Actuarial value (AV)—A measure of a health care plan’s generosity; it is the percentage paid by the plan of the total allowed costs of benefits. Beginning in 2014, all Essential Health Benefits (EHBs) offered in exchange certified plans in the individual and small-group markets, both inside and outside health insurance marketplaces, must meet specified actuarial values.
Affordable Care Act (ACA)—A term commonly used to describe the federal health care law enacted in March 2010. “Affordable Care Act” is Delta Dental’s preferred use; however, it also is known as the Patient Protection and Affordable Care Act, or casually as Obamacare.
Balance bill—A nonparticipating provider’s right to bill the patient for the remainder of his or her submitted fee following adjudication of the claim by the health plan. Participating providers have agreed to accept the health plan’s determination of a fee—defined as the approved amount—as the maximum amount that can be collected from the patient or health plan.
Benchmark plan—The benchmark plan is the health plan chosen by a state to serve as the standard for determining the mandatory Essential Health Benefits (EHBs) that must be offered in that state.
Benefit year—A 12-month period of benefits coverage under an individual policy or group health plan. For group health plans, the 12-month period may not be the same as the benefit year.
Center for Consumer Information and Insurance Oversight (CCIIO)—CCIIO is charged with helping to implement many provisions of the ACA and oversees the implementation of the provisions related to private health insurance. It works closely with governors and the state insurance commissioners, consumers and stakeholders.
Centers for Medicare and Medicaid Services (CMS)—The federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program and also the federally facilitated marketplace.
Children’s Health Insurance Program (CHIP)—An insurance program jointly funded by state and federal government that provides health insurance to low-income Americans, primarily children. States run these programs within guidelines set by the federal government, but have the ability to expand coverage. While the federal government only requires certain dental coverage for children, several states have expanded dental coverage for individuals covered by Medicaid and CHIP. Medicaid currently covers more than 50 million people, and CHIP covers approximately 6 million children.
Deductible—The deductible is the amount an individual and/or a family must pay toward covered services before the health plan begins paying for services.
Dental coverage—Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleanings, X-rays and fillings. In the exchange or marketplace, dental coverage is available either as part of a comprehensive medical plan or by itself through a "stand-alone" dental plan.
Department of Health and Human Services (HHS)—The federal agency that oversees Centers for Medicare and Medicaid Services (CMS), which administers programs for protecting the health of all Americans, including Medicare, the exchanges, Medicaid and CHIP.
Dependent coverage—Insurance coverage for family members of the policyholder, such as spouses, children or partners.
Embedded coverage—Embedded coverage generally refers to policies where dental coverage is provided under the same contract as medical coverage.
Essential Health Benefits (EHBs)—The ACA mandates that all policies issued in the small-group and individual insurance markets provide coverage for certain benefits, which are commonly referred to as Essential Health Benefits or EHBs. Those benefits include:
- Ambulatory patient services
- Emergency services
- 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
- Pediatric services, including oral and vision care
Unless specified otherwise by the state, EHB pediatric dental services are those services identified in the benchmark plan that are provided to an individual under the age of 19.
Excepted benefits—Dental, vision and other miscellaneous health benefits are examples of excepted benefits. Excepted benefits by law are exempt from many of the ACA requirements.
This means that stand-alone dental coverage, whether purchased on or off the exchange, is exempt from many provisions in the ACA, but if the coverage is purchased as an integrated piece of a major medical plan, it is not exempt and would be subject to insurance market reforms.
For group health plans to be considered an excepted benefit, the stand-alone dental plan must either: 1) be offered pursuant to a separate policy, certificate or contract of insurance; or 2) not be an integral part of the group health plan. In order for the dental component of a group health plan to be considered “non-integral,” employees must have the ability to opt out of the group health plan and must pay a minimal contribution.
Exchange (see health insurance marketplace)
Federal Employees Dental and Vision Program (FEDVIP)—The Federal Employees Dental and Vision Program selected by the federal government to serve as the benchmark plan for determining EHBs in those states that have not selected a state benchmark plan.
Federally Qualified Health Center (FQHC)—Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally Qualified Health Centers provide primary care services regardless of the ability to pay.
Full-time employee—An employee who works an average of at least 30 hours per week.
Full-time equivalent (FTE)—A standard, based upon a calculation, that represents the number of part-time employees it takes to equate to a full-time employee.
Grandfathered plans—The "grandfather provision" allows plans that already existed when the ACA became law to be grandfathered and therefore exempt from some of the new law's provisions. In order to be grandfathered, a plan must have made a separate election prior to March 23, 2010.
Health insurance marketplace (also called an “exchange”)—The ACA requires each state to create a health insurance marketplace where individuals and small employers can shop for health plans. If a state elects not to establish a marketplace, the federal government will establish a marketplace in that state. The marketplace is a resource where individuals, families and small businesses can:
- learn about health coverage options
- compare health insurance plans based on costs, benefits and other features
- choose a plan
- enroll in coverage.
Health Insurance Portability and Accountability Act (HIPAA)—A 1996 federal law that improves the portability and continuity of health coverage. It also mandates standards for health care information on electronic billing, and requires the protection and confidentiality of protected health information.
Individual mandate—A requirement of the ACA which states that everyone must have health care coverage as of 2014. Individuals not covered by their employer must buy coverage or pay a fine.
Large group—A company with more than 50 full-time employees or full-time equivalent employees.
Market reforms—The ACA requires implementation of a number of reforms prior to its full implementation date for plan years beginning on or after January 1, 2014. These reforms fall into two broad categories: immediate and private.
The ACA term “immediate” refers to the legal effective date of the provision. The actual implementation date, however, may not be immediate due to the time required to make the provision operational.
The following are “immediate” reforms:
- rate review
- Internet portal to assist consumers in identifying coverage options
- prohibition on lifetime limits and restriction of annual limits
- prohibition on rescissions
- coverage of preventive health services with no cost-sharing
- extension of dependent coverage
- prohibition of discrimination based on salary
- medical loss ratio (MLR)
- appeals process
- coverage of pre-existing health conditions for children
- patient protections
- uniform explanation of coverage documents
- reporting requirements regarding quality of care
In addition to the immediate reforms in ACA, there are additional private insurance market reforms that become effective for plan years beginning on or after January 1, 2014.
These reforms include the following:
- nondiscrimination based on health status
- guaranteed issue and guaranteed renewability
- coverage of pre-existing health conditions (regardless of age)
- nondiscrimination regarding clinical trial participation
- rating restrictions
- waiting period limitation
- nondiscrimination regarding health care providers
Minimum essential coverage (MEC)—The type of coverage an individual must have to meet the ACA’s individual mandate requirement. This requirement can be met through individual market policies, Medicare, Medicaid, CHIP, employment-based coverage and certain other coverage.
Navigator—An individual or organization that is trained and able to help consumers, small businesses and their employees as they look for health coverage options through the health insurance marketplace, including completing eligibility and enrollment forms.
Network—A group of providers that have signed a specific contract to render services as a participating provider for one or more clients.
Out-of-pocket maximum—The most a subscriber pays for in-network EHBs during a policy period (usually a year) before a plan begins to pay 100 percent of the allowed amount. An out-of-pocket maximum does not include premium, payments made to out-of-network providers, payments made for non-covered services or payments made for non-EHB services.
Part-time employee—An employee who works an average of less than 30 hours per week.
Patient Protection and Affordable Care Act (PPACA)—A United States federal statute signed into law by President Barack Obama on March 23, 2010. Also known as ACA and informally referred to as Obamacare.
Qualified health plan (QHP)—Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the health insurance marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each marketplace in which it is sold.
Reasonable assurance—Medical carriers outside of an exchange may offer EHB medical plans that exclude pediatric dental benefits if they are “reasonably assured” that such coverage is sold only to individuals who purchase exchange certified stand-alone dental plans.
Small Business Health Options Program (SHOP)—The Small Business Health Options Program is a new program designed to help employers with 50 or fewer full-time-equivalent employees (FTEs). An individual who is self-employed and has no employees may get coverage through the individual market health insurance marketplace, but not through SHOP.
Small-group—In most states, a company with 50 or fewer full-time employees.
Stand-alone dental coverage—Most dental benefits are purchased separately from medical insurance (stand-alone coverage) and most covered children already have dental coverage through a stand-alone family dental plan. Congress recognized the value of stand-alone dental coverage by allowing insurers that specialize in dental benefits to offer kids’ coverage on exchanges. That means parents have the choice to purchase their children’s dental benefits separately from their medical benefits.
Summary of benefits and coverage (SBC)—The ACA requires group health plans and health insurers to provide access to a brief, standardized document that describes the benefits and coverage under the applicable health plan so that those covered can compare plan benefits among and between other plans and insurers. Fully insured stand-alone dental plans are exempt from having to provide SBCs. Similarly, self-insured dental plans that are not integral to the group health are not required to provide SBCs.