affordable Care Act. Obamacare Summary: Signed into law March 23, 2010 by President Obama, which is where the term “Obamacare” comes from. The next Open Enrollment period will begin on November 1, 2015, but you may qualify for coverage now.

Open Enrollment Period
The yearly period when people can enroll in a health insurance plan through the Health Insurance Marketplace. The Open Enrollment Period is November 1 – January 31. People may qualify for Special Enrollment Periods allowing them to enroll outside of Open Enrollment if they have certain life events, like getting married, having a baby, or losing other coverage. You can apply for Medicaid or CHIP at any time of the year.

Out-of-network Co-insurance
The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered health care services from providers who don’t contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-pocket maximum/limit (In-Network)
The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments (doctor office visits and prescription copays), or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. The maximum out-of-pocket cost limit for any individual Marketplace plan for 2015 can be no more than $6,600 for an individual plan and $13,200 for a family plan.

Unlike Grandfathered or Transitional/Grandmothered policies (see definitions), once you have met your deductible the coinsurance % applies until you have reached your out of pocket maximum. The copays for doctor visits and prescriptions does not help to meet your out of pocket maximum.

Outpatient Care
Care that does not require a patient to stay overnight in a medical facility.

Point of Service (POS) Plan
A managed care plan that combines the benefits of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Like an HMO, POS plans require members choose a Primary Care Physician (PCP). Like a PPO, they provide coverage with any in or out-of-network health care providers.

Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Pre-Existing Condition
A health problem you had before the date that new health coverage starts.

Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Primary Care
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

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.

Preventive Services
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), 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.

Prior Authorization
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Provider
Includes doctors, physicians, hospitals, clinics, specialists, or any health care professional.

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) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.

Quote
Insurance plan options provided by an automated quoting service, an agent, or an insurance company.

Reconstructive Surgery
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

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/or outpatient settings.

Rider (exclusionary rider)
A rider is an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy). In most states today, an exclusionary rider is an amendment permitted in individual health insurance policies that permanently excludes coverage for a health condition, body part, or body system. Starting in September 2010, under the Affordable Care Act, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.

Risk
An insurance company’s chance of loss. Also refers to the chance of an individual becoming ill or having an accident.

Short-Term Disability
An illness or injury that prevents an employee from working for a period of time.

Short-Term Medical Insurance
An insurance plan that provides insurance coverage for a designated period of time ? usually between one month and one year. Many individuals who purchase short-term coverage include recent college graduates and people in-between jobs.

Skilled Nursing Care
Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Specialist
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Special Enrollment Period
A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days.

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 the “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.

“Transitional renewal plans” also called “Grandmothered” health plans
These plans must have been in existence on October 1, 2013 and renewed prior to October 1, 2014. They include some but not all of the ACA features. These plans will be subject to updated premium rates. You may only apply for a renewal policy, not a newly issued policy.

Travel Insurance
Health plans that provide coverage for people while during a trip to another country.

Urgent Care
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.

Usual, Customary, and Reasonable Fees
The standard amount that is usually covered or charged for medical services and supplies, as recommended by health care professionals.

Utilization Review
The process in which the care of patients are monitored for cost-effectiveness, efficiency, and quality.

Waiting Period
Also known as the elimination period, it refers to the temporary amount of time an insured will not be covered for certain health care costs.

Waiver of Premium
An additional insurance policy that can be purchased. It waives premiums for a period of time if the insured becomes totally disabled and cannot make monthly payments.

(You may find these and additional definitions at www.Heathcare.gov)