Actuarial Value (AV)
The percentage your insurance company will pay for services covered by your plan. For example, if a plan’s actuarial value is 80 percent, the insurance company will pay approximately 80 percent of your medical costs. You must pay the remaining 20 percent.
Advanced Premium Tax Credits (APTC)
Money available to you or your family, if you qualify, to help pay for your premiums. Vermonters whose income falls under 400 percent of the Federal Poverty Level may be eligible for some level of APTC. These tax credits can be used right away to lower your monthly premiums. For example, an individual making less than $46,680 OR a family of four making less than $95,400 a year may be eligible. Learn more about these tax credits and see if you or your family might be eligible.
Affordable Care Act (The Federal Health Care Reform Law also known as “Obamacare”)
The 2010 Patient Protection and Affordable Care Act (ACA) required states to establish and operate a health insurance marketplace by 2014, or to have the federal government run a marketplace on the state’s behalf. Vermont chose to create Vermont Health Connect, a marketplace for Vermonters to shop for and enroll in health plans, in order to ensure that Vermonters have access to Vermont-based financial assistance and the plans meet certain quality controls established to protect our residents.
See Family Deductible.
The most money your insurance company will pay for a covered procedure or service.
The point at which you complete and file any forms needed to sign up for a health plan.
Health care services that your insurance plan covers. Examples of benefits include cancer screenings, hospital stays, and prescription medicines. Every plan you can buy through Vermont Health Connect offers the same basic benefits and some plans offer more. Learn more about these benefits, called Essential Health Benefits. For specific benefits and cost details about Vermont Health Connect 2015 plans, see the Plan Comparison Brochures.
A person or company who buys or negotiates insurance for you, your family, or your business. You pay a broker for this service. A broker must be licensed by Vermont’s Department of Financial Regulation.
Your share of the costs of medical services you get that are covered by the your insurance plan. Co-insurance is calculated as a percentage. For example, your insurance plan may cover 70 percent of a hospital stay, leaving you to pay the remaining 30 percent. To get a covered service, you may have to pay co-insurance plus any deductible you may owe.
The money you pay for health services, such as a doctor’s appointment, usually when you get the service. The co-pay is a fixed amount of money (for example, $45) set by your insurance plan for each service you receive. The money you pay is a separate cost from your monthly premium payments.
Money you pay out of your pocket because you share the cost of health services with your insurance company. Cost sharing generally includes deductibles, co-insurance, and co-pays. It does not include your monthly premium payments. It also does not include the cost for health services you receive that are not covered by your insurance plan.
Financial help available to some to reduce out-of-pocket medical expenses. If you buy health insurance on your own—not through your employer—you may be able to reduce your out-of-pocket medical costs by buying a Silver plan through Vermont Health Connect. If you are unsure how your income translates into Federal Poverty Level, take a look at the FPL Chart below or try out our Subsidy Calculator.
The money you must pay for health care services and prescriptions before your health insurance plan begins to pay. Sometimes you may not have to pay the deductible, such as when you get a check-up or other preventive service.
Donut Hole (Medicare Prescription Drug)
A gap in coverage for seniors with Medicare Part D, the prescription drug program. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay for all of your prescriptions up to a yearly limit. Once you reach the limit, your drug plan helps pay for covered drugs again.
Emergency Room (ER)
The point at which you are covered for benefits by the insurance plan you buy.
Essential Health Benefits
Ten types of health care benefits that health plans sold through health insurance marketplaces in all states cover by law. These include hospital stays and emergency room visits, care before and after your baby is born, mental health care, prescription drugs, dental and vision care for children, lab tests, and vaccines and other preventive services. Learn more about Vermont’s package Essential Health Benefits.
A deductible that applies to more than one person on the same insurance plan. A family deductible can be either aggregate or stacked. With an aggregate family deductible, your family must meet the family deductible before the insurance plan pays benefits. With a stacked deductible, the insurance plan pays benefits once you meet either your individual deductible or your family deductible.
Federal Poverty Level (FPL)
The amount of money—usually income—that the federal government determines each year that you need for basic needs such as food, clothing, and shelter. The federal poverty level is used to figure out how much financial help you can get to lower your health care costs. See FPL and Eligibility Thresholds for a specific year.
Full-Cost Individual Direct Enrollment (FCIDE)
The process that individuals and families can use to sign up for health insurance through an insurance carrier, rather than through Vermont Health Connect. “Full-Cost” refers to the fact that Vermonters who choose to direct enroll cannot receive financial help to reduce the cost of monthly premiums and/or out-of-pocket costs. If a Vermonter wants to apply for financial help, they must enroll or renew through Vermont Health Connect. Read "8 Things to Know about Full-Cost Individual Direct Enrollment."
Generic Drugs (Generic Scripts)
Prescription drugs that have the same active ingredient formula as brand-name drugs. Generic drugs are usually cheaper than brand-name drug co-pay. For examples of prescription drugs, view one of Vermont Health Connect’s Plan Comparison Brochures. To check on specific drugs, view your insurance carrier’s drug lists.
In insurance, a period beyond the due date of a premium during which the payment may be made to keep the policy in good standing. To learn more, view Vermont Health Connect's guide to grace periods.
Green Mountain Care Board
An appointed group of people who are tasked with finding ways to improve the quality of the health care you receive while also lowering the cost. Learn more about Green Mountain Care Board.
Health care services that help you keep, learn, or improve skills you use everyday. Examples include therapy for a child who is not walking or talking by a certain age. This is different from rehabilitation services, which help you regain skills you lost after an illness or accident. These services are considered an Essential Health Benefit.
Health Insurance Marketplace
A resource where individuals, families, and small business owners in a state buy health insurance and access financial help, if they’re eligible. The Health Insurance Marketplace is also called Exchange. In Vermont, the Marketplace is called Vermont Health Connect.
Health care you get in a hospital whether you stay overnight or just for the day (also called outpatient or ambulatory care). Hospital services also include other services such as an MRI. For an example, view one of Vermont Health Connect’s Plan Comparison Brochures.
Part of the federal law that requires all Americans to have health insurance. You may be able to get help paying for your health insurance. If you do not have health insurance, you will pay a shared responsibility fee when you pay your income taxes the following year. For 2016 federal taxes, the federal fee is the greater of two options: 1. 2.5% of yearly income above the filing threshold, or 2. $695 per adult, $347.50 per child under 18, $2,085 per family. This federal fee will increase each year. There are some exceptions to this mandate. Read more on the federal HealthCare.gov website.
A group (or network) of health care providers your insurance company selects to provide services to you. For most insurance plans, going to a health care provider that is “in-network” means your insurance plan will pay for more of your costs than it would if you went to an out-of-network provider. Most plans do not cover medical expenses when you go out of your network.
A type of deductible where both prescription drugs and medical costs contribute towards your medical deductible.
The dollar amount that insurance plans use to cap how much care you can receive during your lifetime. After you reach the limit, your insurance company will no longer pay for your health services. Because of the federal health law, health insurance plans issued or renewed on or after September 23, 2010 can no longer place dollar limits on your care.
A health insurance program run by the state of Vermont. Medicaid provides low-cost or free care for children from low-income families, adults under age 21, parents, pregnant people, relatives who are caretakers, people who are blind or disabled, and people 65 years old or older. In Vermont, Medicaid is also one of the Green Mountain Care programs.
A federal health insurance program that covers health care for people age 65 and older and younger people with certain disabilities. People on Medicare do not have to buy insurance through Vermont Health Connect. Visit Medicare.gov to learn more.
The way the federal health care reform law describes the different types of plans you can get through Vermont Health Connect. The quality of the coverage and benefits is the same for all plans. The levels refer to the amount of money you and your insurance company will pay towards your health care. There are four metal levels: Bronze, Silver, Gold, and Platinum. For example, the Bronze plan’s cost sharing is 60 percent. That means that if you have a Bronze plan, the insurance company will pay for about 60 percent of your care (on average) and you will have to pay 40 percent. The insurance company pays more for each level: Bronze = 60 percent, Silver = 70 percent, Gold = 80 percent, and Platinum = 90 percent. Bronze plans have the least expensive monthly premiums, but you have to pay more for the services you use.
Modified Adjusted Gross Income (MAGI)
An amount of income used to determine your eligibility for lower costs on a state's health insurance marketplace (such as Vermont Health Connect). It is also used to determine your eligibility for Medicaid, Dr.Dynasaur, advanced premium tax credits, and cost-sharing reductions. Generally, MAGI is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income. Read a more detailed definition of how to compute your MAGI.
A certified person who meets with you in person to help you select a health insurance plan. Find a Navigator or other Assister near you.
Office Visit (OV)
There are two types of office visits. The first type is an office visit with a primary care provider or mental health professional. The second type is an office visit with a care provider who focuses on a specific area of medicine (for example, dermatology). The second type also includes physical therapy, occupational therapy, vision, and any alternative treatment benefits. You pay a lower co-pay or co-insurance for an office visit with a primary care provider or mental health professional than an office visit with a specialist. For an example, view one of Vermont Health Connect’s Plan Comparison Brochures.
Open Enrollment Period
A set time period when you can enroll in a new private health insurance plan, or switch plans. Although Vermont Health Connect's 2016 Open Enrollment has ended, you might not have to wait for the next open enrollment period (fall 2016) to sign up for health insurance. First of all, Medicaid and Dr.Dynasaur enrollment continues year round. To see if you might qualify for one of these programs, view the Subsidy Estimator. Alternatively, if you've recently experienced a qualifying life event, you might qualify for a special enrollment period. Learn more about qualifying for a Special Enrollment Period.
Health care providers whose services are not covered by your insurance plan. Insurance plans are not required to cover services provided by out-of-network doctors. Always check if your health care provider is in your network, so you do not have to pay additional costs. See In-Network.
Costs you pay in addition to your monthly premium. Examples of out-of-pocket costs include your co-pays, money you pay toward your deductible, and your share of co-insurance. The monthly premiums you pay are not included. The federal health care reform law sets limits on the out-of-pocket costs you or your family has to pay.
Out-of-Pocket Maximum (OOPM) or Maximum Out-of-Pocket (MOOP)
The most you could pay in out-of-pocket costs in a health insurance plan year.
The money you must pay to your health insurance company, usually each month. How much you pay depends on the plan you buy. To keep your health insurance, it is important to pay your premium on time. For more information about the cost of the plans check out the Subsidy Estimator. For more information on payment, visit our Payment FAQs.
Premium Tax Credits
Health care services that can detect illnesses and help prevent you from getting sick. Examples include checkups, vaccines, and screenings. You do not have to pay a co-pay for preventive care services.
Primary Care Physician (PCP)
The medical provider (such as a doctor, physician assistant, or nurse practitioner) you choose to directly provide or coordinate all of your health care services. Learn more about finding a primary care provider.
Qualified Health Plan
A certified health insurance plan you can buy through Vermont Health Connect. Qualified health plans provide Essential Health Benefits, have set limits on cost sharing, and meet other requirements.
Insurance plans defined by the number of family members who need coverage. For medical plans, the tiers are Single, Couple, Parent and Child(ren), and Family.
|VT Rate Tier Level||VT Tier Title||Definition - Individual|
One person - the subscriber (may be an
adult or a child)
Two persons who are married to each
other or are in a civil union, according to
the rules of Vermont
Single Head of Household (HoH) with
One or More Children
One adult subscriber and one or more
dependent child(ren), up to the age of 26
Couple with one or more dependent
children, up to the age of 26
The process the federal government uses to determine if you or your family received the right amount of Advanced Premium Tax Credits (APTC). If you received more than you were eligible for, you may have to pay some money back. If you received less, you should be paid back. This process happens at the end of the year, after you have filed your federal income tax return.
Single Payer Health Care in Vermont
The plan for the state’s health care system that will ensure that all Vermonters have health insurance. Single payer health care is also called Green Mountain Care. It will replace the health insurance you can get from your employer. This new system will make sure everyone is covered for primary, preventive, and chronic care. It will also include urgent care and hospital services.
See Family Deductible.
Defined by the federal government for 2017 as health insurance offered by your employer that covers only you and has a premium that is more than 9.69 percent of your household income.
If you have not accepted your employer’s coverage because it is unaffordable, you can get insurance that works better for your budget through Vermont Health Connect. To check 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.
Value-Based Insurance Design (VBID)
Prescription drug coverage that pays for your medication if you have certain diseases or illnesses that continue or come back again and again. For an example, view one of Vermont Health Connect’s Plan Comparison Brochures or learn more at MVP Health Care. To check on specific drugs, view the insurance carriers' drug lists.
Vermont Cost-Sharing Reduction (also referred to as Vermont Cost-Sharing Assistance or VCSA)
Money from the state of Vermont available to you or your family, if you qualify, to help pay for your deductible and out-of-pocket costs. You must buy one of the Silver plans to get these reductions. This money is in addition to the money the federal government may give you. Learn more about Cost-Sharing Reductions.
Vermont Premium Reduction (also referred to as Vermont Premium Assistance or VPA)
Money from the state of Vermont available to you or your family, if you qualify, to help pay for your premiums for any metal level health plan (Bronze through Platinum). This money is in addition to the money the federal government may give you. Learn more about Advanced Premium Tax Credits (APTC).
Wellness Drugs (Wellness Scripts)
Medications that could be eligible for special benefits if prescribed to prevent a disease or condition or help you manage an existing issue.