September 22, 2019
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An ACA glossary

Catastrophic plan: You’re young, poor and feel invincible — this is the plan for you. Offers low monthly cost, high yearly deductible, limited benefits. Basically, it’s there in case you’re in a major car accident, get cancer or suffer some other major medical problem. You know, a catastrophe. Thus the name.

Co-insurance: Your share of the medical bill after you have paid your annual deductible. Usually shown in a percentage, as in 20 percent paid by you and 80 percent paid by the insurance company.

Co-op: A new kind of nonprofit insurance company run by members for members. Think credit union. Maine has one co-op: Maine Community Health Options in Lewiston.

Co-pay: That money you plunk down at the receptionist’s window when seeing the doctor.

Deductible: How much you’ll pay each year before the insurance company starts kicking in its share.

Exchange/marketplace: Are you an individual or small business or group? If so, you can buy insurance here. Insurance will be sold elsewhere, sure, but this is the only place where individuals can use their federal subsidy to help pay the cost. It’s also the only place small business owners can get a tax break for buying insurance for their employees. Originally dubbed the “exchange,” it’s now officially the “marketplace.”

Government-sponsored insurance: Insurance paid by the state or feds. Includes Medicaid and Medicare.

Grandfathered plan: Insurance bought before March 2010. If you have a grandfathered plan, your costs and benefits don’t have to meet ACA requirements.

Individual: You. Or you-and-family.

In-network: The doctors and hospitals your insurance company will happily pay for. (It may pay for out-of network care, but not as much.)

Medical loss ratio: This kicks in when your insurance company spends too much on the corporate jet and not enough on flu shots. If the insurance company doesn’t spend at least 80 or 85 percent of overall premiums on medical care, you get a rebate.

Metal levels: Bronze, silver, gold and platinum. Like medals in the Olympics, these metals help you tell the difference between good, better and best insurance plans.

The lowest insurance levels, bronze and silver, cost less each month, but you’ll get fewer benefits and will pay more when you go to the doctor. The highest levels, gold and platinum, cost more each month, but they offer better benefits, and you won’t have to pay a lot when you see the doctor. (FYI: No one is offering a platinum plan in Maine yet.)

Narrow network: Want to see Dr. Smith? Go for it, because your insurance company likes her. Dr. Jones? Nope, sorry (unless you want to pay the bill all by yourself). When an insurance company strictly limits the doctors and hospitals a patient can see in an effort to control costs, it has a narrow network.

Open enrollment: You can buy individual health insurance only during this time unless you lose your job, get married, have a baby or something else big happens in your life. Right now, open enrollment will last from October 2013 to March 2014. In future years it will go from October to January. (FYI: This is the rule for insurance bought on or off the exchange/marketplace.)

Out-of-pocket maximum: The most you’ll have to pay for your health care in a year. Have a $6,350 out-of-pocket maximum with your insurance company? Everything after that is free until the new year rolls around again.

Plan factor: The things about you that can raise the price of your insurance. Typically your age, where you live and whether you smoke.

Premium: How much you pay each month for insurance. Think of it as the price tag.

Preventative care: Shots, colonoscopy, depression screening, counseling for alcohol abuse, diet counseling and a bunch of other services designed to keep you healthy or catch an illness before it gets to the crisis point. Preventative care is free, with no co-pays or co-insurance, even if you haven’t met your annual deductible.

Private insurance: If it’s not government insurance, it’s private. This includes insurance paid by you or your employer. All plans on the exchange/marketplace are private plans, even if you get a subsidy for it.

SHOP: Small Business Health Options Program. It’s where small groups can buy health insurance and get a tax break for it over the next two years. (FYI: Only the employer gets this refundable credit, not employees.) In Maine, SHOP is the same as the exchange/marketplace.

Small group: Fifty or fewer people. Usually means a small business. The definition will change to 100 or fewer people in 2016.

Subsidy: Money the federal government will give to people who need to buy their own insurance (because an affordable plan isn’t offered through their job) and who earn between 100 percent and 400 percent of the federal poverty level. You can get the subsidy in a tax credit or have it paid directly to the insurance company to lower your monthly bill. If you earn less than 250 percent of the poverty level, you can also get a subsidy to discount your out-of-pocket expenses. How big of a subsidy? Depends on your salary. It’s a sliding scale.

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