Frequently Asked Questions
Still can’t find what you need? Ask an expert using the link below!
CONTACT US
1-833-342-5272 TTY: 711
8:30 am to 5:00 pm EST
Monday–Friday
Click on a question to learn more.
What do these common health insurance acronyms mean?
Health insurance can be confusing, and it certainly doesn’t help that there are countless acronyms for complicated terms. We have put together a guide to help you sort through the lingo and the mumbo jumbo so you can better understand your benefits:
ACA |
Affordable Care Act, also called PPACA |
ACO |
Accountable Care Organizations |
ALE |
Applicable Large Employer |
ASO |
Administrative Services Only |
COBRA |
Consolidated Omnibus Budget Reduction Act |
DOL |
Department of Labor |
EPO |
Exclusive Provider Organization |
ERISA |
Employer Retirement Income Security Act |
FMLA |
Family Medical Leave Act |
FSA |
Flexible Spending Account |
HDHP |
High Deductible Health Plan |
HIPAA |
Health Insurance Portability and Accountability Act |
HMO |
Health Maintenance Organization |
HRA |
Health Reimbursement Account |
HSA |
Health Savings Account |
MEC |
Minimum Essential Coverage |
MEWA |
Multiple Employer Welfare Association |
ODI |
Ohio Department of Insurance |
OEP |
Open Enrollment Period |
PBM |
Pharmacy Benefit Manager |
PCMH |
Patient-Centered Medical Home |
PCORI Fee |
Patient-Centered Outcomes Research Institute |
POP doc |
Premium Only Plan document, also called Premium Conversion Plan |
PPACA |
Patient Protection and Affordable Care Act, also called ACA |
PPO |
Preferred Provider Organization |
QHDHP |
Qualified High Deductible Health Plan |
QMCSO |
Qualified Medical Child Support Order |
QSEHRA |
Qualified Small Employer Health Reimbursement Account |
SBC |
Summary of Benefits & Coverage |
SEP |
Special Enrollment Period |
SMM |
Summary of Material Modifications |
SPD |
Summary Plan Description |
TPA |
Third Party Administrator |
What is the Affordable Care Act (ACA)?
The Affordable Care Act (ACA), also known as “Obamacare,” was signed into law by President Obama in March 2010. The ACA was designed so health insurance companies could no longer deny any individual health insurance due to pre-existing conditions. All US citizens or legal residents, both with and without employer coverage, are eligible to apply for the Affordable Care Act insurance, though your income can be no more than 400 percent of the federal poverty level.
President Barack Obama reaches for a pen as he signs the health insurance reform bill in the East Room of the White House, March 23, 2010. (Official White House Photo by Lawrence Jackson)
These types of health care plans can be quoted for any company as long as they provide the health insurer with their name, date of birth, ZIP code, and smoker status. Additionally, if someone is covering their dependent, a spouse and/or a child(ren), the medical carrier would need their information as well. The ACA plans typically work well for companies that have an employee, or their dependent, with medical conditions that might make them ineligible for other products in the market. If you are offered job-based insurance, you will qualify for a subsidy only if your income is low enough and your employer’s insurance is not considered affordable and does not meet minimum quality standards.
For some people, subsidies may make ACA health insurance significantly cheaper than paying for COBRA. Enrolling in ACA health insurance also allows you to pick a different health insurance plan, which can be useful if your previous employer-sponsored one is no longer the best one for your health needs.
What is Telemedicine?
Telemedicine is a cost-effective and accessible option that involves electronic communication and software to provide clinical services to patients without an in-person visit. Many people opt for telemedicine because it can be done from the comfort of your own home or anywhere else like work, vacation, the park, etc. You do not have to bring yourself or your children in contact with illnesses that you may encounter at the doctor’s office. Moreover, every physician you see using telemedicine communications will be considered in network no matter where you are.
What do dental and vision plans cover?
Dental Insurance
Dental insurance is a standalone product that pays portions of dental services, and can be purchased as a separate product from your health insurance. While standard health insurance typically has an out-of-pocket maximum that the subscriber will pay, dental insurance has a cap (no deductible) and once the person reaches that cap, they are responsible for 100 percent of the cost of their care.
Dental services are typically categorized into three groups: preventive, basic, and major. Depending on the nature of the plan, these services may be covered at a certain percentage. Most plans provide coverage for routine exams, cleanings, and X-rays for limited to no out-of-pocket costs. Services that might entail a filling, bonding, veneer, extracting, crown, bridge, root canal, etc., on the other hand, are more comprehensive coverage options in which the insurance companies may only cover up to a certain annual limit.
Vision Insurance
Vision insurance is a great option to help reduce the cost of preventive eye care, glasses, and contacts. Similarly to dental insurance, vision insurance does not typically have a deductible. Vision insurance tends to resemble discount plans more than health insurance. The insurance would usually pay a flat amount, while the subscriber would be responsible for the rest of the payment. Also, vision insurance usually only covers glasses or contact lenses during the same benefit period, not both.
What is critical illness insurance?
“Even with excellent medical insurance, just one critical illness can be a tremendous financial burden,” says CFP Jeff Rossi of Peak Wealth Advisors, LLC. Your health insurance plan may cover some of your medical costs, but not everything. In the event of a serious illness or condition, critical illness coverage (sometimes called catastrophic illness insurance) acts as an additional layer of protection and helps with expenses that your health insurance may not cover. Critical illness insurance provides lump-sum cash benefit that can be used to help you pay for medical expenses not covered by insurance, such as copays or coinsurance, expenses incurred before the deductible has been met, and other out-of-pocket costs. A qualifying illness, like cancer, heart attack, or stroke, will trigger the policy’s benefit, which is paid directly to the insured. The covered conditions under your critical illness policy will vary depending on your plan.
What is Cancer Insurance?
If you have a family history of cancer or at a higher risk for other reasons, a cancer insurance policy may provide you with some peace of mind. Cancer plans cover an array of medical and non-medical costs that your basic health insurance plan may not provide coverage for, including coverage for radiation and chemotherapy, surgical procedures, hospital confinement, loss of income, transportation and lodging while traveling, and more.
Depending on the plan, cancer policies may pay a lump sum when you receive a cancer diagnosis, while others may pay for specific treatment and care expenses either directly to your provider or to you.
When can I purchase health insurance?
Open Enrollment Period
Open Enrollment is the period of time during a year when a business, Medicare eligible, or individual is permitted to purchase, change, or terminate insurance coverage.
For businesses, open enrollment refers to the time when employees are able to make additions, changes, or waive their employer’s offered coverages. Fully insured carriers usually permit employers to make employee changes to elections 30 days prior to the group’s renewal date. The open enrollment window of the carrier can be flexible if there is a business reason for a different time period, such as a calendar year plan, a different fiscal year, or if the group makes major plan changes. However, we do recommend requesting prior approval. Small groups that do not meet participation can purchase ACA plans for a January 1 effective date as long as their application is received by the official Open Enrollment Period deadline (typically November 15 to December 15 each year).
Individuals and families can enroll in plans from November 1 to December 15 each year with starting dates of January 1 the next year.
Medicare eligible can enroll in a plan between October 15 and December 7 (the early shopping period begins October 1). Plans start January 1.
Special Enrollment Period (SEP)
Special Enrollment Period (SEP) is a time outside of Open Enrollment when you can sign up for health insurance. Usually, you qualify for SEP due to certain qualifying events such as:
- Marriage
- Divorce
- Legal separation
- Birth
- Adoption
- Death
- Termination of employment for the employee or their spouse or dependent
- Reduction or increase in hours worked that changes eligibility for the plan
- A significant change in spouse’s employer’s coverage
- Movement out of area
- Dependent no longer eligible
- The purchase of individual or Medicare coverage
Any changes made must be consistent with the type of life change. For example, the birth of a child would involve adding a child to coverage, but not terminating coverage of a spouse.
What are my options for group health insurance?
Association Health Plans
Association Health Plans are group health plans made up of multiple employer groups or associations to provide health coverage for employees. These are similar to MEWAs and Multiple Employer Trusts.
In June 2018, the U.S. Department of Labor provided regulations that allowed the expansion of Association Health Plans to operate but they are still regulated by the states in which they cover people. In Ohio, many insurers and associations had already taken steps to establish MEWAs for small groups (those with 50 employees or less) to offer medically underwritten alternatives to ACA plans which are community-rated.
Fully Insured
Fully Insured products refer to an insurance product that covers certain expenses incurred during the covered period of time according to a policy stating specific benefits and conditions. Employers pay set fees, called premiums, for each covered person each month. Premiums are typically set for 12 months at a time.
Individual Coverage Health Reimbursement Arrangement (ICHRA)
An Individual Coverage Health Reimbursement Arrangement (ICHRA) reimburses employees, tax-free, for individual health insurance premiums and out-of-pocket costs. Essentially, this arrangement reimburses employees for their health insurance rather than purchasing it for them. The arrangement is designed to provide greater cost control for the employer and more options for the employee. With this arrangement, you no longer have the burden of managing a group health insurance plan, which means no more time wasted fussing around with renewals and participation rates, and more time spent focusing on your business and your clients.
When you choose an ICHRA plan for your group, your employees will get their individual health insurance on the marketplace. You, the employer, will then set up a health reimbursement account (HRA) that assists the employee with their individual premiums on a tax-free basis for the employee and the employer has the ability to take the cost of the reimbursements on a business expense basis. The employee may still be eligible for subsidies, but the costs will offset each other.
Level-Funded
A level-funded health plan (also known as a partially self-funded plan) is a type of health insurance plan that combines the cost savings and customization of self-funding with the financial safety and predictability of fully funded plans. Administrative costs are fixed and charged per employee. These are underwritten products that require employees and their dependents to fill out medical applications to get a premium rate.
Multiple Employer Welfare Arrangement (MEWA)
A Multiple Employer Welfare Arrangement (MEWA) is an employee welfare plan that provides welfare plan benefits to the employees of two or more unrelated employers. These are underwritten products that require employees and their dependents to fill out medical applications to determine the risk of the group and the monthly premium to cover that risk. This helps the insurance company to determine a risk score for the business, which will then help in determining the monthly premium for the health insurance plan.
Click here to learn more about MEWAs.
Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
QSEHRAs were introduced in December 2016 as part of the 21st Century Cures Act. QSEHRAs are a type of Health Reimbursement Account that small employers, who don’t offer a group health plan, can establish to reimburse employees who purchase individual health insurance. Employees must provide eligible proof of minimum essential coverage and proof of expense.
Self Funding
Self-funding is sometimes also referred to as Self-Insurance. It is a way for employers to restructure how they pay for health benefits for employees and their families. The employer typically purchases Stop Loss Insurance and hires a third-party administrator (TPA) to manage their plan and assist with pharmacy and network selections. Self-funded employers with good risk can often save year over year versus traditional fully insured arrangements; however, there is financial risk involved.
What is an Employee Assistance Program (EAP)?
An Employee Assistance Program (EAP) is an employer-paid, work-based program that provides confidential and free assessments, short-term counseling, referrals, and follow-up services to employees who have work-related and/or personal issues that require professional help. EAPs address a complex and broad body of issues affecting mental and emotional well-being, such as stress, alcohol and other substance abuse, family problems, grief, and psychological disorders. EAP counselors also take on an advice-giving role with supervisors and managers to address employee and organizational challenges and needs. Many EAPs are instrumental in helping organizations prevent and cope with workplace violence, trauma, and other emergency response situations. These services are available from a variety of different providers and the cost is determined by the amount of employees at a specific workplace or by employee per month.
What are my options for health savings accounts?
Flexible Spending Account (FSA)
Flexible Spending Accounts (FSA) are tax-advantaged financial accounts set up through an employer. These accounts permit employees to set aside a pre-determined, limited portion of his or her earnings to pay for qualified expenses tax free. Money is deducted from payroll into an FSA and is free from federal state, and in most cases, FICA tax and does not appear on a W-2 as reported income. Employers may make contributions to the account but are not required to. Funds in the account are considered “use it or lose it,” so up-front decisions as to how much to contribute should be made wisely. The majority of these accounts are set up for medical expenses and/or dependent day care expenses.
Health Reimbursement Account (HRA)
A Health Reimbursement Account (HRA) is a creative option for employers to mitigate rising premiums by reimbursing (self-funding) a portion of the covered person’s deductible or out-of-pocket expenses. Statistics prove that a small percentage of insureds actually incur more than $500 in benefits. Lower premiums are obtained by purchasing higher deductibles for the group and offsetting expenses of only those who use the plan.
Administration for these plans can be more complicated than what it might seem. An outside administrator is used for claim reimbursement and to prepare filings that must be compiled and reported to the Centers for Medicare and Medicaid Services (CMS) quarterly.
Heath Savings Account (HSA)
Health Savings Accounts (HSA) are tax-advantaged savings accounts funded by the employer, the employee, or a combination of both. They are owned by the individual, they are portable, and they can reimburse current and future medical expenses. Qualifying medical expenses include not only deductible and co-insurance out-of-pocket expenses, but also a vast array of additional expenses not generally covered by insurance carriers. Contributions and earnings are tax deductible and withdrawals for qualified expenses are tax-free. These accounts are set up only in conjunction with qualifying high deductible health plans, which require minimum deductibles and maximum out-of-pocket limits. Funds in the account roll over from year to year.
What is COBRA?
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers, and their families who lose their health benefits, the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances, such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan. COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior calendar year offer their employees and their families the opportunity for a temporary extension of health coverage in certain instances where coverage under the plan would otherwise end.
Get the DOL’s An Employers Guide to Group Health Continuation of Coverage Under COBRA.
What are grandfathered and grandmothered health insurance plans?
Grandfathered Health Plans
Grandfathered plans are small group health insurance plans that were already in existence at an organization on March 23, 2010 when the Affordable Care Act (ACA) was signed into law. These plans can continue offering coverage as they did prior to the ACA with very specific stipulations. These plans are exempt from some of the ACA requirements, such as preventive health services coverage without any cost-sharing and the expanded appeals process and external review. However, they are subject to other provisions and non-compliance can result in a loss of the grandfathered status.
Grandmothered Health Plans
Grandmothered health plans, on the other hand, are small group health insurance plans that have been in place since before January 1, 2014. Grandmothered plans are subject to a Health and Human Services transition policy, allowing insurers in these markets to renew health insurance policies they would otherwise have cancelled due to noncompliance with certain ACA insurance market reforms such as premium rate rules, guaranteed availability and renewability, the requirement to provide essential health benefits, and so on.
Grandmothered plans do not have to comply with the bulk of the ACA’s provisions, they are not required to cover essential health benefits other than preventive care, and they cannot have annual or lifetime benefit limits for covered essential health benefits. Small group grandmothered plans cannot impose pre-existing condition exclusions or benefit waiting periods that exceed 90 days. Transition relief for grandmothered plans has been extended several times over the years.