Glossary

The Affordable Care Act (ACA) — commonly called “Obamacare” — is a complex law created by President Barack Obama and his administration. Here are some key things that changed with the ACA:

• All health insurance plans must now cover Essential Health Benefits.
• You can no longer be denied coverage for a pre-existing condition
• Some Americans now qualify for government tax credits to use towards their health insurance costs
• Children can now stay on their parents’ plans until they are 26
• The ACA led to the creation of the public exchange (a government-operated marketplace where individuals can now shop for and buy health insurance, and apply for government tax credits)

Services that don’t involve a significant laboratory expense for the dentist. These may include fillings and extractions.

This type of plan offers the lowest monthly payments, but higher costs when you need care. While preventive services will be covered at no cost, major care will be more costly as an individual must meet their deductible before the plan will pay for qualified services above that amount. These plans are only available to individuals 29 years old and under.

A fixed amount (for example, $15) a plan requires you to pay for a covered healthcare service. You usually don’t have to meet your Deductible to qualify for Copays: You only pay the Copay from day 1!

Example: My plan has a $20 co-pay for a doctor visit. When I visit my doctor for a qualified service, I only pay the $20 co-payment when I check in.

Usually represented as a percentage, this reflects the costs of a covered healthcare service that you’re responsible for, after you’ve met your deductible

Example: I met my plan’s $1,500 deductible. My plan has a 20% co-insurance so I must pay 20% of the cost of my next qualified health care service. The health insurance plan will pay the remaining 80%.

The contact lens exam is a special exam in addition to your routine eye exam. This special contact lens exam ensures proper fit of your contacts and evaluates your vision with the contacts. Depending on your needs, a doctor will provide training and education based on the type of services and eyewear provided.

Cost Sharing Assistance reduces some Americans out of pocket costs. Some low-income individuals and families will be able to enroll in health plans with lower deductibles, co-payments, and healthcare services costs. It’s important to know that Cost Sharing Assistance can only be applied to Silver Plans on the Public Exchange and only some Americans will qualify for Cost Sharing Assistance.

This is the dollar amount you must pay out of pocket for healthcare services before your health insurance plan kicks in.

Example: My health insurance plan has a deductible of $1,500. If I haven’t yet paid $1,500 towards my deductible, I must continue paying out of my pocket until I do. It’s good to know which things apply toward my deductible, and which ones don’t.

Routine services performed to keep teeth healthy. These may include exams, cleanings, x-rays, fluoride treatments and sealants.

Any dependent that you claim as disabled for IRS tax purposes. Disabled dependents often have differing rules for aging out of an insurance plan, check your plan benefit summary for details specific to your chosen plan.

If you are on a family medical plan with an embedded deductible, the plan will track both an individual deductible and a family deductible. Each member of the family has the opportunity to meet their individual deductible and have their medical bills covered before the entire family deductible is met.

Surgery treating cracked teeth and dental trauma. Most common procedure is root canal.

An important component of the Affordable Care Act is a requirement for health insurance plans to provide adequate coverage for “Essential Health Benefits”–broad categories of important health services.

Essential health benefits must include items and services within at least the following ten categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.

Routine eye exams are an important preventive measure for maintaining your overall health and wellness. During an eye exam, your doctor can look for vision problems and signs of serious medical conditions such as glaucoma, cataracts, diabetes, and even cancer.

This is what insurance companies call the list of drugs they cover. They’re often categorized in four “Tiers”: The lower the tier, the lower the cost. For example, “Tier 1” drugs are sometimes called “Generic Drugs” which cost the least.

Sometimes called a “tax credit,” the government is can provide subsidies to help some individuals decrease their premiums on the Health Insurance Marketplace. If you are eligible for a tax credit, the government will apply the credit to the cost of your health insurance coverage.

Also called the “Public Exchange” or “State Exchange,” the Health Insurance Marketplace is an online resource for individuals to shop for health insurance from different health insurance companies. Tax credits from the government are available to some families to decrease premium costs on the Health Insurance Marketplace.

Some states have their own marketplace, for example, Minnesota has MNSure, but most states use Healthcare.gov.

A Health Reimbursement Arrangement (HRA) is a way for employers to give pre-tax dollars to employees to use towards qualified medical expenses.

An HMO (Health Maintenance Organization) is a type of health plan that has a large network of doctors who agree to provide care to the HMO’s members. If you choose an HMO plan, you’re required to select a Primary Care Doctor, and then are required to visit this doctor whenever you need care. To visit a specialist, you will need to get a referral from your Primary Care Doctor. There are many types of HMOs, but typically members will have lower out of pocket healthcare expenses if they select an HMO plan.

A Health Savings Account (HSA) allows you to put pre-tax money into a savings account to use towards qualified medical expenses. An HSA can only be used with HSA eligible plans.

To determine if a plan is HSA eligible, look for HSA in the name of the plan.

Health insurance companies connect with certain providers and/or healthcare facilities to provide lower rates than out-of-network providers.

Example: I am changing health insurance coverage – it’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise it may cost me more to see that doctor.

Procedures and treatments that are complex in nature and involve a dental laboratory expense. These may include crowns, inlays/onlays, bridgework, and implants.

This is the maximum dollar amount the insurance company will pay towards the cost of dental care within a certain timeframe (usually the 12 months after an enrollment goes into effect). The consumer is responsible for paying any costs above the maximum.

Medicaid provides free or low-cost health coverage for people with low income.

MinnesotaCare is a subsidized program for low-income Minnesotans who do not have access to affordable, employer-based healthcare coverage and who are not eligible for Medical Assistance. MinnesotaCare isn’t the same as MNSure: MNSure is a Marketplace where individuals can buy insurance, MinnesotaCare is a type of health insurance facilitated by the state of Minnesota.

MNsure is Minnesota’s “Public Exchange” or “Marketplace” for health insurance plans. This is Minnesota’s version of Healthcare.gov.

If your plan costs more than your HRA enrollment tier, you’ll receive the total amount offered through your HRA. If your plan costs less than your HRA enrollment tier, you’ll be reimbursed for the total cost of your plan. Gravie makes sure you get the maximum allowable amount reimbursed.

If you are on a family medical plan with a non-embedded deductible, the entire family deductible must be met before any family member’s medical bills will be covered. The family deductible can be met by one member of the family or a combination of family members.

Online care allows for patient/clinician contact via telephone, computer, or app. Online care is often used in place of traditional healthcare due to its cost, speed, and convenience. It is most commonly used for non-emergency medical conditions such as flu, sinus infection, and pink eye, but it may also include other types of care such as dermatology, counseling, and psychiatric.

Open Enrollment is a period of time, usually November 1st through December 15th, when anyone can enroll or change their health insurance plan on the Public Exchange or Private Market. These plans become effective on January 1st the following year.

Surgery to treat many diseases, injuries and defects in the hard and soft tissues of the oral (mouth).

Services to prevent and correct misaligned teeth and jaws.

Providers and/or healthcare facilities that are considered “Out-of-Network” are not connected to the health insurance company and typically cost more than those that are considered “In-Network.” “Out-of-Network” expenses often have a separate much higher deductible and do not have an out of pocket max.

Example: I am changing health insurance coverage. It’s important that I check to see if my preferred doctor is considered in-network with my new health insurance company, otherwise, it may cost me more to see that doctor.

A medical expense is considered out of pocket if your health insurance company will not cover it and it’s above your monthly payment (premium). For example, payments towards deductibles, coinsurance, and copayments are all considered out of pocket expenses.

Also known as “OOP Maximum” or “Out of Pocket Maximum,” this is the most you would pay during the coverage time (typically a year) before your eligible costs are paid 100%. Keep in mind that this does not include premiums, which you have to pay each month.

Example: My health insurance coverage out of pocket max is $5,000. My out of pocket expenses include my annual deductible of $1,500, my copayments for doctors and prescriptions, and the coinsurance on eligible healthcare services. If I spend over $5,000 on qualified health services in these areas, my health insurance company will begin paying 100%.

Pediatric dental is for people 18 years and younger and usually includes routine dental services like cleanings and X-rays. Because of changes in healthcare law, people 18 and under must have dental coverage.

Pediatric dental coverage can be included in your medical plan or offered as a separate dental plan. If it’s not included in your medical coverage, your insurance company may require that you provide proof of your dental coverage.

Treatment for the structure of teeth and surrounding tissue.

Part of the Affordable Care Act is a rating system that has been implemented for health plans available on the Public Exchange. Plans are ranked as Platinum, Gold, Silver, Bronze, and Catastrophic.

Think of the tiers as a type of ranking-from the most amount of coverage for health services (Platinum) to the least amount of coverage for health services (Catastrophic). Keep in mind that “most coverage” does not necessarily mean “better” as Platinum plans also come with the highest monthly cost per month.

Example: I only want health insurance coverage for major health events. A Platinum plan is going to cost the most per month and provide more coverage than I am looking for. A Catastrophic Plan will cost the least per month and provide only minimal coverage.

Pre-tax money is not taxed with the rest of your wages. Taking advantage of pre-tax money can cut down on the amount you owe in taxes.

A Preferred Provider Organization (PPO) is a type of health plan that has a network of doctors that the PPO’s members can visit for reduced rates. These doctors are considered “in-network.” If you visit an “out-of-network” doctor, you will likely have to pay more for your care. You can see a specialist without getting a referral.

Your premium is the amount you pay for your health insurance coverage, typically each month. It’s sometimes referred to as your monthly payment.

Prescription drugs are one of many Essential Health Benefits. They’re often in categories called “Tiers” with an associated friendly term that describes them.

Generic (or Tier 1) Drugs: Generic prescription drugs are not a familiar brand name, but are made of the same active ingredients and must meet the same quality and safety standards. They are the lowest-cost tier of drugs.

Preferred Brand Name (or Tier 2) Drugs: Medications sold under a trademarked name, like Nexium or Advair. Only the company that has the patent can produce and sell these specific medications. Some “Brand Name” drugs have better coverage than others so they can cost less.

Non-Preferred Brand Name (Tier 3) Drugs: Another type of Brand Name Drug that the insurance company doesn’t prefer so they often cost more.

Specialty or Medical (Tier 4) Drugs: These prescriptions are typically extremely costly and are used to treat severe and chronic conditions. They are sometimes prescribed and administered with a medical procedure, for example, chemotherapy.

Preventive care services are an Essential Health Benefit and one of the best ways to stay healthy. These services, which typically include yearly checkups, screenings, and immunizations, can help you avoid, detect, or delay health problems.

Private Market plans are plans purchased directly from the insurance carrier rather than through HealthCare.gov or a state exchange. Private Market plans are not eligible for tax credits.

A provider is a health care professional or medical facility, including doctors, clinics, and hospitals.

A qualifying life event is when something happens in your life that allows you to make changes or enroll in new insurance coverage outside of Open Enrollment.

Common examples of Qualifying Events include, but aren’t limited to:

Loss of Coverage

I lost my existing coverage because:

• I left my previous job and lost my employer sponsored insurance
• I’m turning 26 and can’t be on my parent’s insurance anymore
• I lost eligibility for Medical Assistance, a State Program or other government-sponsored coverage

Note: This does not include loss of coverage that is voluntarily for example a plan became unaffordable and you want to change the plan mid-year or you didn’t pay your premiums.

Marriage

I got married.

Change in Family Size

My family got bigger or smaller:

• Birth or adoption – I had or adopted a child
• Dissolution of Marriage – I’ve legally divorced my spouse and lost coverage
• Death – I lost insurance when my spouse/parent died

Permanent Move

• I permanently moved to a place that my insurance company doesn’t offer my plan.
• I moved from one state to another.

Other

There are some other special circumstances that can grant a special enrollment period including eligibility for a tax credit or change in citizenship status. These are rarer and can be discussed further with the Gravie Care Team.

A Recurring Reimbursement is offered with a Health Reimbursement Arrangement (HRA) whenever possible. When you set up a Recurring Reimbursement, Gravie is able to submit a claim on your behalf each month, so you can easily receive your reimbursement.

A special enrollment period is a window of time when you’re allowed to purchase or make changes to your health insurance plan because you’ve experienced a Qualifying Event. For example, you have a 60 day special enrollment period with MNSure if you leave a job and lose your health insurance.

The amount you qualify for in Government Tax Credit or “subsidy” can be used towards the cost of Tax Credit Eligible plans. To receive the tax credit, you must:

• Fill out an additional application via your state’s exchange. This will take between 20-60 minutes.
• Make sure dependents on the insurance plan are tax dependents of the main applicant. If you’re married and have your spouse on the plan, you must file your income taxes jointly with them.
• You’ll also need to fill out some extra forms when you file your income taxes at the end of the year.

Please note: The tax credit amount displayed is an estimate based on the information you’ve provided about your household. The final amount you may qualify for will be determined during the application process.