- Accountable Care Collaborative (ACC)
The Accountable Care Collaborative is a Health First Colorado program to improve members’ health and reduce costs. Health First Colorado members in the Accountable Care Collaborative will receive the regular Health First Colorado (Colorado’s Medicaid Program) benefit package and be connected to a medical home and community resources. Health First Colorado members will also belong to a Regional Organization. A Health First Colorado member’s Regional Organization works together with their communities and providers to find out what a member’s needs are and help get members to the right services.
- Advance Premium Tax Credit (APTC)
The Affordable Care Act provides a tax credit to help you afford health coverage purchased through the Connect for Health Colorado marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
Once you have picked a health plan through Connect for Health Colorado marketplace, you must report certain life changes. This information may change the coverage or saving your qualify for.
- Affordable Care Act
You may have heard of the Affordable Care Act — sometimes called Obamacare — 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, took 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 Health First Colorado (Colorado’s Medicaid Program) coverage to more low income Coloradans and aligned state health insurance regulations with new federal laws.
- Annual Income
Annual income is the total income you expect to make from your job in the coverage year. For example, if you are applying for 2020 coverage in 2020, you will provide job income for 2020. If you are applying for 2020 coverage in 2019, you will give estimated job income for 2019.
- Authorized Representative
An Authorized Representative is either a person or an organization that you trust and let fill out your application, talk about this application with us, see your information, get information about your application, and sign your application on your behalf. An Authorized Representative also takes legal responsibility for the information provided in an application. If an Authorized Representative is a person, they must be 18 or older. An Authorized Representative is NOT an Agent/Broker, Health Coverage Guide, or a Certified Application Counselor.
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 Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus, covered benefits and excluded services are defined in state program rules.
- Broker or Agent
A broker offers policies from Marketplace insurers that they are contracted to represent. Brokers can provide free assistance in comparing the rates and benefits of health plans from several companies. An experienced broker can provide expert and detailed information on plan specific features and limitations of various policies.
Connect for Health Colorado has certified brokers can walk you through the application process and apply for financial assistance to reduce your monthly costs. They are also able to work with small business owners to offer the advantage of an enhanced choice model. You can meet with a Broker for free to understand your options. Find a certified Connect for Health Colorado broker or agent on ConnectforHealthCO.com
If you are a Certified Connect for Health Colorado broker or agent and need assistance helping your client through the application or enrolling them in coverage, please contact the Broker Support Line or call the Connect for Health Colorado Service Center at 1-855-752-6749.
- 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 Health First Colorado (Colorado’s Medicaid Program), 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. If you or your child qualify for CHP+, you may have to pay an annual enrollment fee.
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.
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 you experience another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee. Get more information about COBRA from the U.S. Department of Labor.
- 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 Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+) can include premiums, co-payments and enrollment fees. Some individuals who qualify for Health First Colorado or CHP+ may be exempt from cost-sharing.
- Coverage Year
The coverage year is the calendar year you are applying to get tax credits or help to lower your health care costs. For example, if you are applying in November of 2014 for 2015 health care coverage, the coverage year would be 2015. Or if you are applying in February of 2015 for 2015 health care coverage, the coverage year would be 2015.
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. Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+) do not have deductibles.
A deduction is an amount you can take off of the total amount you earn (gross income). Common deductions include alimony and student loan interest. We do not need you to tell us about things like charitable contributions or home mortgage interest. For additional information, visit the IRS website.
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.
Having a disability means you cannot do any substantial gainful activity or major activity to receive pay (or, in the case of a child having marked and severe functional limitations or have an easily recognized and extreme lack of ability to do everyday activities) because you have been medically determined to have a physical or mental impairment that will either result in death or which has lasted or is expected to last for 12 months in a row or more.
The charge for the use of borrowed money. Interest you get from a bank or dividends from a stock you own are examples of investment income, which you should tell us about if you apply for help paying for health coverage.
- Division of Insurance
The Department of Regulatory Agencies’ Division of Insurance regulates the insurance industry and assists consumers and other stakeholders with insurance issues. For more information go to DORA.colorado.gov/healthinsurance.
- Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
The EPSDT benefit provides comprehensive and preventive health care services for children (ages 0-20) who qualify for Health First Colorado (Colorado’s Medicaid Program).
- Estate Recovery
Federal law requires states to operate an Estate Recovery Program to help pay for the costs of their Medicaid program. We recover medical assistance payments paid on behalf of former Health First Colorado (Colorado’s Medicaid Program) members from their estates. We may only recover medical assistance costs from the estates of members who received services in an institutionalized setting or for the cost of services received by members who were age 55 and older. The law also provides exceptions to estate recovery and the ability to compromise claims.
- 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.
- Federally-Recognized Tribe
Any Indian or Alaska Native tribe, band, nation, pueblo, village or community that the Department of the Interior acknowledges to exist as an Indian tribe.
- 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.
Get more information on Grandfathered Plans at HealthCare.gov.
- Gross Pay/Income
Profits before taxes, deductions, or expenses are paid.
- Health Coverage Guide
Health Coverage Guides are certified by Connect for Health Colorado to provide free assistance to customers who are applying for health coverage and financial assistance programs that help reduce health insurance costs. They also help customers to understand coverage options and provide unbiased assistance in shopping for and selecting health plans.
- Health First Colorado (Colorado’s Medicaid Program)
Health First Colorado (Colorado’s Medicaid Program) is public health insurance for low income Coloradans who qualify. The Colorado Department of Health Care Policy and Financing offers an overview of benefits included as part of Health First Colorado coverage.
To see if you qualify and to apply for coverage online go to colorado.gov/PEAK.
- 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 qualify 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.
- Income Eligibility and Verification System (IEVS)
IEVS is a system that compares the income that an individual reports when they apply for Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+) with the income employers report to the Colorado Department of Labor and Employment for all of their employees. If there is a big difference between an individual’s self-reported income and the employer-reported income in IEVS, an individual may be asked to provide an explanation of why the numbers are different, and/or to provide proof of their income.
- Individual Shared Responsibility Exemption
You may be exempt from having to buy health coverage. Find out if there are health coverage exemptions that apply to you.
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 Connect for Health Colorado.
For more information about the Connect for Health Colorado open enrollment period visit ConnectforHealthCO.com or contact Connect for Health Colorado at 1-855-752-6749 / TDD 1-855-346-3432.
Outside of open enrollment, you can still shop for insurance if you have a qualifying life event.
- Out-of-Pocket Costs
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and co-pays 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.
- 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.
- Prior Authorization Request
Some services and benefits require a health care provider to complete a form or make a phone call that gives permission to get extra services and supplies if you have a special health care need. Your insurance carrier will have their own list of services and benefits that require a prior authorization. If you have questions about what requires a prior authorization, contact your insurance carrier. If you have Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+), you can find out what benefits and services are covered.
- Qualifying Life Event
A change in your life may mean you can qualify for a Special Enrollment Period to enroll in private health coverage through the Marketplace, Connect for Health Colorado. 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 or have a baby). Read more about reporting a life change.
Get more information from Connect for Health Colorado at 1-855-752-6749 / TDD 1-855-346-3432.
You can apply for Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+) at any time. If you qualify for Health First Colorado, you can enroll right way. If you or someone in your household qualify for CHP+, you may be required to pay an annual enrollment fee before you can enroll. You can learn more about whether you will need to pay a CHP+ enrollment fee by clicking on the “Payment” tab in your Colorado.gov/PEAK account. You will also get a letter in the mail about the annual enrollment fee for CHP+. You can pay your annual enrollment fee online through your PEAK account or by downloading the free PEAKHealth mobile app from the iTunes and Google Play stores.
- Real Time Eligibility Determination
When an online application for Medical Assistance through Colorado.gov/PEAK or ConnectforHealthCO.com receives immediate approval or denial. It is important to fill out your application for Medical Assistance completely and accurately to increase your ability to find out right away if you qualify for Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+).
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. Referrals are not required for Health First Colorado (Colorado’s Medicaid Program) members enrolled in the Accountable Care Collaborative (ACC).
Check with your health insurance plan to see what requires a referral.
- Regional Organization
Regional Organizations are a part of the Accountable Care Collaborative (ACC). A Regional Organization connects Health First Colorado (Colorado’s Medicaid Program) members to providers and also helps members find community and social services in their area. The Regional Organization helps providers communicate with Health First Colorado members and with each other, so Health First Colorado members receive coordinated care. A Regional Organization will also help Health First Colorado members get the right care when they are returning home from the hospital or a nursing facility by providing the support needed for a quick recovery. Regional Organizations help with other care transitions, too, like moving from children’s health services to adult health services, or moving from a hospital to nursing care.
Get more information about Health First Colorado Regional Organizations.
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.
A health care program for active-duty and retired uniformed services members and their families. See TRICARE.mil for more information.
- Veterans Administration (VA) Health Care
A health care program for Veterans who qualify. See va.gov/health for more information.