- Affordable Care Act
You may have heard of the Affordable Care Act — sometimes called health care reform — a 2010 federal law intended to increase the value spent on health care, create a culture supporting healthy living and wellness and expand access to care. The law accomplishes this through health insurance mandates as well as financial assistance and tax credits for individuals and businesses to purchase insurance through the marketplace. Many of the law’s changes, including the requirement to have health insurance, will take effect in January 2014.
Colorado passed its own set of health care reform laws that established a state based marketplace called Connect for Health Colorado. Other laws passed in Colorado expanded Medicaid coverage to more low income Coloradans and aligned state health insurance regulations with new federal laws.
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 Child Health Plan Plus, covered benefits and excluded services are defined in state program rules.
- Child Health Plan Plus (CHP+)
Insurance program jointly funded by state and federal government. Child Health Plan Plus (CHP+) is low cost health and dental insurance for Colorado’s uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for Medicaid, but not enough to afford private health insurance. Colorado’s Child Health Plan Plus (CHP+) program is administered by the Department of Health Care Policy and Financing.
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 co-insurance 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 co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
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.
- Cost Sharing
Cost-sharing: The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, co-insurance, and co-payments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.
Cost-sharing in Medicaid and Child Health Plan Plus (CHP+) can include premiums, co-payments and enrollment fees. Some individuals who qualify for Medicaid or Child Health Plan Plus may be exempt from cost-sharing. For more information about Medicaid or Child Health Plan Plus contact the Medicaid Customer Contact Center at 1-800-221-3943 (TDD: 1-800-659-2656).
The amount you owe for health care services your health insurance or plan covers 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.
- Federal Poverty Level
A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.
- Grandfathered Plans
Employer insurance plans that were in place on March 23, 2010 are referred to as “grandfathered plans.” These plans are subject to some of the new rules resulting from the health reform law, but exempt from others. In order to maintain its grandfathered status, an insurance plan cannot reduce or eliminate benefits to treat particular conditions, increase employee cost-sharing (such as deductibles, coinsurance, and co-payments) above certain thresholds, reduce the employer share of the premium cost, or change insurers. Once a plan loses its grandfathered status, it will have to comply with all the new rules.
Beginning on September 23, 2010, grandfathered plans were required to:
- eliminate lifetime limits on coverage and restrict annual limits on coverage,
- eliminate pre-existing condition exclusions for children, and
- if the plan provides dependent coverage, extend that coverage to adult children up to age 26.
Beginning in 2014, grandfathered plans will be required to:
- eliminate annual limits on coverage,
- eliminate pre-existing condition exclusions for adults, and
- limit waiting periods for coverage to no more than 90 days.
Although grandfathered plans will be required to meet some consumer protections, these employer plans will not be required to alter their benefits to meet the new minimum benefit standards. Grandfathered plans are also exempt from having to limit enrollee cost-sharing, or provide coverage for preventive services with no cost-sharing.
Find out if your employer’s insurance plan is grandfathered by asking your human resources or employee benefits personnel.
- Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
- HIPAA Privacy Laws
The Health Insurance Portability and Accountability Act (HIPAA) is a 1996 federal law designed to protect sensitive health care information and reduce the administrative burden of health care for health care providers.
Colorado Medicaid is public health insurance for families, children, pregnant women, the elderly, people with disabilities and some adults without children. Beginning in 2014, Medicaid will cover individuals and families with up to 133%* of the Federal Poverty Level. The Colorado Department of Health Care Policy and Financing offers an overview of benefits included as part of Medicaid coverage.
To see if you qualify and to apply for coverage online go to colorado.gov/PEAK.
*Some making more may be eligible.
A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. Go to Medicare.gov for more information.
- Open Enrollment
You can apply for financial assistance to help you buy insurance through the Connect for Health Colorado. Open enrollment starts in October 2013 and ends March 31, 2014. Coverage starts as early as January 1, 2014.
The next open enrollment period will begin November 15, 2014 and end January 15, 2015. For more information about the Connect for Health Colorado open enrollment period visit ConnectforHealthCO.com.
Outside of open enrollment, you can still shop for insurance but cannot apply for financial assistance to help lower the costs of your plan unless you have a qualifying life event.
Medicaid and Child Health Plan Plus (CHP+) do not have open enrollment periods. You can apply at any time. Get more information about how to apply.
- Out-of-Pocket Costs
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
- Out-of-Pocket Maximum/Limit
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. For private insurance this limit never includes your premiums or health care the plan doesn’t cover. Some health insurance plans don’t count your co-payments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and Child Health Plan Plus, the limit does include any premiums.
- Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
The amount that must be paid for your health insurance or plan. You or your employer usually pay it monthly, quarterly or yearly.
- Primary Care Provider or Primary Care Physician (PCP)
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.
- 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, changes in your income, and changes in your family size (for example, if you marry, divorce, have a baby, or become pregnant).
- Real Time Eligibility Determination
When a PEAK online application for Medical Assistance receives immediate approval or denial. Click here for more information.
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Check with your health insurance plan to see what requires a referral.
The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
- State of Health
Colorado’s commitment to become the healthiest state: