Actuarial Value (AV)
The percentage your insurance company will pay for services covered by your plan, averaged over all the services the plan covers. For example, if a plan’s actuarial value is 80%, the insurance company, over time, will pay approximately 80% of your covered medical costs. In this example, you pay about 20% of your covered medical costs. Since insurance plans can cover services at different rates, your plan might cover more or less than 80% of costs for a given service. Over time, your plan will pay about 80% of costs, on average.
Advanced Premium Tax Credits (APTC)
A tax credit you can take in advance to lower your healthcare premium during the plan year. If you are eligible for APTC, you can choose to take the credit each month to lower your healthcare premium, or you can wait and take the entire credit when you file your taxes. If your household income changes during the year, your tax credit can also change. It’s important to tell Vermont Health Connect if you have changes of income or household size so we can update your APTC. If you take too much APTC, you may have to pay it back when you file federal taxes.
The amount of APTC you can get depends on things like your income and family size. You must apply for healthcare through Vermont Health Connect to get APTC. Use the Plan Comparison Tool to estimate the amount of APTC you can get through Vermont Health Connect.
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 create and run 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 state-run marketplace. The ACA also allowed states to expand their Medicaid programs, and Vermont chose to expand Medicaid to include people making up to 138% of the federal poverty level.
Vermont Health Connect is a marketplace where Vermonters can shop for, and enroll in, health plans which meet certain quality controls that protect our residents. Eligible Vermonters can also get Vermont-based financial help, in addition to financial help offered by the federal government.
This type of deductible is meaningful when more than one person is covered by the same health plan. With an aggregate deductible, the entire family deductible amount must be met before the plan begins to cover services for any covered member. With an aggregate deductible, it is possible for the medical expenses of one family member to meet the deductible amount for the entire family.
The largest amount of money your insurance company will pay for a covered procedure or service. For example, if your doctor charges $500 for a procedure, but your insurance only pays $400, you can be billed the $100 not covered by your insurance.
To 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, called essential health benefits, and some plans offer more. Learn more about essential health benefits.
Some plans offer more benefits, though it can cost more to get them. For specific benefits and cost details about Vermont Health Connect plans, see the plan comparison brochures.
A person or company licensed by the State of Vermont to help you, your family, or your business to buy insurance. You pay a broker for this service.
Catastrophic health plans have low monthly premiums and very high deductibles. They can be an affordable way to protect yourself from high costs in a healthcare emergency, but you pay out of pocket for most of your medical care. Catastrophic plans have some restrictions: 1) only people under age 30 (or with an approved hardship exemption) can get a catastrophic health plan; 2) you can’t get premium tax credits if you enroll in a catastrophic health plan. Catastrophic health plans include the same essential health benefits as qualified health plans, including free preventive care.
Certified Application Counselor (CAC)
Most assisters in the state of Vermont are certified application counselors (CAC). CACs are typically employed by a local organization, like a doctor’s office or hospital, and they help customers of that organization sign up for health insurance. CACs cannot charge a fee for their services as a healthcare assister.
COBRA is a federal law that lets people who experience job loss continue their employer-sponsored insurance for a limited amount of time. People who decide to take COBRA coverage might have to pay up to 102% of their health insurance premium. If you enroll in a COBRA plan, you can’t get premium tax credits. In addition, you won’t have an enrollment period to switch to Vermont Health Connect until the next Open Enrollment period, or the full term of your COBRA expires.
Your share of the costs of medical services that are covered by your insurance plan. Co-insurance is a percentage. For example, if your insurance plan covers 70 percent of a hospital stay, you must pay the remaining 30 percent. To get a covered service, you may have to pay co-insurance plus any deductible you may owe.
Your share of the costs of medical services that are covered by your insurance plan. A co-pay is a fixed amount of money (for example, $45) set by your insurance plan for each service you receive. Co-pays are often due at the time of service. To get a covered service, you may have to pay co-pays plus any deductible you may owe.
During the cost-sharing stage of your health insurance, your insurance company pays most of your covered healthcare costs, and you will pay a smaller amount. Deductibles, co-insurance, and co-pays are examples of cost-sharing. Added together, your cost-sharing payments may reach your plan’s yearly max-out-of-pocket limit (also known as MOOP). Once you have met your plan’s MOOP you don’t have to share the cost of covered services with your insurance company for the rest of your plan year. Once you’ve reached your plan’s MOOP amount, your insurance company must pay 100% of your covered services.
Monthly premium payments, as well as payments for any uncovered services, do not count as cost-sharing.
Financial help available to eligible Vermonters to lower out-of-pocket medical expenses. If you buy health insurance through Vermont Health Connect, you may be able to reduce your out-of-pocket medical costs by buying an Enhanced Silver plan, if you are eligible. Enhanced Silver plans (sometimes called cost-sharing reduction plans) offer consumers a higher actuarial value (AV), or average percent of coverage, than regular silver plans. For example, a regular silver plan (not enhanced) usually has an AV of about 70%—meaning the insurance company pays about 70% of covered expenses and you pay the remaining 30%. If you are eligible for an Enhanced Silver 94 plan, that plan has an AV of 94%—meaning that it covers about 94% of your covered costs. This means the Enhanced Silver 94 plan pays about 24% more of your covered expenses than a regular silver plan. Enhanced silver plans have the same monthly premium as the same non-enhanced silver plan. Contact Vermont Health Connect to find out of you are eligible for an Enhanced Silver Plan during your next enrollment period.
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 people with Medicare Part D, the prescription drug program. After you and your drug plan have spent a certain amount of money for covered drugs, you may have to pay more for all of your prescriptions up to a yearly limit. Once you reach the limit, your drug plan helps pay for covered drugs again. Some insurance plans, such as Vermont’s VPharm program, provide coverage during the “donut hole” gap in Medicare prescription drug coverage. People with Medicare who get “extra help” from Social Security paying Part D costs won’t enter the coverage gap.
To enroll in health insurance coverage through Vermont Health Connect, you must first apply for coverage, then select a plan. If a premium is due, you must pay your first month’s premium to complete your enrollment and start your coverage.
The time when you can sign up for a qualified health plan at Vermont Health Connect. There are two types of enrollment periods: Open Enrollment and Special Enrollment Periods. Open Enrollment occurs once per year, typically November 1 through December 15. Open Enrollment is the time when any Vermonter can sign up for a qualified health plan through Vermont Health Connect. Individuals and families may also be eligible for Special Enrollment Periods when they have a major life change such as marriage, divorce, birth of a child or significant change of income. Please see our full list of qualifying events.
Essential Health Benefits
Ten types of health care benefits that health plans sold through health insurance marketplaces in all states cover by law:
- Visits to your healthcare provider’s office
- Hospital stays
- Emergency room visits
- Care for mother and child before, during and after the birth
- Care for mental health and substance use disorders
- Prescription drugs
- Services for children—including vision and dental care
- Lab tests
- Rehabilitative and habilitative services and devices
- Preventive services, including vaccines and check-ups
Services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills. Learn more about Vermont’s essential health benefits.
A service that helps people shop for and enroll in health insurance. Vermont’s exchange allows individuals to apply for and enroll in qualified health plans (and financial help paying for those plans), Medicaid for Children and Adults and other programs that help pay for healthcare costs.
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 to each family member who meets an individual deductible and to all family members once the family meets the family deductible.
Federal Poverty Level (FPL)
A measure of income sent out every year by the Department of Health and Human Services (HHS). The federal government and State of Vermont use federal poverty levels to determine your eligibility for certain programs and benefits, including financial help to pay your healthcare costs and Medicaid for Children and Adults.
If you want to know more, see FPL and eligibility tables for a specific year.
Full-Cost Individual Direct Enrollment (FCIDE)
The way individuals and families sign up for health insurance through an insurance carrier directly, rather than through Vermont Health Connect. “Full-Cost” refers to the fact that Vermonters who choose to direct enroll can’t get financial help to reduce the cost of monthly premiums and out-of-pocket costs. Vermonters who want to get financial help paying for coverage must enroll or renew through Vermont Health Connect.
Prescription drugs that have the same active ingredient formula as brand-name drugs. Generic drugs are usually cheaper than brand-name drugs. To find out if your prescription medications are covered by your insurance plan, view your insurance carrier’s drug lists.
If you don’t pay your monthly premium by the date it’s due, your insurance plan will go into a grace period. During a grace period, your insurance company may stop covering your medical expenses, but you can start coverage again by paying everything that you owe, plus your premium for the next month. If your grace period ends before you are fully caught up on your premium payments, your coverage will end. If your coverage ends, you may not be able to get health insurance until the next Open Enrollment period. To learn more, view Vermont Health Connect's guide to grace periods.
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 the Green Mountain Care Board.
Health care services that help you learn, keep, or improve skills you use every day. 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. Habilitation and rehabilitation services are considered an essential health benefit.
Health Insurance Company
A health insurance company designs, sells and fulfills health insurance plans that protect customers from financial risk involved in seeking healthcare services. Health insurance companies may also be known as “health insurance carriers” or “health insurance issuers”. If you have a qualified health plan through Vermont Health Connect, your health insurance company may be Blue Cross and Blue Shield of Vermont or MVP Health Care®. The health insurance company for dental coverage through Vermont Health Connect is Northeast Delta Dental.
Health Insurance Marketplace
A resource where eligible individuals, families, and small business owners in a state buy health insurance and get financial help with healthcare costs, The Health Insurance Marketplace is also called the Exchange. In Vermont, the Marketplace is called Vermont Health Connect.
Healthcare you get in a hospital—such as surgery and overnight stays. Hospital services also include some tests that are done in hospitals. Hospital services are considered an essential health benefit.
Household (or Tax Household)
When applying for healthcare through Vermont Health Connect, the household (or tax household) includes family members who file taxes together. People who live with you, but file taxes separately, should not be included in your application for health insurance unless they are a child under the age of 26 who will be covered by your insurance plan. Any relatives or dependents who file taxes with you must be included in your application for health coverage through Vermont Health Connect—even if they don’t live with you. Unmarried couples who live together and have a child should both apply together.
The part of the federal law (ACA) that requires all Americans to have health insurance. Starting with tax year 2019, the federal penalty for being uninsured is $0. Vermont also has a state-based law requiring Vermonters to have health insurance. The penalty is also $0.
You can learn more at the federal HealthCare.gov website.
The facilities, providers and suppliers your health insurance company has contracted with to provide health care services. For most insurance plans, going to a health care provider that is “in-network” means your out-of-pocket costs will be lower than if you went to a provider who was out-of-network. 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. 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.
Maximum Out-of-Pocket (MOOP) or Out-of-Pocket Maximum (OOPM)
The most you could pay in out-of-pocket costs in a health insurance plan year. The federal government sets a maximum limit every year, although your plan could have a limit that is lower. Check your plan documents to be sure.
Medicaid provides free or low-cost health coverage Vermonters: including eligible low-income adults, children, pregnant women, people 65 and older and people who are disabled.
A federal health insurance program that covers health care for people age 65 and older and younger people with certain disabilities and younger people determined disabled through the Social Security Administration. People on Medicare do not have to buy insurance through Vermont Health Connect. Visit Medicare.gov to learn more.
The way different coverage levels are described under the Affordable Care Act for qualified health plans. Metal levels show the average percent of your medical expenses your insurance company will cover—this is often called the actuarial value (AV) of a plan. The quality of the coverage is the same for all plans, but the amount of coverage is different for each metal level.
There are four metal levels:
- Platinum plans have an AV of about 90%. This means the insurance company pays for about 90% of your covered healthcare costs, on average. You pay the remaining 10% of the cost.
- Gold plans have an AV of about 80%. This means the insurance company pays for about 80% of your covered healthcare costs, on average. You pay the remaining 20% of the cost.
- Silver plans have an AV of about 70%. This means the insurance company pays for about 70% of your covered healthcare costs, on average. You pay the remaining 30% of the cost.
- Bronze plans have an AV of about 60%. This means the insurance company pays for about 60% of your covered healthcare costs, on average. You pay the remaining 40% of the cost.
Most times, you will pay a higher premium when your insurance company pays more of your healthcare. When you’re getting ready to pick the metal level that’s right for you, it’s a good idea to think about how much you expect to use your health coverage. If you expect to need a lot of healthcare, it might be less expensive in the long run to get a plan that covers more of your medical expenses—like a platinum or gold plan.
An insurance plan that meets the Affordable Care Act requirement for having health coverage. Every plan offered by Vermont Health Connect is considered minimum essential coverage, although some plans you can buy outside of Vermont Health Connect might not be.
Modified Adjusted Gross Income (MAGI)
A way of counting income to see if you can get financial help when you enroll in health insurance through Vermont Health Connect. Modified adjusted gross income is used to see if you are eligible for the following programs:
- Advance premium tax credits
- Vermont premium assistance
- Cost sharing reductions (also known as Enhanced Silver plans)
- Medicaid and Dr. Dynasaur
Learn more about what’s included in your modified adjusted gross income.
A person or organization certified to meet with you in person to help you select a health insurance plan. Find a navigator, or other assister, near you. Your navigator’s services will be free.
Healthcare service you get in a healthcare provider’s office.
There are two types of office visits:
- An office visit with a primary care provider or mental health professional.
- An office visit with a specialist who focuses on one area of medicine (for example, dermatology).
- Physical therapy, occupational therapy, chiropractic, vision, and alternative treatments might have different cost sharing (like co-pays or co-insurance) than other office visits. Check your plan documents to be sure.
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 qualified health plan, or switch plans. Vermont Health Connect's Open Enrollment starts November 1. However, if you miss Open Enrollment, you might not have to wait for the next Open Enrollment period to sign up for health insurance.
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 don’t have to pay additional costs. See in-network.
Costs you pay in addition to your monthly premium. Examples of out-of-pocket costs include the deductible you pay before your insurance starts to cover services, co-pays, and co-insurance. Monthly premiums are not part of your out-of-pocket costs. The federal health care reform law sets limits on the out-of-pocket costs you or your family must pay.
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 Plan Comparison Tool. For more information on payments, visit our Payment FAQs.
Premium Tax Credits
Premium tax credits (PTC) are also known as advance premium tax credits (APTC). These are tax credits that can be taken in advance to lower the amount of premiums you pay each month. If you are eligible for premium tax credits, you can get the money in advance (APTC) to lower your monthly premiums or you can claim the money when you file your federal taxes. The amount of APTC you can get depends on things like your income and family size. You must enroll through Vermont Health Connect to get premium tax credits. To estimate your eligibility for premium tax credits, use the Plan Comparison Tool.
The medical provider (such as a doctor [including naturopathic], physician assistant or nurse practitioner) you choose to directly provide or coordinate all your health care services.
Qualified Health Plan
A health insurance plan that has been certified by a health insurance marketplace, such as Vermont Health Connect. Qualified health plans provide essential health benefits, have set limits on cost sharing, and meet other federal and state requirements. To get government subsidies, such as premium tax credits, eligible Vermonters must be enrolled in a qualified health plan through Vermont Health Connect.
Insurance plans defined by the number of family members who need coverage. For health insurance, the tiers are Single, Couple, Parent and Child(ren), and Family.
One person - the subscriber (may be an adult or a child.)
Two people who are married to each other or are in a civil union, according to the rules of Vermont.
Parent and Child(ren)
Single adult with one or more dependent children, up to the age of 26.
Two adults 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 advance 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 get a credit on your taxes. This process happens at the end of the year, after you have filed your federal income tax return, including Form 8962.
The Small Business Health Options Program (SHOP) allows small businesses to offer health insurance to their employees, and to claim the Small Business Health Care Tax Credit if they qualify. To get the tax credit, businesses must first submit an eligibility application to Vermont Health Connect. Then, they can enroll in a VHC-certified health plan directly through their insurance carrier—either Blue Cross and Blue Shield of Vermont or MVP Health Care®. For more information regarding the tax credit, please consult your business’s tax advisor, the IRS or Vermont Department of Taxes.
Special Enrollment Period
A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
Depending on your Special Enrollment Period type, you may have 60 days to enroll in a plan. If you miss your Special Enrollment Period window, you may have to wait until the next Open Enrollment Period to enroll.
This type of deductible is meaningful when more than one person is covered by the same health plan. With a stacked deductible, the insurance plan pays benefits to each family member who meets an individual deductible, and to all family members once the family meets the family deductible. With a stacked deductible, an individual family member could meet their deductible before the other family members do.
Health insurance offered by your employer that covers only you and has a premium that is higher (as a percent of your household income) than the affordability rate for the current year. The federal government uses the lowest cost plan your employer can offer to figure out if your employer’s insurance is affordable. To check if the coverage you have been offered is considered unaffordable, visit our Affordability Estimator page.
Urgent Care (UC)
You can visit an urgent care facility if you have an illness, injury or condition that’s serious enough to get care right away, but not so serious that you should go to the emergency room. Urgent Care is a separate service category in your health plan and visits typically costs you less out-of-pocket than going to the emergency room.
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, visit MVP Health Care®. To check on specific drugs, review the drug list for each insurance carrier.
Vermont Cost-Sharing Reduction (also referred to as Vermont Cost-Sharing Assistance or VCSA)
Money from the state of Vermont available to eligible Vermonters to reduce out-of-pocket costs. To get VCSA, you must buy an Enhanced Silver plan through Vermont Health Connect. Enhanced Silver plans are designed with lower deductibles and out-of-pocket costs than regular silver plans. You must be eligible for APTC to be eligible for CSR and VCSR. Learn more about cost-sharing reductions.
Vermont Premium Reduction (also referred to as Vermont Premium Assistance or VPA)
Money from the State of Vermont that eligible Vermonters can get to help pay health insurance premiums, no matter the metal level of the health plan. If you are eligible for premium assistance under federal rules, you will also get Vermont Premium Reduction. Learn more about advance premium tax credits (APTC).
Medications that could be eligible for special benefits if prescribed to prevent a disease or condition or help you manage an existing issue.
For other health care definitions, visit HealthCare.gov.