Glossary of Terms

Actuarial Value

The percentage of an average enrollee’s medical costs that an insurance provider is expected to cover. For example, if a plan’s actuarial value (AV) is 80 percent, the insurance company will pay approximately 80 percent of that person’s medical costs and the remaining 20 percent must be paid by the individual.

Advanced Premium Tax Credits (APTC)

The financial assistance available to some Vermonters to help pay for their premium. Vermonters whose income falls under 400 percent of the Federal Poverty Level (FPL) may be eligible for some level of APTC. For example, a family of four making less than $94,200 a year may be eligible. The tax credits are “advanceable,” meaning that families do not have to wait until their taxes have been filed and processed in order to receive the tax credit and enroll in coverage. 

Individuals or families with Medicaid are not eligible for this tax credit because they do not have to pay premiums. In 2014, a family of four making less than $31,322 a year will be eligible for Medicaid. If you have an offer of health coverage that is considered adequate and affordable (e.g. from Medicare or from your employer), then you are not eligible to receive APTC or cost-sharing reductions on Vermont Health Connect. Learn more about these tax credits and see if you or your family might be eligible

Affordable Care Act (federal health care law) 

The comprehensive federal health care reform law that was 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.

Aggregate Deductible

See Family Deductible.

Allowed Amount

The maximum dollar amount an insurance company will pay for a given procedure or service. If a provider has a contract with an insurance company, the provider and the insurance company negotiate an allowed amount for each service or procedure. 

Ambulance (Amb)

In reference to a health plan's service categories, the use of an ambulance in case of emergency. For an example, view one of Vermont Health Connect's Plan Comparison Brochures.

Apply

The point at which an individual completes or files any forms required to sign up for a health plan. This is not the same as when an application is successful and the individual has been enrolled in a health plan.

Benefits

The health care services that an insurance plan covers. In addition to the essential health benefits that all plans are required to cover and requirements for Medicaid plans, an insurance plan will define which services it covers and which ones it does not. Examples of benefits include cancer screenings, hospital stays and prescription drug coverage. All plans that will be available through Vermont Health Connect will offer the same basic benefits. Learn more about these benefits, called Essential Health Benefits.

Broker

A person or entity licensed by the State who buys or negotiates insurance on behalf of an individual, family or business, and is compensated for doing so.

Co-insurance

A type of cost-sharing in which an individual pays a percentage of the cost of the medical service s/he receives.  For example, health insurance may cover 80 percent of charges for a covered hospitalization, leaving the individual responsible for the other 20 percent. The percentage covered depends on the service and the health plan.  Co-insurance is typically stated as the percent of member responsibility (e.g. 20 percent).

Co-pay

A defined flat dollar amount that an individual must pay when s/he receives a covered medical service. For example, an individual may have to pay $20 for each covered primary care visit. The cost of the co-pay depends on the service and plan. The money paid for the co-pay is not counted toward the deductible.

Cost-sharing

All costs to the individual beyond premiums, including deductible, co-pays, and co-insurance. Also called out-of-pocket costs (see definition below).

Cost-sharing reductions
Vermonters who purchase coverage as an individual (not through an employer) and have a household income of less than 300% FPL ($34,470 for an individual or $70,650 for a family of four) may be eligible for help to reduce out-of-pocket medical expenses. In order to qualify for these cost-sharing reductions, the applicant must purchase a silver-level plan on Vermont Health Connect. The table below shows how the deductible and out-of-pocket caps will be reduced by cost-sharing reductions.  If you are unsure how your income translates into FPL, view the FPL chart in our glossary or try out our Subsidy Calculator.
Cost-Sharing Reduction Table
 

Deductible

The amount an individual must pay for covered care before health insurance begins to pay for services.  It is common for the deductible to be waived for preventive services.  For some plans, the deductible may also be waived for office visits and other services.

Donut Hole

A coverage gap for seniors with Medicare Part D, the prescription drug program. If seniors fall into the donut hole, they are required to pay the full cost of their prescriptions until they have paid enough to come out of the gap. The federal health care law is slowly closing the donut hole over time. It will be closed completely in 2020. Until then, seniors who fall in the Medicare Part D donut hole get a 50 percent discount on brand-name prescriptions and a 7 percent discount on generic prescriptions. Medicare is not offered through Vermont Health Connect. Medicare enrollees will continue to access their coverage the same way they did in the past.

The Affordable Care Act enhanced Medicare. Learn more about the ACA's added benefits to Medicare.

Emergency Room (ER)

In reference to a health plan's service categories, emergency services you get in an emergency room. The ER co-pay is waived if the patient is admitted to the hospital. For an example, view one of Vermont Health Connect's Plan Comparison Brochures.

Enroll

The point at which an individual is covered for benefits under a health plan (that is, when coverage becomes effective). An individual can only be enrolled in a health plan if they have submitted a completed application through Vermont Health Connect. The insurance carrier or public health program (i.e. Medicaid) will then review the application and determine if the applicant will be covered, and therefore enrolled. 

Essential Health Benefits

Health care benefits that health plans in all states are required to cover beginning in 2014, as required by the federal health care law. These benefits include hospitalizations and other emergency services, maternity and newborn care, mental health, preventive care, children’s services and more. Learn more about Vermont’s package of Essential Health Benefits.

Exchange

See Health Insurance Marketplace.

Family Deductible

A deductible that applies to more than one person on the same health plan. A family deductible can be either aggregate or stacked. With aggregate, all individuals in a family contribute to one family deductible. Once this deductible is met, cost-sharing (co-pays and co-insurance) goes into effect for all family members. With stacked, the individual deductible still exists, giving family members a second way to meet their deductible. If the individual deductible is met before the family deductible, cost-sharing goes into effect for that individual family member.

Federal Poverty Level (FPL)

The Federal Poverty Level (FPL) is the amount of money – usually income – that the federal government has determined is necessary for an individual or family to pay for basic needs such as food, clothing and shelter. In 2014, the Federal Poverty Level is $11,670 for an individual and $23,850 for family of four. Modified Adjusted Gross Income (MAGI) relative to 2013 FPL is used to determine eligibility for Advanced Premium Tax Credits and cost-sharing reductions, while MAGI relative to 2014 FPL is used to determine eligibility for Medicaid and Dr. Dynasaur. The two charts below show FPL levels that are relevant to these programs.

2013 FPL Chart for APTC and CSR

 

2014 FPL for Medicaid and Dr. Dynasaur

Generic Drugs (Generic Scripts)

In reference to a health plan's prescription drug coverage, a prescription drug that has the same active ingredient formula as a brand-name drug. For examples of co-pays, view one of Vermont Health Connect's Plan Comparison Brochures. To check on specific drugs, view the insurance carriers' drug lists.

Green Mountain Care Board

The Green Mountain Care Board is an independent body charged with improving health quality while lowering costs. The Board was created through Act 48 and the members of the board were appointed by Governor Shumlin. The Board is focused on reviewing insurance rates, approving an insurance benefits package, regulating hospital budgets, and launching “pilot projects” that test different methods for paying for health care to improve quality and minimize costs. Learn more about the Green Mountain Care Board.

Habilitation Services

Health care services that help individuals keep or improve skills that are a part of their daily life. This is different from rehabilitation services that help individuals regain skills lost as a result of an illness or accident.

Health Insurance Marketplace

The term "Health Insurance Marketplace,” or "Exchange," is used in the federal health care law to describe the marketplace where individuals, families and small business owners in a state will access health insurance in 2014. In Vermont, the Marketplace is called Vermont Health Connect. Every state now has a Health Insurance Marketplace, whether it is run by the state or the federal government.

Hospital Services

In reference to a health plan's service categories, hospital services include: Inpatient (including surgery, ICU/NICU, maternity, SNF and MH/SA); Outpatient (including ambulatory surgery centers); Radiology (MRI, CT, PET). For an example, view one of Vermont Health Connect's Plan Comparison Brochures

Individual Mandate

Starting January 1, 2014, federal law requires all Americans to have health insurance. Many people will be eligible for public programs or financial assistance to help pay for their care.  Americans who do not have health insurance will face a tax penalty which will be assessed on their following year's taxes.  In 2014, the federal fee is either 1% of yearly income or $95 per adult and $47.50 per uninsured child, whichever is higher. The fee increases in future years. There are some exceptions to this requirement, including individuals who 1) have an income that is low enough that they do not file income taxes (this equals an annual income of about $9,500 for an individual), 2) have specific religious beliefs, or 3) are unable to find an affordable plan. Vermonters who sign up for a plan through Vermont Health Connect by the end of open enrollment (March 31, 2014) will not face a penalty. Read more on the federal healthcare.gov website.

In-network

A specific group (a “network”) of health care providers, contracted by your health plan. For most plans, going to a health care provider that is in-network means your plan will pay for more of your costs than they would if you went to an “out-of-network” provider. Most plans do not cover medical expenses when you go out-of-network.

Integrated Deductible

A type of deductible where both prescription drugs and medical expenses contribute towards the medical deductible. If the deductible is not integrated, only medical claims accumulate to the medical deductible and prescription drug claims accumulate only to the prescription drug deductible. 

Lifetime Limit

The dollar amount that insurance plans use to cap how much care you can receive during your lifetime. Because of the federal health care law, health insurance plans issued or renewed on or after September 23, 2010 can no longer place dollar limits on your care.

Medicaid

The State’s public health coverage program that provides low-cost or free coverage for low-income children, young adults under age 21, parents, pregnant women, caretaker relatives, people who are blind or disabled and those ages 65 or older. In Vermont, Medicaid is also referred to as Green Mountain Care and administered by the Department of Vermont Health Access. In 2014, a family of four making less than $31,322 a year will be eligible for Medicaid.

Medicare

A federal health insurance program that covers health care for people 65 and older and individuals with certain disabilities. Medicare enrollees will continue to access coverage the same way the have in the past and do not have to interact with Vermont Health Connect. Through Medicare, individuals 65 and older are considered to have an adequate offer of health care coverage and are therefore not eligible to access subsidies through Vermont Health Connect. Visit Medicare.gov to learn more.

Metal levels

The way the federal health care law describes the different types of plans that will be available through state marketplaces such as Vermont Health Connect. It is important to note that the plans differ only in payment structure; the quality of coverage and benefits is the same for all plans. More specifically, the metal level refers to the cost-sharing, or amount you and your insurance company will pay towards your health care. There are four metal levels: bronze, silver, gold and platinum. Each level has a defined actuarial value (AV), or cost-sharing percentage. For example, the bronze plan’s cost-sharing is 60%. That means that if you have a bronze plan, the insurance company will pay for about 60% of your care (on average) and you will have to pay the rest. The insurance company’s share increases for each level – Bronze = 60%, Silver = 70%, Gold = 80% and Platinum = 90%. Bronze plans have the least expensive monthly premiums, but you have to pay more for the services that you use. 

Modified Adjusted Gross Income (MAGI)

The figure used in reference to Federal Poverty Level (FPL) to determine a tax household's eligibility for Medicaid, Dr. Dynasaur, Advanced Premium Tax Credits, and cost-sharing reductions. Generally, MAGI is Adjusted Gross Income(AGI) plus any tax-exempt Social Security, interest, or foreign income. Read a more detailed definition of how to compute your MAGI.

Navigator

A certified person who offers Vermonters in-person, one-on-one assistance with selecting a health plan.

Office Visit

In reference to a health plan's service categories, office visits can fall into one of two service categories: 1) Office visits with a primary care provider or mental health professional have a lower co-pay or co-insurance; 2) Office visits with a care provider who focuses on a specific area of medicine (e.g. dermatologist) have a higher co-pay or co-insurance.  Specialist co-pay also applies to physical therapy (PT), occupational therapy (OT), vision, and any alternative medicine benefits, as appropriate. For an example, view one of Vermont Health Connect's Plan Comparison Brochures.  

Open Enrollment

A set time period when you can enroll in a new health insurance plan or switch plans. Vermont Health Connect’s first open enrollment period runs from October 1, 2013 through March 31, 2014.

Out-of-Network

Health care providers who are not a part of your health plan. Health plans are not required to cover services provided by out-of-network doctors. Always check if your health care provider is “in-network” to avoid paying additional costs.

Out-of-Pocket

Costs in addition to your premium, also referred to as "cost-sharing." Examples of out-of-pocket costs include your co-pays, the money you pay toward your deductible and your share of co-insurance. Premiums are not included as an out-of-pocket cost. The federal health care law set caps, or limits, on the out-of-pocket costs an individual or family would have to pay. In 2014, those limits are $6,350 for an individual and $12,700 for a family. Some Vermonters will qualify for cost-sharing reductions to further lower these caps.

Out-of-Pocket Maximum (OOPM)

The annual maximum amount an individual will have to pay out-of pocket for covered services. Generally, this includes the deductible, co-insurance, and co-payments.

Premium

A specified amount of money that you pay your insurance company for your health plan. Most people pay their premiums on a monthly basis.

Premium Tax Credits

See Advanced Premium Tax Credits (APTC).

Preventive Care

Health care services that can detect illnesses and help prevent someone from getting sick. As a result of the federal health care law, you do not have to pay a co-pay for preventive care services. 

Primary Care Physician (PCP)

A physician (M.D. - Medical Doctor, D.O. - Doctor of Osteopathic Medicine, or N.D. - Naturopathic Doctor) who directly provides or coordinates a range of health care services for a patient. An individual chooses her primary care physician as her main point of contact for health concerns. 

Qualified Health Plan

A health insurance plan that is certified to be offered through Vermont Health Connect. Qualified Health Plans provide essential health benefits, follow established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meet other requirements established by the State and the Affordable Care Act.

Rate Tier

Insurance plans can be purchased at various rate tiers, which are definited by the number of family members who need coverage. For medical plans, the tiers are Single, Couple, Parent and Child(ren), and Family.

The processDefinition of Medical Rate Tiers for Single, Couple, Parent and (Child), Family

Reconciliation

The process the federal government will use at the end of the year after federal income tax returns are filed to determine if individuals/families received the right amount of Advanced Premium Tax Credits (APTC). Those who received more than they were eligible for may have to pay some back. Those who received less should get a reimbursement.

Single Payer Health Care in Vermont

The plan for the State’s health care system that will ensure that all Vermonters have health coverage. Also known as Green Mountain Care, it will replace private insurance tied to employment with universal coverage that encourages efficiency, lowers overhead costs, and incentivizes health outcomes. It will be a comprehensive health care system that will make sure every Vermont resident is covered for primary, preventive, and chronic care, as well as urgent care and hospital services.

Stacked Deductible

See Family Deductible

 

Unaffordable Coverage 

Under Vermont Health Connect employer-sponsored health coverage is considered “unaffordable” if the employee's premium (self-only) is more than 9.5% of household income.

If your offer of coverage meets this definition of “unaffordable” and you have not enrolled in the coverage you are eligible to find an alternative plan -- and financial help -- through Vermont Health Connect that works better for your budget. To see if the coverage you have been offered is considered unaffordable, visit our Affordability Calculator.

Urgent Care (UC)

In reference to a health plan's service categories, care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. For an example, view one of Vermont Health Connect's Plan Comparison Brochures.

Value-Based Insurance Design (VBID)

In reference to a health plan's prescription drug coverage, a prescription drug coverage feature that covers maintenance medication for members with some chronic conditions For an example, view one of Vermont Health Connect's Plan Comparison Brochures.

 

Vermont Cost-Sharing Reduction (also referred to as Vermont Cost-Sharing Assistance or VCSA)

In addition to federal Cost-Sharing Reductions (CSR), Vermont Cost-Sharing Reductions lower the deductible and out-of-pocket maximum costs for income-qualifying Vermonters who purchase Silver plans. Vermont is one of only two states (along with Massachusetts) that provides a state supplement to federal premium and cost-sharing reductions. Learn more about Cost-Sharing Reductions.

 

Vermont Premium Reduction  (also referred to as Vermont Premium Assistance or VPA)

In addition to the federal Advanced Premium Tax Credit (APTC), Vermont Premium Reduction can lower the monthly health insurance premium for income-qualifying Vermonters who purchase any metal level health plan (Bronze through Platinum). Vermont is one of only two states (along with Massachusetts) that provides a state supplement to federal premium and cost-sharing reductions.  Learn more about Advanced Premium Tax Credits.

Wellness Drugs (Wellness Scripts)

In reference to a health plan's prescription drug coverage, a drug that could be eligible for special benefits if prescribed by a network pharmacy to prevent the occurrence of a disease or condition if a member has a risk factor for that disease or condition, or to prevent the recurrence of a disease or condition if recovered.  For examples of co-pays, view one of Vermont Health Connect's Plan Comparison Brochures. To check on specific drugs, view the insurance carriers' drug lists.

 

For other health care definitions, visit HealthCare.gov or the U.S. Department of Labor’s glossary.