Acturial Value:
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70 percent, on average, members would be responsible for 30 percent of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy. Placing an average value on health plan benefits allows different health plans to be compared.

Affordable Care Act:
The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name "Affordable Care Act" is used to refer to the final, amended version of the law.

Catastrophic Plan:
Catastrophic coverage is a high-deductible plan that is available to young adults (under the age of 30) and individuals with a certification of exemption based on hardship or the inability to afford or obtain coverage. This type of plan will cover essential health benefits after you reach the annual out-of-pocket costs. In addition, the plan will cover at least three primary care visits per year before you reach the deductible.

Children's Health Insurance Program (CHIP):

Enacted in 1997, CHIP is a federal-state program that provides health care coverage for uninsured low-income children who are not eligible for Medicaid. States have the option of administering CHIP through their Medicaid programs or through a separate program (or a combination of both). The federal government matches state spending for CHIP, but federal CHIP funds are capped.

COBRA:
A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100 percent of the premiums, including the share the employer used to pay, plus a small administrative fee.

Coinsurance:
The percentage of allowed charges for covered services that you're required to pay. For example, health insurance may cover 80 percent of charges for a covered hospitalization, leaving you responsible for the other 20 percent. This 20 percent is known as the coinsurance.

Community Rating
A method for setting premium rates for health insurance plans under which all policy holders are charged the same premium for the same coverage. "Modified community rating" generally refers to a rating method under which health insuring organizations are permitted to vary premiums based on specified demographic characteristics (e.g., age, gender, location), but cannot vary premiums based on the health status or claims history of policy holders. New York requires a community rating for all small group and individual policies.

Consumer Operated and Oriented Plans (CO-OP):
Qualified nonprofit, customer-governed, private health insurers that will offer qualified health plans in the exchanges.

Copayment:
A flat dollar amount you must pay for a covered program. For example, you may have to pay a copayment for each covered visit to a primary care doctor.

Cost-Sharing:
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost-sharing in CHIP also includes premiums.

Deductible:
The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. For example, under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage.

Employer Shared Responsibility Provision:
The Employer Shared Responsibility provision, also known as the "employer mandate" or the "pay-or-play" provision, requires employers with 50 or more full-time equivalent employees to offer affordable, minimum essential coverage to substantially all of its full-time employees. Failure to do so can result in financial penalties imposed on the employer.

Employer-Sponsored Insurance:
Insurance coverage provided to employees, and, in some cases, their spouses and children, through an employer.

Essential Health Benefits:
A set of health care service categories that must be covered by certain plans, starting in 2014.

The Affordable Care Act defines essential health benefits to "include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; 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; and pediatric services, including oral and vision care.''

Insurance policies must cover these benefits to be certified and offered in Exchanges, and all Medicaid state plans must cover these services by 2014.

Health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014.

Exchange:
A competitive insurance marketplace where individuals and small businesses can buy qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Also referred to as a "health insurance marketplace" or "marketplace."

Federal Poverty Level (FPL):
A competitive insurance marketplace where individuals and small businesses can buy qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Also referred to as a "health insurance marketplace" or "marketplace."

Flexible Spending Account (FSA):
A flexible spending account (FSA) allows you to put money aside from your paycheck on a pre-tax basis to spend on your health and/or dependent care expenses in the coming year. Generally, the FSA will be funded from your own income, although your employer may opt to contribute, as well. You choose how much money to deduct from each paycheck to use for your health care expenses and/or dependent care costs in the coming year. In 2013, the ACA enacted a provision that put a $2,500 cap on the amount an employee can contribute to his or her health FSA.

Grandfathered Health Plan:
As used in connection with the Affordable Care Act: A group health plan that was created -- or an individual health insurance policy that was purchased -- on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their "grandfathered" status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

Guaranteed Issue:
A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn't limit how much you can be charged if you enroll.

Guaranteed Renewal:
A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Except in some states, guaranteed renewal doesn't limit how much you can be charged if you renew your coverage.

Health Insurance Marketplace:
A competitive insurance marketplace where individuals and small businesses can buy qualified health benefit plans. Health insurance marketplaces will offer you a choice of health plans that meet certain benefits and cost standards. Also referred to as a "health benefit exchange" or "exchange."

Health Reimbursement Arrangement (HRA):
A tax-exempt account that can be used to pay for current or future qualified health expenses. HRAs are established benefit plans funded solely by employer contributions, with no limits on the amount an employer can contribute. HRAs are often paired with a high-deductible health plan, but are not required to do so.

Health Savings Account (HSA):
A medical savings account available to taxpayers who are enrolled in a high deductible health plan. The funds contributed to the account aren't subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a flexible spending account (FSA), funds roll over year to year if you don't spend them.

High Deductible Health Plan:
A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

Individual Health Insurance Policy:
Policies for people who aren't connected to job-based coverage.

Individual Mandate:
A federal requirement, effective January 1, 2014, that American citizens be enrolled in a health insurance plan that meets the basic minimum standards as defined by the Department of Health and Human Services and the Department of the Treasury. The failure to do so may result in a tax penalty imposed upon the individual. There are special exemptions for financial hardships and religious exemptions.

Lifetime Limit:
A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

Medicaid:
A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. New York will expand Medicaid eligibility to individuals and families below 133 percent of the federal poverty level.

Medical Loss Ration (MLR):
A basic financial measurement of the amount of premium health plans use to cover medical costs. If an insurer uses 80 cents out of every premium dollar to pay its customers' medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80 percent. A medical loss ratio of 80 percent indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

Medicare:
A federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Minimum Value:
An eligible employer-sponsored health plan that possesses at least 60% actuarial value.

Modified Adjusted Gross Income (MAGI):
A definition of income from the tax system that will be used under the Affordable Care Act to determine eligibility for Medicaid in all states and for tax credits available to people buying insurance in exchanges. The income calculations will take into account family size and income from all family members.

Non-Grandfathered Plan:
As used in connection with the Affordable Care Act: A health plan that is not a grandfathered health plan and therefore subject to all reforms in the Affordable Care Act.

In the individual health insurance market, a plan that your family is purchasing for the first time will generally be a new plan.

In the group health insurance market, a plan that your employer is offering for the first time will generally be a new plan. Note that new employees and new family members may be added to existing grandfathered group plans - so a plan that is "new to you" and your family may still be a grandfathered plan.

In both the individual and group markets, a plan that loses its grandfathered status will be considered a new plan. A plan loses its grandfathered status when it makes significant changes to the plan, such as reducing benefits or increasing cost-sharing for enrollees.

A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.

Nonstandard Plan:
A qualified health plan offered in state and federal health insurance marketplaces by participating health insurance carriers that differs from a standard plan in covered benefits and cost-sharing. Carriers can offer up to two nonstandard plans at each metal tier level on the New York Health Benefit Exchange.

Out-of-Pocket Costs:
Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren't covered.

Out-of-Pocket Maximum (OOP):
The maximum amount you will have to pay for covered services in a year. Generally, this includes the deductible, coinsurance, and copayments. This definition may vary from plan to plan. For example, in some plans the out-of-pocket limit doesn't include cost-sharing for all services, such as prescription drugs. Plans may have different out-of-pocket limits for different services.

Pre-Existing Condition:
A condition, disability, or illness (either physical or mental) that you have before you're enrolled in a health plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. This term is defined under state law and varies significantly by state. The Affordable Care Act eliminates pre-existing condition exclusions, effective January 1, 2014.

Premium:
A monthly payment you make to your insurer to obtain and keep insurance coverage. Premiums can be paid by employers, unions, employees, or individuals, or shared among different payers.

Preventive Services:
Routine health care that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems. The Affordable Care Act expands the amount of preventive services that are provided at no cost to members.

Qualified Health Plan:
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by a health insurance marketplace (aka exchange), provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each health insurance marketplace in which it is sold.

Reinsurance:
A reimbursement system that protects insurers from high claims. It usually involves a third party paying part of an insurance company's claims once they pass a certain amount. Reinsurance is a way to stabilize an insurance market and make coverage more available and affordable.

Self-Insured Plan:
Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees' and dependents' medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.

Small Business Health Options Program (SHOP):
State health insurance exchanges that will be open to small businesses with 2 to 50 employees. In 2016, it is expected to be available to groups of 2 to 100 employees.

Standard Plan:
A federally mandated, qualified health plan to be included in state and federal health insurance marketplaces by participating health insurance carriers. Standard plans will be offered at each of the four metal tier levels and include a mandated catastrophic plan, child only plans, Native American plans, and Cost Share Reduction (CSR) plans. The covered benefits and cost-shares in each standard plan will be uniform for each carrier participating in the exchange, although the premium amounts and network arrangements will vary by carrier.