Glossary

Actuarial value (AV) measures the average value of expected benefit costs in a health insurance plan. Health plans are grouped into four metal levels based on actuarial value: bronze, silver, gold and platinum. A bronze plan pays 60 percent of the cost of covered benefits. A silver plan pays 70 percent. A gold plan pays 80 percent. A platinum plan pays 90 percent of the cost of covered benefits. Premiums are lowest in a bronze plan, highest in a platinum plan.

The Affordable Care Act (ACA) was signed into law on March 23, 2010. It aims to help make health insurance accessible and affordable for everyone. It is changing who can get health insurance, how they receive care, what it costs and who pays for it.

The Affordable Care Act (ACA) defines “affordable coverage” for employer plans. Employer coverage is “affordable” if employee costs do not exceed certain limits. The employee share of the premium cannot be more than a set percentage of the household income. Employees may get a lower-cost health plan through the Marketplace if employer coverage is not affordable.

There are two types of deductibles: aggregate deductible and embedded deductible. In general terms, a deductible is the dollar amount you pay until health insurance kicks in to pay some (or all) of your costs. When you have an aggregate deductible, your deductible amount applies for the whole family. It can be met by one family member or multiple family members covered by the plan.

For example, with an aggregate deductible, one person with high medical costs could reach the deductible amount for the whole family and then the health plan will pay for all family members. This is different from an embedded deductible, which is set up with lower, single deductible amounts for each person covered. With an embedded deductible, each member of a family plan must meet their individual deductible amount before the health plan will pay for their medical costs.

A brand-name drug is sold under a name that is protected by a patent. Brand-name drugs generally cost more than generic drugs that have the same active-ingredient formula. The amount you pay at the pharmacy may vary based on whether the medication is a generic or a brand-name drug.

An insurance agent or broker is a person or business who can help you enroll in a health plan. They are typically licensed and regulated by the state. Insurance agents and brokers get payments (or commissions) from health insurers for enrolling consumers or employer groups in health plans.

There are catastrophic level health plans available on the Marketplace. These plans are for young adults under age 30 and/or those who qualify based on income and other factors. MVP has named these “Secure” plans. In general, these plans have lower premiums and higher costs when you use health services. They are designed to cover your costs if you have a major medical event.

Child Health Plus is a health insurance plan for children in the state of New York. Child Health Plus provides low-cost or free health coverage to children under age 19. Families can go to the NY State of Health, The Official Health Plan Marketplace, to find out if they are eligible for Child Health Plus and enroll in the program.

Co-insurance is a cost-sharing agreement in a health insurance plan. After the deductible is met, the member pays a set percentage of his or her medical costs. Here’s an example:

• Minor surgery costs $1,000.
• The patient is responsible for 20 percent co-insurance.
• The patient would pay $200 in co-insurance (20 percent of the cost of surgery). This assumes the deductible has already been met. If it has not, the patient would pay the full amount up to the deductible. After the deductible is met, the patient would pay 20 percent co-insurance.

A co-pay, or co-payment, is the dollar amount you pay for health care services at the doctor’s office, hospital or pharmacy. The co-pay amount varies by the type of service. (For example, primary care visit, specialist visit, urgent care or emergency visit.) After you pay the co-pay, the insurer generally pays a portion or all of the remaining costs.

COBRA coverage is a form of continuation coverage for group health plans. If employees lose job-based coverage for any reason, there’s an option to continue group health coverage for 18 months. Employees who elect COBRA coverage have to pay 100 percent of the premiums. Marketplace coverage may cost less than COBRA, so it’s best to explore all the options before making a decision.

A plan with cost-sharing reductions (CSR) reduces the cost you pay for health services at doctor’s office, hospital or pharmacy. CSR plans are available for those who qualify based on income. Note: CSR is only available with silver level plans through the Marketplace.

The annual deductible is the dollar amount you pay before the health plan kicks in to pay some (or all) of your costs.

A dependent child is a child up to age 26 who can be claimed as a dependent on the parent’s tax return. When you apply for health coverage, you’ll include information about your dependent children under age 19 and dependent children ages 19 to 25. Learn more about dependent coverage for adult children.

The Affordable Care Act (ACA) makes it possible for dependent adult children to stay on their parents’ health plans up to age 26. Coverage is offered regardless of the child’s marital status, financial dependency, residency, student status and employment status. New York currently provides options for dependents to obtain or continue coverage on their parent’s group policy until they turn 30. This is an option for families to consider, but parents are not required to add adult children to their health plan.

Individuals and Small Groups in New York and Vermont can buy health plans directly from MVP. With direct enrollment, you complete the enrollment process through your insurer and/or with the help of your broker or insurance agent. Qualified health plans sold outside the Marketplace (or Off-Exchange) must still meet state requirements for benefits. However, there could potentially be differences in benefits design and prices may vary from what is found on the Marketplace. Note: Premium subsidies and/or cost-sharing reductions are not available with plans sold outside the Marketplace.

Dr. Dynasaur is a health insurance plan for children in the state of Vermont. It provides low-cost or free health coverage to children under age 19 and pregnant women. Families can go to Vermont Health Connect to find out if they are eligible for Dr. Dynasaur and enroll in the program.

People who are dual eligible qualify for both Medicare and Medicaid. Medicare is for people who have reached the age of 65 or have a qualifying disability at age 18 or older. Medicaid is health insurance option for people who need financial assistance. Eligibility is based on many factors, including income and family size and is determined by New York State.

There are two types of deductibles: aggregate deductible and embedded deductible. An embedded deductible is set up so there’s a single deductible amount for each person covered by the plan. When one family member reaches his or her single deductible amount, the plan will begin to pay for that family member’s costs. Each family member’s deductible amounts count toward the family deductible. When the family deductible is met, the plan pays for all members. An embedded deductible may provide greater financial protection because each person’s costs are capped at a lower amount compared to an aggregate deductible.

A minimum set of benefits called essential health benefits must be covered by health plans. They include ambulatory patient services; emergency room services; hospitalization; maternity and newborn care; mental health and substance use disorders; 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.

The Marketplace (also called the Exchange) is a place where individuals, families and small businesses can shop for health plans and enroll in coverage. When you apply through the Marketplace you’ll find out if you qualify for financial help based on income. If you do, you may get a break on costs with premium tax credits, cost-sharing reductions or other programs. NY State of Health, The Official Health Plan Marketplace, is New York’s state-run Marketplace. Vermont Health Connect is the state-run Marketplace for Vermont.

An EOB is a document to keep you informed of the health care claims that have been submitted on your behalf. It shows what your health plan has paid to the provider, what the health plan has reimbursed to you (if applicable), any financial responsibility you may have for services provided, and if services were not paid for by your health plan. Please note, this is not a bill.

Express Pay is a quick, convenient, and safe way to make one-time premium payments without signing into your online member account. Members can use it to make their first premium payment to begin coverage, or to check their balance.

Federal Poverty Level (FPL) is a measure of income level based on household income and family size. FPL is used to determine eligibility for Medicaid, premium subsidies and other programs. The Department of Health and Human Services issues new FPL guidelines each year.

A flexible spending account (FSA) is set up by an employer. It can be used to pay for out-of-pocket medical expenses. You decide how much money to take out of your paycheck and put into your FSA, up to certain limits. Your contributions are made with pre-tax wages, so you don’t have to pay taxes on the money you put in.

Some plans (such as MVP Option Child and Healthy NY) have a two-tier benefit where only generic and formulary brand drugs are covered. If a non-formulary, tier 3 drug is medically necessary, your provider must submit a request for the non-formulary drug.

A generic drug has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Gia is your ultimate health care connection. Available 24/7 by phone, web, or mobile app, Gia expertly assesses your health needs and quickly refers you the right care, including virtual and in-person care. To get started, download the Gia by MVP app on the Apple App Store or Google Play Store or visit GoAskGia.com.

Plans that were created before March 23, 2010, may have the option to maintain special “grandfathered” plan status. If your employer’s health plan is grandfathered, you may not have all the same rights and protections that other plans offer. Look at your plan materials and check with your employer to find out if your plan is grandfathered.

A family of low-cost and free health coverage programs for Vermonters that includes Medicaid and Dr. Dynasaur.

The Green Mountain Care Board is charged with reducing the rate of health care cost growth in Vermont while ensuring that the State of Vermont maintains a high quality, accessible health care system.

A group health plan covers a group of employees. It is also called an employer-sponsored health plan or job-based coverage. An employer or employee organization may offer a group health plan for employees and their families.

The Affordable Care Act (ACA) removes barriers to getting health insurance. Everyone can get approved for health insurance regardless of health status. Your coverage can be renewed regardless of health status. Children and adults cannot be denied coverage due to physical or mental conditions, illnesses, injuries or disabilities.

Health insurance is a contract with an insurer. The insurer agrees to pay for some or all of your health care costs and you agree to pay a monthly premium. (If you qualify for premium subsidies or other programs help to pay for insurance, you may have low or no premiums.)

The Marketplace (also called the Exchange) is a place where individuals, families and small businesses can shop for health plans and enroll in coverage. When you apply through the Marketplace you’ll find out if you qualify for financial help based on income. If you do, you may get a break on costs with premium tax credits, cost-sharing reductions or other programs. NY State of Health, The Official Health Plan Marketplace, is New York’s state-run Marketplace. Vermont Health Connect is the state-run Marketplace for Vermont.

A health reimbursement arrangement (HRA) is a tax-exempt account. It is set up for employees to pay for qualified health expenses in an employer plan. HRAs are funded with contributions from your employer. In general, HRAs are not portable (you can’t take the funds with you) if you leave your employer. The employer has ownership of the account, and the employer decides if funds should roll over from year to year. An HRA is usually paired with a high-deductible health plan.

A health savings account (HSA) works with a high-deductible health plan (HDHP) so you can save for health expenses. An HSA is a tax-exempt account that can be used for qualified health expenses for you and your family—even if your spouse and dependents are not covered by the HDHP. Any funds remaining in the account roll over from year to year. If you have an employer plan, your employer may provide an HSA option. You keep the HSA and the funds in the account even if you change employers. The HSA is owned by you. If you buy your own health plan, you may open an HSA if you have a qualified high-deductible health plan. The HSA is owned by you and can be used to pay health expenses for you and your family.

High-deductible health plans (HDHPs) have higher deductibles and lower monthly premiums compared to traditional plans. If your plan has a high deductible, you’ll pay the full cost for health services you use until the deductible is met. After the deductible is met, the plan begins to pay for some (or all) of your costs. With an HDHP, you may have higher costs when you use health care, but you’ll pay less for insurance on a monthly basis. In addition, HDHPs can be paired with an HSA or HRA. These accounts allow you to save for current and future health expenses.

A health plan network is the group of providers and facilities the health plan has contracted to provide health care services. It often includes a group of doctors, hospitals and clinics. Staying in your plan’s network can help keep costs down. You’ll typically pay less for health services from providers in the plan’s network. Review your plan documents to learn more about in-network and out-of-network costs.

In-person assistors guide people through health plan enrollment. Navigators and Marketplace facilitated enrollers (FEs) are trained by the state to provide one-on-one help. Their services are free.

For plan years through 2018, those individuals who could afford health insurance, but chose not to buy it, may have to pay a penalty. This fee is referred to as the individual mandate or Shared Responsibility Payment. There are exceptions to this rule, such as those who had a coverage gap of less than three months out of the year; those whose income was below a certain level; those with religious reasons; and some other reasons. The individual mandate does not apply to the 2019 plan year.

LIS, sometimes called “Extra Help” helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. There are different levels of LIS based on varying factors.

The Marketplace (also called the Exchange) is a place where individuals, families and small businesses can shop for health plans and enroll in coverage. When you apply through the Marketplace, you’ll find out if you qualify for financial help based on income. If you do, you may get a break on costs with premium tax credits, cost-sharing or other programs. NY State of Health, The Official Health Plan Marketplace, is New York’s state-run Marketplace. Vermont Health Connect is the state-run Marketplace for Vermont.

Marketplace facilitated enrollers (FEs) guide people through health plan enrollment. They are trained by the state to provide one-on-one help. Their services are free.

Medicaid is a state program providing health coverage to those with low incomes. Medicaid may cover adults, children, pregnant women and disabled people if they qualify. You can check if you qualify and enroll through the Marketplace.

Medicare is a federal health insurance program for people age 65 and older. It also covers certain younger people with permanent disabilities. Medicare benefits are managed through the Medicare program. The Marketplace does not include Medicare plans.

Health plans are grouped into four metal levels. Bronze = Highest cost when you use health services. (The plan pays 60 percent, you pay 40 percent.) Silver = Higher cost when you use health services. (The plan pays 70 percent, you pay 30 percent.) Gold = Lower cost when you use health services. (The plan pays 80 percent, you pay 20 percent.) Platinum = Lowest cost when you use health services. (The plan pays 90 percent, you pay 10 percent.)

With bronze and silver plans, you pay more for the health services you use. In return, you enjoy a lower premium. With gold and platinum plans, you pay less for health services. But, you’ll pay a higher monthly premium.

Minimum essential coverage is health coverage required by law. It is the type of coverage (not the level of benefits) a person must have. Examples include (but are not limited to): individual market policies, job-based coverage, COBRA coverage, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), Veterans’ health plans and retiree health plans.

Health plans must pass the test for minimum value. They should cover at least 60 percent of the cost of benefits. For example, if a plan pays for 60 percent of covered costs, the member or employee would have to pay about 40 percent of the costs. If a health plan pays less than 60 percent of covered costs, it would not meet minimum value. Some large employers have to pay penalties if they don’t offer employees health coverage that meets minimum value.

Each Special Needs Plan program develops a Model of Care (MOC) and a Quality Improvement Plan to evaluate its effectiveness. The MOC is a plan for delivering care management and care coordination to: improve quality, increase access, create affordability, integrate and coordinate care across specialties, provide seamless transitions of care, improve use of preventive health services, encourage appropriate use and cost effectiveness, and to improve overall member health.

Use your phone, tablet, or computer with a web cam to access telemedicine services, including 24/7 urgent care, psychiatry, behavioral health, nutrition, and lactation consultations. Learn more and get started at myvisitnow.com or download the myVisitNow app on the Apple App Store or Google Play Store.

MyVisitNow is available to most MVP members. Refer to your plan documents to see if myVisitNow is available on your MVP health benefits plan. You can also access telemedicine services through Gia.

Also known as In Person Assistors (IPAs), Navigators are certified by the state and trained to educate and provide enrollment assistance to individuals, families and small businesses, and their employees, about the health insurance options available through the Marketplace. Their services are free.

A health plan network is the group of providers and facilities that has a contract with the health plan to provide health care services. It usually includes a group of doctors, hospitals and clinics.

NY State of Health, The Official Health Plan Marketplace, is the official health plan Marketplace for New Yorkers. It is a place where individuals, families and small businesses can shop for health plans and enroll in coverage. You can apply online, in person, over the phone or by mail. The Marketplace checks if you qualify for government programs (like Child Health Plus and Medicaid), and premium subsidies and/or cost-sharing reductions.

New Yorkers can buy health plans directly from an insurer. This is also called off-Exchange. With direct enrollment, you complete the enrollment process with your insurer and/or with the help of your broker or insurance agent. Qualified health plans sold outside the Marketplace still have to meet state requirements for benefits. However, there could potentially be differences in benefits design and prices may vary from what is found on the Marketplace. Note that help with premium subsidies and/or cost-sharing reductions are not available with off-Exchange plans. Affordability programs are only available through the Marketplace. 

Help prevent and treat pain with Omada for Joint & Muscle Health. Access mini-workout, educational articles, and virtual physical therapy.

Health plans sold on the Marketplace are also referred to as on-Exchange plans.

The annual period when individuals and groups can enroll in a health insurance plan. Please check the healthcare.gov site for current open enrollment information. Individuals may be able to enroll in a marketplace health insurance plan outside of the Open Enrollment period if they qualify for a Special Enrollment Period.

A health plan network is a group of providers and facilities that has a contract with the health plan to provide health care services. All other providers and facilities are “out-of-network.” Depending on your health plan, care provided by out-of-network health professionals may or may not be covered. If out-of-network services are covered in part, you’ll pay a higher cost for these services. You’ll pay lower costs for care from in-network providers. Review your plan documents to learn more about in-network and out-of-network costs.

Out-of-pocket costs are the costs you pay that are not covered by insurance. When you visit the doctor, you might pay for services right away in the form of a co-pay. Or, you might be billed later for your share of the costs. You’ll be responsible to pay your deductible and co-insurance amounts. These are your out-of-pocket costs. The premiums you pay for your health plan are not considered out-of-pocket costs. (That’s why premiums do not count toward your plan’s out-of-pocket limit.)

The annual out-of-pocket limit is the maximum amount you may be responsible to pay for health care expenses in a contract year. The out-of-pocket limit is above and beyond the monthly premium. The health plan pays for all services after you reach the out-of-pocket limit.

A pharmacy benefit manager (PBM) is a company under contract with a managed care organization to manage pharmacy networks, maximize drug effectiveness and adjudicate prescription drug claims. MVP Health Care’s pharmacy benefit manager is CVS Caremark^®

The plan year or policy year is the 12-month period of coverage in your health plan, usually January 1 through December 31. Check your health plan documents if you are not sure when your policy year starts and ends. If you have a group health plan through your job, ask your employer for more information.

A premium is the cost you pay, usually monthly, for a health plan. If you have a health plan through your job, your employer typically pays for part of the premium each month. If you buy an individual or family health plan on your own, you are responsible for paying the premium. There’s an opportunity to lower your premiums if you qualify for a premium subsidy in an individual Marketplace plan

Premium subsidies (or advance premium tax credits) are available for those who qualify. Premium subsidies lower the costs you pay for a health plan through the Marketplace. The subsidy amount may be applied at purchase to lower the cost of your health insurance premium. Or you may choose to claim the credit when you file your taxes.

A health plan with prescription drug coverage helps pay for your prescription medications. You may pay a co-pay for your medicine when you fill prescriptions at the pharmacy. The amount you pay may vary based on whether the medicine is a generic drug or brand-name drug.

Preventive care helps improve your health and prevent illness. It helps detect and treat diseases early. All health plans include a set of essential health benefits, including preventive care. These services may be covered at no cost if you receive care from a provider in your plan’s network.

Primary care is the first place you go for routine health care. A physician, physician assistant or nurse practitioner may see you for primary care. A primary care physician helps you access a range of health services. If you need specialized care, you may see a health provider who focuses on a certain area of medicine. A primary care physician usually works within a network of participating providers to coordinate your care. 

A requirement that your physician obtain approval from your health insurance plan to prescribe a medication or a service. Benefits are usually only paid if the medical care or drug has been pre-approved by the insurance company.

Qualified health plans are certified by the state to provide comprehensive coverage. They include essential health benefits and meet other requirements to be sold on the Marketplace.

If you have a qualifying life event, you don’t have to wait for open enrollment to change your health plan. You may be able to enroll during a special enrollment period. Examples of qualifying life events include (but are not limited to):

• Getting married
• Having a baby
• Adopting a child or placing a child for adoption or foster care
• Gaining status as a U.S. citizen
• Losing job-based coverage
• Getting divorced or legally separated
• Having a dependent who no longer qualifies for the plan due to age
• Permanently moving to a new area (outside the service area of your current health plan)
• Losing eligibility for Medicaid or Children’s Health Insurance Program (CHIP)
• If you’re already enrolled in a Marketplace plan: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions

Certain prescription drugs have limits on the amount of the drug that is covered per prescription or require a defined period of time. For example, MVP will provide up to 30 capsules per month for Nexium. If your prescription is for a quantity greater than what MVP allows, prior authorization is required. Some examples of drug classes where quantity limits apply include, but are not limited to, sleep agents, headache medications, chemotherapy anti-emetics, proton pump inhibitors (ulcer medication) and erectile dysfunction drugs.

A single-payer system for health care is a model for universal health insurance with coverage for everyone. Providers are paid and fees are collected by one entity instead of private insurers.

Small business tax credits can help small businesses pay for employee health insurance. Starting in 2014, eligible small business employers with fewer than 25 employees may earn tax credits that cover up to 50 percent of premiums. Tax credits are only available through the Marketplace. Consult your tax advisor to learn more.

When there are big changes in life, it’s time to change your health plan. If you have a qualifying life event, you may be able to make changes or enroll in a new health plan during a special enrollment period. The length of the special enrollment period is:

• 60 days after certain life events for individuals and families
• 30 days after certain life events for employees covered by employer plans

A specialist is a health care provider who focuses on a certain area of medicine. For instance, seeing a cardiologist for your heart health or a podiatrist for your feet. Your health plan may have different co-pay amounts for different types of visits (primary care, specialist visit, urgent care, emergency room). A specialist visit usually costs more than a primary care visit.

A special needs plan is a Medicare Advantage coordinated care plan specifically designed to provide targeted care and limits enrollment to special needs individuals. There are three types of SNPs that are designed for specific groups of members with special health care needs. Individuals dually eligible for Medicare and Medicaid (D-SNP), individuals with chronic conditions (C-SNP), and individuals who are institutionalized or eligible for nursing home care (I-SNP).

In some cases, an insurer requires you to first try one drug to treat your medical condition before another drug will be covered for that condition. For example, if Drug A and Drug B both treat a medical condition, an insurer may require your doctor to prescribe Drug A first. If Drug A does not work for you, then Drug B will be covered with prior authorization.

A tax credit is an amount you can subtract from the income tax you owe when you file your taxes. If the amount of the credit is greater than the amount owed, the credit may be issued as a payment from the government. Premium tax credits (or premium subsidies) are tax credits that help pay for health insurance premiums.

With the MVP Treatment Cost Calculator, members can search for a medical treatment, service or condition; review an estimate of their costs (based on health plan benefits); identify doctors, hospitals and clinics nearby; and compare those doctors by cost and location.

Vermont Health Connect is the official health plan Marketplace for Vermont. It is a place where individuals and families can shop for health plans and enroll in coverage. You can apply online, in person, over the phone or by mail. The Marketplace also checks if you qualify for government programs (like Medicaid and Dr. Dynasaur) and premium subsidies and/or cost-sharing reductions.