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GLOSSARY OF TERMS:
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Affordable Care Act:
Also sometimes called “Obamacare,” the Patient Protection and Affordable Care Act is a law passed by the U.S. Congress to make it easier for people to get good quality, affordable health insurance.
A state agency created to help Californians who cannot find affordable health insurance through their job
or a public program. To help insure people, we’ve set up a new health insurance marketplace where
private insurance companies offer plans at affordable rates. You can use this marketplace to compare
insurance companies, and find the plan that’s right for you.
Your share of your health care costs after the deductible is paid. Sometimes instead of a copayment, your
health insurance will ask you to pay for a percentage of a health care service, like a major surgery.
Co-pay or Copayment:
What you pay each time you go to the doctor, or visit the emergency room. These costs are a lot lower
when you have health insurance than when you don’t.
The total amount you pay each year for health care services before your insurance starts to pay. The deductible will be different for each health insurance plan. Many preventive health care services do not cost you anything. Any health plan from Covered California will pay for services like vaccinations, cancer screenings and preventive care for infants, children and adolescents at no cost to you.
Essential Health Benefits:
According to the Affordable Care Act, essential health benefits consist of 10 categories that must be covered by all health insurance plans offered through an exchange. These categories are:
1. Ambulatory patient services
2. Emergency services
4. Maternity and newborn care
5. Mental health and substance abuse disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
Covered California has created the “Enhanced Silver Option,” which can greatly cut your out-of-pocket
costs. Enhanced Silver is a Silver health insurance plan in which copay costs for doctor visits, prescription drugs, and routine tests are reduced on a sliding scale, based on your income. Individuals who earn
between $15,856 and $28,725 or a family of four earning between $32,499 and $58,875 may be eligible
to enroll in the Enhanced Silver option.
Modified Adjusted Gross Income (MAGI):
The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.
Minimum Essential Coverage (MEC):
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes plans available through Covered California, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
Cost Sharing Reduction (CSR):
A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category.
Premium assistance (PA):
When you receive premium assistance, the federal government pays a portion of your insurance bill every month. Federal money is sent at the same time you pay your portion of the bill. You can only get premium assistance when you buy insurance through Covered California. Premium assistance is based on your income, and comes in the form of a tax credit from the federal government. If your income changes during the year, so will your amount of premium assistance. Individuals making between $15,856 and $45,960 or a family of four making between $32,499 and $94,200 may be eligible for premium assistance on a sliding scale.
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