ACA definitions: Enrollment period basics

The fourth annual Affordable Care Act open enrollment period is set to start Nov. 1, and the one thing that’s certain is that many high-level discussions of the ACA and exchange plans will sound like gibberish.

The agencies and organizations responsible for the ACA have invented a language all of their own, and the number of terms and concepts has multiplied since the ACA exchange came to life, and since individuals began wrestling with the individual mandate.

Related: ACA World dictionary expands

Now that employers are facing the full effect of the ACA employee counting rules, the ACA language is going through another growth spurt, with new federal agencies and offices popping up to ask employers, and their benefits advisors, puzzling questions.

At press time, the presidential election was less than a week. No matter who is in the Oval Office in January, that president’s new programs are likely to add a new layer of ACA (and, possibly, ACA Replacer or ACA Fixer) language.

Related: ACA definitions: Federal executive branch agencies

Here’s a rough first draft of a collection of ACA enrollment period vocabulary basics, divided by section, with a complete list of all the terms alphabetically given at the end.

This is meant as a rough-and-ready ACA-to-English first aid kit. For an official definition of any of these terms, seek competent legal, accounting or actuarial advice. Recognize that the precise legal definition of many of these terms may ultimately be resolved through legislation, or litigation.

Continue reading …

Enrollment period basics: Application process

Application	The electronic document that serves as the basis for an individual, family or employer participating in the ACA exchange system.
Attest	To promise an ACA exchange that something is true, and to face the possibility that lying to the exchange will lead to huge legal problems.
Data matching issue	Conflicts between the information an exchange plan user has given an exchange or exchange plan issuer and the information in another data source, such as an Internal Revenue Service database or credit bureau database, used to verify the information provided by the consumer.
Dependent	The HealthCare.gov glossary gives this definition: “A child or other individual for whom a parent, relative or other person may claim a personal exemption tax deduction.”
Domestic partnership	A household such that two people live together and share a domestic life, but aren’t married or joined by a civil union.
Effectuated enrollment	A move by a consumer to activate the exchange plan health coverage chosen through an ACA exchange by paying for the coverage.
Eligibility assessment	In the ACA exchange context, this is the review agencies in some states do to see whether an exchange applicant qualifies to get Medicaid benefits.
Eligible	Capable of meeting federal government standards, exchange standards, issuer standards or other standards for ACA programs.
Exchange	A program that tries to use websites and other mechanisms to help users compare products on an apples-to-apples basis and buy the products as if they were buying airline tickets from Travelocity, or stock from the New York Stock Exchange.
Family size	The number of people on an exchange application. Managers of HealthCare.gov describe who applicants can include on an application here.
Federal poverty level (FPL)	The measure of income, published every year by the U.S. Department of Health and Human Services, that determines whether people using ACA programs or other federal health programs are officially classified as having a low or moderate income. For 2016, in most of the country, the federal poverty level for a one-person household is $11,880 in income per year.
FPL	The federal poverty level. This is the measure of income, published every year by the U.S. Department of Health and Human Services, that determines whether people using ACA programs, or other federal health programs, are officially classified as having a low or moderate income. For 2016, in most of the country, the federal poverty level for a one-person household is $11,880 in income per year.
Hardship exemption	Permission from the government or an ACA exchange to avoid complying with an ACA provision because of unusual difficulties.
Health insurance exchange	A program that tries to use websites and other mechanisms to help users compare health coverage products on an apples-to-apples basis and buy the products as if they were buying airline tickets from Travelocity.
HealthCare.gov	The web-based ACA health coverage enrollment and administration system that federal regulators set up to provide exchanges in states that are unwilling or unable to do the job themselves,
Identity proofing or identity verification	The process an ACA exchange and the Federal Data Services Hub uses to verify whether an exchange user really is who the user says he or she is.
Inconsistency	A difference between information in an ACA exchange user’s applications and tax returns and the information in the database the government uses to screen the applications and tax returns.
Individual marketplace	The part of an ACA health insurance exchange that individuals and families use to buy exchange plan coverage.
Marketplace	An ACA exchange.
MEC	Minimum essential coverage, or what the regulators classifying the ACA classify as solid health coverage.
Member	A health plan enrollee.
Mixed household	A group of related people who normally could share an ordinary ACA exchange plan application, in which some people qualify for some type of government health coverage assistance, and others qualify for another type or level of assistance.
Open enrollment period	The period during which people can buy individual medical coverage without showing they have what the exchange classifies as a good excuse to be buying individual major medical coverage. The open enrollment period for 2017 starts Nov. 1 and is set to end Jan. 31. The open enrollment period system is supposed to discourage healthy people from waiting until they get sick to pay premiums for health coverage.
Policy year	The year when insurance coverage is in effect.
Portal	A website that helps a user find and reach other, related websites.
Qualifying life event:	Something that happens that makes an individual eligible for an individual major medical coverage special enrollment period. Some common types of qualifying life events include moving to a new market, having a child or losing access to employer-sponsored health coverage.
SEP	Special enrollment period. The time of the year when a consumer who wants to buy individual major medical coverage is supposed to have what the exchange system classifies as a good excuse for shopping for coverage, such as moving to a new community. The SEP system is supposed to discourage healthy people from waiting until they get sick to pay for coverage.
Special enrollment period (SEP)	A time of the year when a consumer who wants to buy individual major medical coverage is supposed to have what the exchange system classifies as a good excuse for shopping for coverage, such as moving to a new community. The SEP system is supposed to discourage healthy people from waiting until they get sick to pay for coverage.
Stand-alone dental plan (SADP)	A dental plan sold on an ACA exchange alongside major medical plans.
State partnership marketplace:	A state ACA public exchange operated by HealthCare.gov for a state that makes an effort to help market and support the exchange program.
State-based exchange	An ACA public exchange governed and managed by a state-based entity.
State-based marketplace	An ACA public exchange governed and managed by a state-based entity.

Continue reading … 

Enrollment period basics: Benefits

Affordable coverage	In the ACA exchange context, this is employer-provided coverage such that the worker’s share of the cost of self-only coverage is less than or equal to a designated percentage of income. The best-known method for computing affordability is based on the employee’s share of the premium for the cheapest available self-only employer coverage as a percentage of the worker’s W-2 wages from that employer. In 2017, for users of that method, the affordability cut-off is 9.69 percent of W-2 wages for purposes of the employer meeting its ACA “shared responsibility” coverage mandate target, and 8.16 percent of W-2 wages for purposes of the worker escaping from the ACA individual shared responsibility coverage mandate.
Annual benefit maximum	The limit on what a health coverage issuer or other coverage issuer will spend on claims in a year for an insured. The ACA now prohibits non-grandfathered plans from imposing limits in the amount they’ll in a year for core benefits, or essential health benefits.
Annual deductible	The amount of eligible health claims an enrollee must have before the issuer begins paying for care. In many cases, insurers will pay for at least some routine care before the enrollee meets the deductible.
Basic Health Program	A low-cost, Medicaid-like health coverage provider aimed at people in a state who earn too much to qualify for Medicaid but so little they would qualify for large ACA exchange plan subsidies. The ACA Basic Health Plan provision lets a state get most of the cash that could be spent on the enrollees’ ACA exchange plan coverage and use the cash to buy coverage for those people through a state-run procurement process. A program must give the enrollees a choice of coverage from at least two different providers. In 2016, Minnesota and New York State were the only two states that had set up Basic Health Plan programs.
Brand-name drugs	Medications from well-known manufacturers. In many cases, the makers of the medications may have protection from patents, or government documents that give the holders of the documents temporary, exclusive control over manufacturing rights.
Bronze plan	A major medical plan that covers about 60 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.
Catastrophic health plan	Plans that keep the premium low by setting the deductible at a very high level. They are available only to young adults under age 30 and to other consumers who do not qualify for exchange plan subsidies and do qualify for a hardship exemption from the ACA.
Co-payment	The fixed amount of cash that a health coverage holder must spend to get a covered product or service. Any co-payment requirements are part of a plan’s cost-sharing provisions, or system for determining what portions of the medical bill the coverage holder must pay. A plan may use co-payment requirements in place of other cost-sharing arrangements or together with other arrangements. A plan might require only a co-payment for primary care and only a deductible for inpatient hospital care, or it could require use of both deductible and a co-payment for both types of care.
COBRA	The Consolidated Omnibus Budget Reconciliation Act, a law that includes a provision giving workers and their families the right to continue employer health coverage after the employees leave the employer.
Coinsurance	The percentage of bills for specified covered services an enrollee pays after meeting a health plan deductible and before reaching a plan’s out-of-pocket spending limit.
Community rating	A system that requires insurers to offer customers in the same geographical region prices based on the average level of risk for the entire region, not on the individual customer’s apparent level of risk.
Continuation coverage	COBRA coverage, or similar health coverage obtained using a similar state-law program.
Copper plan	A type of proposed major medical plan, not yet available, that would covers about 60 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.
Cost-sharing reduction (CSR) subsidy	An ACA subsidy system that helps reduce what exchange plan users with income from 100 percent to 250 percent of the federal poverty level spend on exchange plan deductibles, co-payments, coinsurance amounts and other cost-sharing provisions. The subsidy is supposed to keep out-of-pocket costs from keeping poor people from getting necessary medical care.
Cost-sharing	A health plan provision that requires an individual or family that has plan coverage to pay part or all of the cost of the coverage. Plan managers may use the cost-sharing mechanisms both to reduce use of unnecessary care and to reduce the amount spent on the claims that do come in.
CSR subsidy	The ACA cost-sharing reduction subsidy system. The system helps reduce what exchange plan users with income from 100 percent to 250 percent of the federal poverty level spend on exchange plan deductibles, co-payments, coinsurance amounts and other cost-sharing provisions. The subsidy is supposed to keep out-of-pocket costs from keeping poor people from getting necessary medical care.
Deductible	The amount a coverage holder must spend on specified types of covered events or services before the issuer begins to pay a significant percentage of the bills related to the covered events or services.
EHB package	The essential health benefits package, or what the ACA defines as the core collection of goods and services that a solid major medical plan should cover.
Essential health benefits (EHB)	What the ACA defines as the core collection of goods and services that a solid major medical plan should cover.
Exclusive provider organization	A health plan that covers only care from in-network providers, except in emergencies, but does not require enrollees to get permission from a primary care doctor to see a specialist.
Fee for service	A system for paying doctors, hospitals or other medical care providers for each service provided.
Flexible spending account (FSA)	A mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.
Flexible spending arrangement (FSA)	This is another term for flexible spending account, or a mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.
Formulary tiers	A mechanism managers of drug benefits use to impose higher out-of-pocket costs on some types of drugs and lower out-of-pocket costs on others. A drug plan might require a $5 co-pay for an inexpensive antibiotic, and a $50 co-pay for an expensive brand-name drug.
Formulary	A list of drugs that a prescription drug plan covers.
FSA	A flexible spending account, or flexible spending arrangement. This is a mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.
Gold plan	A major medical plan that covers about 80 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.
Grace period	The time between when a payment for ACA exchange plan coverage or other coverage is due and when the coverage is canceled because of the coverage holder’s failure to pay the premium.
HDHP	A high-deductible health plan, or health insurance arrangement that requires enrollees to have high medical costs before the insurance pays for all or designated types of care.
Health maintenance organization (HMO)	A health plan that requires, or strongly encourages, an enrollee to use a primary care physician to keep the enrollee healthy and manage use of other types of care.
High-deductibl health plan (HDHP)	A health insurance arrangement that requires enrollees to have high medical costs before the insurance pays for all or designated types of care.
Lifetime benefits limit	The cap on how much an insurance plan will spend on claims over the course of an insured’s life. The ACA prohibits non-grandfathered major medical plans from imposing lifetime benefits limits.
Limited benefit wraparound plan	An insurance policy designed to help fill in the gaps in ACA-compliant major medical coverage.
Metal levels	An ACA system for classifying how rich a major medical plan is. A bronze plan is supposed to pay about 60 percent of the actuarial value of the cost of the ACA essential health benefits package. A silver plan pays about 70 percent of the actuarial value of the EHB package; a gold plan, about 80 percent; and a platinum plan, about 90 percent. Some have asked regulators to create a new class of copper plans that would cover 50 percent of the actuarial value of the EHB package.
Narrow network	A list of doctors, hospitals and other providers that a health plan covers at the best rates that’s noticeably shorter than the provider lists health plans in the same market typically offered in 2013, before many major ACA health system changes began to take effect.
Non-grandfathered	In the ACA context, a major medical plan subject to all relevant ACA requirements.
Out-of-pocket costs	The cash people have to get from their own checking accounts, savings accounts, mattresses, friends or other resources to pay for medical care.
Out-of-pocket maximum	The cap on how much personal cash a health plan expects an enrollee to spend in a year on covered essential health benefits.
Platinum plan	A major medical plan that covers about 90 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.
PPO plan:	A preferred provider organization health plan, or plan that encourages enrollees to uses doctors, hospitals and other providers listed in the plan’s provider directory.
Preferred provider organization (PPO) plan	A health plan that encourages enrollees to uses doctors, hospitals and other providers listed in the plan’s provider directory.
Preventive services	Medical care that’s supposed to keep healthy people healthy.
Provider	A doctor, hospital, clinic or other individual or entity that delivers medical care.
QHP	A qualified health plan, or insurance policy that can be sold through an ACA public exchange and meets the requirements of the ACA premium tax credit subsidy
Qualified health plan (QHP)	An insurance policy that can be sold through an ACA public exchange and meets the requirements of the ACA premium tax credit subsidy program.
SADP	Stand-alone dental plan. A dental plan sold on an ACA exchange alongside major medical plans.
SBC	Summary of benefits and coverage. A standardized document, required by the ACA, that gives a short description of an insurance plan’s features.
Silver plan	A major medical plan that covers about 70 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.
Summary of benefits and coverage (SBC)	A standardized document, required by the ACA, that gives a short description of an insurance plan’s features.
Uniform glossary	An official health insurance definition list. The ACA calls for health plans to provide uniform glossaries for all enrollees and health coverage shoppers, to help consumers understand health coverage and shop for health coverage.
Zero-cost-sharing plan:	A plan available to some members of federally recognized Native American tribes and Alaska Native Claims Settlement Act Corp. shareholders that provides plans with no deductibles, coinsurance amounts or co-payment requirements. To be eligible, applicants must have income from 100 percent to 300 percent of the federal poverty level and qualify for premium tax credits.

 

Enrollment period basics: Non-ACA products

Critical illness insurance	An insurance policy that pays benefits only when an insured suffers from a serious illness, or type of serious illness, described in the policy.
Excepted benefit	A benefit that falls outside the scope of most or all of the provisions of the ACA, and of earlier health insurance, health care and employee benefits laws, such as the Employee Retirement Income Security Act of 1974 (ERISA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
High-risk pool	An insurance arrangement or other arrangement designed to pay the medical bills for people who are unable to qualify for traditional, medically underwritten insurance. The ACA banned use of medical underwriting individual and small group markets in 2014.
Hospital indemnity insurance	An insurance policy that pays a fixed amount of cash when the insured needs hospital care.
Private exchange	A program separate from the ACA public exchange system that helps individuals, employers or other people shop for insurance coverage or other products.
Short-term health insurance	A coverage arrangement that pays for health care for less than a full year. Also known as short-term medical insurance.
Short-term medical insurance	A coverage arrangement that pays for health care for less than a full year. Also known as short-term health insurance.

Related: H.R. 3590 and H.R. 4872: A guide to a new health reform world

Continue reading … 

Enrollment period basics: Government agencies

Center for Consumer Information and Insurance Oversight	The division of the Centers for Medicare and Medicaid Services that oversees the ACA exchange system and other ACA programs that affect the commercial health insurance market. CMS is part of the U.S. Department of Health and Human Services.
Centers for Medicare & Medicaid Services (CMS)	The division of the U.S. Department of Health and Human Services that’s responsible for Medicare, Medicaid and ACA coverage expansion programs.
CMS Enterprise Portal	A webpage people can use to get to the systems the Centers for Medicare & Medicaid Services uses to run many big programs, such as Medicare and the Marketplace Learning Management System (MLMS).
CMS	The Centers for Medicare & Medicaid Services, the division of the U.S. Department of Health and Human Services that’s responsible for Medicare, Medicaid and ACA coverage expansion programs.
Federal data services hub	A system ACA exchange program managers use to share the sensitive information used in ACA exchange application and eligibility review processes, such as information from tax returns and information about criminal records.
Federally facilitated marketplace (FFM)	HealthCare.gov.
FFM	The Federally Facilitated Marketplace, or HealthCare.gov.
HHS	U.S. Department of Health and Human Services.
MLMS	The Marketplace Learning Management System. A system HealthCare.gov managers use to administer HealthCare.gov agent and broker training requirements.
U.S. Department of Health and Human Services (HHS)	The department that oversees the health aspects of ACA requirements and programs.

Enrollment period basics: Government programs

Children’s Health Insurance Program (CHIP)	A program, created in 1997, that provides subsidized health coverage for low-income and moderate-income children.
CHIP	The Children’s Health Insurance Program, a program, created in 1997, that provides subsidized health coverage for low-income and moderate-income children.
Consumer Operated and Oriented Plan (CO-OP)	A kind of nonprofit, member-owned health insurance provider created with startup loans provided by the Affordable Care Act. A CO-OP could be organized as an insurance company, as a health maintenance organization that is not an insurance company, or as some other type of entity.
CO-OP carrier	A health coverage provider that’s part of the ACA Consumer Operated and Oriented Plan program. A CO-OP carrier is a kind of nonprofit, member-owned health insurance provider created with startup loans provided by the Affordable Care Act. A CO-OP could be organized as an insurance company, as a health maintenance organization that is not an insurance company, or as some other type of entity.
Guaranty fund	A mechanism that’s supposed to protect coverage holders against the insolvency of a coverage issuer. In many states, a guaranty fund collects assessments from surviving issuers when an issuer fails. Before an issuer fails, the fund may have little or no assets on hand.
Health insurance issuer	An entity that provides health coverage. In the ACA context, an insurance issuer might be licensed as an insurance company, but it might be chartered as some other type of company, such a non-insurance company health maintenance organization or a health care service organization.
HMO	A health plan that uses a primary care provider to manage care, keep an enrolled healthy and discourage unnecessary use of care.
Issuer	A health insurance company, a managed care company, a health care services company, or other company that provides exchange plan coverage.
Medicaid	A federal and state program that covers medical care and nursing home care for the poor.
Medicare Advantage	Private plans that serve as a substitute for traditional Medicare coverage.
Medicare Part A	Traditional Medicare hospitalization insurance.
Medicare Part B	Traditional Medicare outpatient and physician services coverage.
Medicare Part C	Medicare Advantage.
Medicare Part D	Medicare prescription drug coverage.
Medicare	The federal health insurance program for the elderly, the disabled and people on kidney dialysis.
Multi-state plan	An ACA program that gives an insurer, or other coverage issuer, a limited ability to sell coverage across state lines. The program is run by the U.S. Office of Personnel Management.

Related: New ACA tax form drafts have a language all their own

Continue reading …

Enrollment period basics: Tax basics

8962	The form ACA exchange plan enrollees use to report any ACA advanced premium tax credits they’ve used to pay for coverage, seek ordinary ACA premium tax credits if they think they qualify for help and haven’t gotten any, and deal with any other gaps between the amount of premium tax credit help they did receive and the amount they should have received.
1095-A	The form ACA exchanges use to describe the health coverage they’ve provided for an individual, or a family.
1095-B	The form insurers and small self-insured employer plans use to describe the health coverage they’ve provided for an individual, or a family.
1095-C	The form employers use to describe the health coverage they’ve provided for an individual, or a family.
Advance premium tax credit (APTC)	An ACA mechanism for helping some ACA exchange plan users pay for their health coverage. The enrollees estimate when they apply for coverage how much they’ll earn in the coming calendar year. The exchange and the IRS use the cost of the coverage and the applicant’s income to decide how much the applicant can get. If the applicant qualifies for APTC and buys an exchange plan, the government sends the APTC help to the health coverage issuer while the plan year is still under way. The enrollee does not get to touch the APTC cash.
Adverse selection	A situation in which a plan, exchange or other provider of insurance, or other risk-management products, attracts more than its fair share of high-risk users.
APTC	The advance premium tax credit, the ACA mechanism for helping some ACA exchange plan users pay for their health coverage. The enrollees estimate when they apply for coverage how much they’ll earn in the coming calendar year. The exchange and the IRS use the cost of the coverage and the applicant’s income to decide how much the applicant can get. If the applicant qualifies for APTC and buys an exchange plan, the government sends the APTC help to the health coverage issuer while the plan year is still under way. The enrollee does not get to touch the APTC cash.
Excess advance payment	For exchange plan advance premium tax credit subsidy users, this is what the Internal Revenue Service says is the gap between the high amount the government paid for the subsidy and the lower amount the government should have paid. In many cases, the IRS will want the tax credit user to pay the extra help received back.
MAGI	Modified adjusted gross income, or the income total used in ACA coverage expansion program eligibility calculations.
Modified adjusted gross income (MAGI)	The income figure the ACA exchange system uses to determine an applicant’s eligibility for health coverage assistance programs.
Non-tax filer	An individual who does not have to file a tax return, such as someone with a very low income.
Premium tax credit (PTC)	The subsidy program the ACA uses to help low-income and moderate-income exchange plan users help pay for their coverage. Many exchange plan buyers receive the tax credit ahead of time, while the coverage year is still under way, to reduce what they pay out of pocket for premiums. Other taxpayers wait to get PTC help in the spring after the end of the coverage year, when they file their taxes for the coverage year.
PTC	Premium tax credit. This is the subsidy program the ACA uses to help low-income and moderate-income exchange plan users help pay for their coverage. Many exchange plan buyers receive the tax credit ahead of time, while the coverage year is still under way, to reduce what they pay out of pocket for premiums. Other taxpayers wait to get PTC help in the spring after the end of the coverage year, when they file their taxes for the coverage year.
Shared responsibility fee, or penalty	The amount an individual or employer may have to pay when the individual or employer fails to meet the ACA shared responsibility coverage standards.
Tax dependent	A “qualifying child” or other “qualifying relative” that a taxpayer claims as a dependent on a federal income tax return.

 

Enrollment period basics: Employer issues

Employer mandate	The ACA Employer Shared Responsibility provision, which exposes some employers that fail to provide affordable coverage with a minimum value to the possibility of having to pay penalties.
Employer shared responsibility payment	The employer mandate program, which exposes some employers that fail to provide affordable coverage with a minimum value to the possibility of having to pay penalties.
Enrollee	A health plan member. Usage: Maybe preferred by agents and brokers who think “member” sounds like an overly positive term for the relationship between a consumer and a health plan.
FTE	Full-time equivalent. This is a measure used to incorporate some or all part-time workers, seasonal workers, and other workers who work less than a full schedule in employee counts for ACA program purposes or other purposes.
Full-time equivalent employee (FTE)	This is a measure used to incorporate some or all part-time workers, seasonal workers, and other workers who work less than a full schedule in employee counts for ACA program purposes or other purposes.
Job-based health plan:	Employer-sponsored medical coverage.
Minimum essential coverage (MEC)	What the government classified as a solid, responsible level of health coverage.
Minimum value	A measure of how rich an employer health benefit plan has to be to count as “minimum essential coverage,” or solid health coverage.
Self-insured plan	An employer-sponsored coverage arrangement that requires the employer to set aside its own cash to pay enrollees’ claims.
SHOP Marketplace	An ACA Small Business Health Options Program small-group exchange coverage division.
SHOP	An ACA Small Business Health Options Program small-group exchange coverage division.
Skinny plan	A health plan designed for employers that want to offer just enough coverage to meet the ACA employer shared responsibility standards and no more.
Small Business Health Options Program (SHOP)	The division of an ACA public exchange that sells health plan programs for small employers.
Stop-loss insurance	An insurance plan that protects an employer that sponsors a self-insured group health plan against catastrophic losses.

Related: IRS tackles 1095-B versus 1095-C filing confusion  

Continue reading … 

Enrollment period basics: Distribution

A/B	HealthCare.gov managers’ short way of referring to agents and brokers.
Agent broker registration status	Whether an agent or broker has met the requirements for selling HealthCare.gov coverage or other the coverage available from other ACA exchanges.
Agent	An individual appointed to sell health coverage for an issuer.
Assister	Someone who helps people use the ACA exchange system.
Authorized representative	Someone who has permission to act on behalf of an exchange user. An authorized representative could be the exchange user’s family member or another trusted person.
Broker	An individual who acts on behalf of a consumer and helps the consumer choose, buy and use health coverage.
Carrier	A company that provides a health plan. This term may be used in place of “health insurance company” because, in many states, entities regulated separately from insurance companies may issue health coverage. In California, for example, health insurance companies regulated by the California Department of Insurance compete with companies regulated by the California department of Managed Health Care.
Certified application counselor	A nonprofit assister who helps a consumer apply for exchange plan coverage.
Continuing education unit	A measurement of how much content a class aimed at professionals appears to contain. Managers of HealthCare.gov and other ACA exchanges may require agents, brokers and other people who work with consumers to take a certain number of classes on exchange-related topics on a periodic basis.
Creditor order of precedence	The official rules that govern which types of people and organizations that are owed money by an insolvent individual or an insolvent entity, such as a failed health plan, come first when rehabilitators or liquidators are deciding who to pay first.
FFM producer and assister help desk	The HealthCare.gov operations that’s supposed to help agents and brokers.
HAFA	Health Agents for America, a Baton Rouge, Louisiana, group for health insurance agents and brokers.
Health Agents for America (HAFA)	A Baton Rouge, Louisiana, group for health insurance agents and brokers.
Household	HealthCare.gov managers define this as “your household, your spouse if you’re married, and your tax dependents.”
Marketplace Learning Management System (MLMS)	A system HealthCare.gov managers use to administer HealthCare.gov agent and broker training requirements.
NAHU	The National Association of Health Underwriters, an Arlington, Virginia-based group for health insurance agents and brokers.
National Association of Health Underwriters (NAHU)	An Arlington, Virginia-based group for health insurance agents and brokers.
National Producer Number (NPN)	A unique identification code a National Association of Insurance Commissioners system assigns to specific licensed insurance brokers, insurance adjustments, navigators and other individuals.
Navigator	A nonprofit ACA public exchange program ombudsman.
NPN	National Producer Number. A unique identification code a National Association of Insurance Commissioners system assigns to specific licensed insurance brokers, insurance adjustments, navigators and other individuals.
Registration completion certificate	The document that shows whether an ACA exchange agent or broker meets the requirements to sell exchange plan coverage.
Termination list	A database that shows which exchange agents have lost exchange registration.
Web broker authorized representative	A company executive who had the right to declare that a Web broker entity meets federal WBE requirements.
Web broker entity	A company that has permission to connect its computers with HealthCare.gov exchange system computers, or the computers of another ACA exchange.

Related: ACA tax credit: What if you get married?

Continue reading … 

 

Enrollment period basics: Laws and legal concepts

ACA	The Affordable Care Act — the two-law package consisting of the Patient Protection and Affordable Act of 2010 and the Health Care and Education and Reconciliation Act of 2010.
Actuarial value	The percentage of core benefits, or “essential health benefits,” a health plan provides.
Affordable Care Act (ACA)	The Affordable Care Act. The two-law package consisting of the Patient Protection and Affordable Act of 2010 and the Health Care and Education and Reconciliation Act of 2010.
CLAS	Culturally and linguistically appropriate services, or the federal standards for efforts to help health system users who have trouble with English.
Consolidated Omnibus Budget Reconciliation Act (COBRA)	A law that includes a provision giving workers and their families the right to continue employer health coverage after the employees leave the employer.
Culturally and Linguistically Appropriate Services (CLAS)	Federal standards for efforts to help health system users who have trouble with English.
Effective rate review program	A state entity that meets federal ACA standards for collecting information about proposed major medical insurance issuer rate changes and assessing how reasonable the proposals are. The ACA and ACA regulations call for HHS to handle rate reviews for states that are unable or unwilling to meet the federal rate review standards.
FAQ	Frequently asked question. Federal agencies often present batches of informal advice about how ACA rules and programs work as answers to FAQs.
Federal Register	A publication the government uses to share draft regulations, final regulations and other official documents.
Frequently asked question (FAQ)	This is a term federal agencies often use when presenting batches of informal advice about how ACA rules and programs work. The agencies pose a question, and then give an answer to the question.
Grandfathered coverage	Health coverage in effect on or before March 23, 2010, when President Obama signed the bill that created the Patient Protection and Affordable Care Act of 2010 into law. The ACA exempts a grandfathered plan that normally would be subject to ACA major medical coverage rules from most ACA major medical coverage rules.
Grandmothered coverage	Federal regulators, state regulators and insurers have used “grandmothering,” or transitional rules, to let consumers and employers keep some major medical plans that are not eligible for ACA grandfathering and are not fully compliant with the ACA major medical rules.
Guaranteed issue	A system for requiring a coverage issuer to sell coverage to all applicants within a designated class of people or entities, without regard to those applicants’ apparent level of risk.
Guaranteed renewability	A system for requiring a coverage issuer to keep an insurance arrangement in force as long as the coverage holder pays the premiums, unless the issuer discontinues the product involved for all holders of that type of coverage in a given market.
Guidance	Government agency advice about how to interpret laws or regulations, or how to run or participate in government programs.
HCERA	The Health Care and Education Reconciliation Act of 2010, one of the two laws in the ACA package.
Health Care and Education Reconciliation Act of 2010 (HCERA)	One of the two laws in the Affordable Care Act package.
Health Insurance Portability and Accountability Act (HIPAA)	A federal law that created limited right for people with solid health coverage, or “creditable coverage,” to replace that coverage with other coverage. The law also set federal health information and data security requirements.
HHS Notice of Benefit Payment and Parameters	A document HHS uses to establish how ACA programs will work. HHS has been publishing new parameters notices every year.
Individual mandate	The ACA provision requiring many people to have solid health coverage, or minimum essential health coverage, or else pay a penalty.
Individual shared responsibility provision	The ACA provision requiring many people to have solid health coverage, or minimum essential health coverage, or else pay a penalty.
LEP	Low English proficiency, or having difficulty with using English.
Liquidation	The process of shutting down a failed company.
Low English proficiency (LEP)	Having difficulty with using English.
Medical loss ratio	How much an insurer spends on claims, divided by revenue.
Medical loss ratio	The ration of a health insurer’s spending on enrollees’ claims to its revenue.
Medical underwriting	The process of using questionnaires, lab tests, medical record reviews and other means to analyze an individual’s health.
Minimum medical loss ratio (MLR)	A provision that requires a coverage issuer to spend at least 85 percent of large-group premium revenue, and at least 80 percent of individual and small-group premium revenue, on health care and quality improvement efforts, or else send rebates to the insureds.
MLR	Medical loss ratio, or how much an insurer spends on claims, divided by revenue.
Obamacare	The Affordable Care Act.
Patien Protection and Affordable Care Act of 2010	One of the two laws in the Affordable Care Act package.
PCIP (PPACA)	The Pre-existing Condition Insurance Plan. An effort to provide affordable coverage for sick people from 2010 until Jan. 1, 2014, when the ACA major medical underwriting restrictions took effect. Enrollment was much lower than expected, and claims per enrollee were much higher than expected.
Personally identifiable information (PII)	Social Security numbers, bank account numbers and other information governed by state and federal privacy and data security rules.
PII	Personally identifiable information. This includes Social Security numbers, bank account numbers and other information governed by state and federal privacy and data security rules.
Pre-existing Condition Insurance Plan (PCIP)	The Pre-existing Condition Insurance Plan. An effort to provide affordable coverage for sick people from 2010 until Jan. 1, 2014, when the ACA major medical underwriting restrictions took effect. Enrollment was much lower than expected, and claims per enrollee were much higher than expected.
Privacy and data security agreement	A document that shows an agent, broker, Web broker entity or other individual or entity meets health information privacy and date security requirements.
Rate review	The process of deciding whether an insurance issuer’s rate change proposal is reasonable.
Regulation	A formal rule developed by a government agency.
Risk pool	In the context of the ACA, this usually refers to all of the high-risk, low-risk and medium-risk people in a market who sign up for a particular kind of coverage, such as individual exchange plan coverage, or all types of individual major medical coverage.
Second-lowest-cost silver plan	The price of the silver-level health plan in a market that’s more expensive than the cheapest plan available but cheaper than the third-cheapest plan. ACA exchange system managers use this coverage price as a benchmark figure when performing subsidy calculations. Managers use the second-cheapest silver plan’s cost to try to adjust for the possibility that the cheapest silver plan could be an outlier with an unrealistically low premium.
Tagline	A line in a language other than English that tells readers how to get help in the readers’ preferred language.

Related: ACA eligibility: The flowchart 

Continue reading … 

Enrollment period basics: All terms in this section

1095-A: The form ACA exchanges use to describe the health coverage they’ve provided for an individual, or a family.

1095-B: The form insurers and small self-insured employer plans use to describe the health coverage they’ve provided for an individual, or a family.

1095-C: The form employers use to describe the health coverage they’ve provided for an individual, or a family.

8962: The form ACA exchange plan enrollees use to report any ACA advanced premium tax credits they’ve used to pay for coverage, seek ordinary ACA premium tax credits if they think they qualify for help and haven’t gotten any, and deal with any other gaps between the amount of premium tax credit help they did receive and the amount they should have received.

A/B: HealthCare.gov managers’ short way of referring to agents and brokers.

ACA: The Affordable Care Act – the two-law package consisting of the Patient Protection and Affordable Act of 2010 and the Health Care and Education and Reconciliation Act of 2010.

Actuarial value: The percentage of core benefits, or “essential health benefits,” a health plan provides.

Advance premium tax credit (APTC): An ACA mechanism for helping some ACA exchange plan users pay for their health coverage. The enrollees estimate when they apply for coverage how much they’ll earn in the coming calendar year. The exchange and the IRS use the cost of the coverage and the applicant’s income to decide how much the applicant can get. If the applicant qualifies for APTC and buys an exchange plan, the government sends the APTC help to the health coverage issuer while the plan year is still under way. The enrollee does not get to touch the APTC cash.

Adverse selection: A situation in which a plan, exchange or other provider of insurance, or other risk-management products, attracts more than its fair share of high-risk users.

Affordable coverage: In the ACA exchange context, this is employer-provided coverage such that the worker’s share of the cost of self-only coverage is less than or equal to a designated percentage of income. The best-known method for computing affordability is based on the employee’s share of the premium for the cheapest available self-only employer coverage as a percentage of the worker’s W-2 wages from that employer. In 2017, for users of that method, the affordability cut-off is 9.69 percent of W-2 wages for purposes of the employer meeting its ACA “shared responsibility” coverage mandate target, and 8.16 percent of W-2 wages for purposes of the worker escaping from the ACA individual shared responsibility coverage mandate.

Affordable Care Act (ACA): The two-law package consisting of the Patient Protection and Affordable Act of 2010 and the Health Care and Education and Reconciliation Act of 2010.

Agent: An individual appointed to sell health coverage for an issuer.

Agent broker registration status: Whether an agent or broker has met the requirements for selling HealthCare.gov coverage or other the coverage available from other ACA exchanges.

Annual benefit maximum: The limit on what a health coverage issuer or other coverage issuer will spend on claims in a year for an insured. The ACA now prohibits non-grandfathered plans from imposing limits in the amount they’ll in a year for core benefits, or essential health benefits.

Annual deductible: The amount of eligible health claims an enrollee must have before the issuer begins paying for care. In many cases, insurers will pay for at least some routine care before the enrollee meets the deductible.

Application: The electronic document that serves as the basis for an individual, family or employer participating in the ACA exchange system.

Attest: To promise an ACA exchange that something is true, and to face the possibility that lying to the exchange will lead to huge legal problems.

Assister: Someone who helps people use the ACA exchange system.

APTC: The advance premium tax credit, the ACA mechanism for helping some ACA exchange plan users pay for their health coverage. The enrollees estimate when they apply for coverage how much they’ll earn in the coming calendar year. The exchange and the IRS use the cost of the coverage and the applicant’s income to decide how much the applicant can get. If the applicant qualifies for APTC and buys an exchange plan, the government sends the APTC help to the health coverage issuer while the plan year is still under way. The enrollee does not get to touch the APTC cash.

Authorized representative: Someone who has permission to act on behalf of an exchange user. An authorized representative could be the exchange user’s family member or another trusted person.

Basic Health Program: A low-cost, Medicaid-like health coverage provider aimed at people in a state who earn too much to qualify for Medicaid but so little they would qualify for large ACA exchange plan subsidies. The ACA Basic Health Plan provision lets a state get most of the cash that could be spent on the enrollees’ ACA exchange plan coverage and use the cash to buy coverage for those people through a state-run procurement process. A program must give the enrollees a choice of coverage from at least two different providers. In 2016, Minnesota and New York State were the only two states that had set up Basic Health Plan programs.

Brand name drugs: Medications from well-known manufacturers. In many cases, the makers of the medications may have protection from patents, or government documents that give the holders of the documents temporary, exclusive control over manufacturing rights.

Broker: An individual who acts on behalf of a consumer and helps the consumer choose, buy and use health coverage.

Bronze plan: A major medical plan that covers about 60 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.

Carrier: A company that provides a health plan. This term may be used in place of “health insurance company” because, in many states, entities regulated separately from insurance companies may issue health coverage. In California, for example, health insurance companies regulated by the California Department of Insurance compete with companies regulated by the California department of Managed Health Care.

Catastrophic health plan: Plans that keep the premium low by setting the deductible at a very high level. They are available only to young adults under age and to other consumers who do not qualify for exchange plan subsidies and do qualify for a hardship exemption from the ACA may require that most individuals at least have bronze-level coverage or else pay a penalty.

Center for Consumer Information and Insurance Oversight: The division of the Centers for Medicare and Medicaid Services that oversees the ACA exchange system and other ACA programs that affect the commercial health insurance market. CMS is part of the U.S. Department of Health and Human Services.

Centers for Medicare & Medicaid Services (CMS): The division of the U.S. Department of Health and Human Services that’s responsible for Medicare, Medicaid and ACA coverage expansion programs.

Certified application counselor: A nonprofit assister who helps a consumer apply for exchange plan coverage.

Children’s Health Insurance Program (CHIP): A program, created in 1997, that provides subsidized health coverage for low-income and moderate-income children.

CHIP: The Children’s Health Insurance Program, a program, created in 1997, that provides subsidized health coverage for low-income and moderate-income children.

CLAS: Culturally and linguistically appropriate services, or the federal standards for efforts to help health system users who have trouble with English.

CMS: The Centers for Medicare & Medicaid Services, the division of the U.S. Department of Health and Human Services that’s responsible for Medicare, Medicaid and ACA coverage expansion programs.

CMS Enterprise Portal: A webpage people can use to get to the systems the Centers for Medicare & Medicaid Services uses to run many big programs, such as Medicare and the Marketplace Learning Management System (MLMS).

COBRA: The Consolidated Omnibus Budget Reconciliation Act, a law that includes a provision giving workers and their families the right to continue employer health coverage after the employees leave the employer.

Coinsurance: The percentage of bills for specified covered services an enrollee pays after meeting a health plan deductible and before reaching a plan’s out-of-pocket spending limit.

Community rating: A system that requires insurers to offer customers in the same geographical region prices based on the average level of risk for the entire region, not on the individual customer’s apparent level of risk.

Consolidated Omnibus Budget Reconciliation Act (COBRA): A law that includes a provision giving workers and their families the right to continue employer health coverage after the employees leave the employer.

Consumer Operated and Oriented Plan (CO-OP): A kind of nonprofit, member-owned health insurance provider created with startup loans provided by the Affordable Care Act. A CO-OP could be organized as an insurance company, as a health maintenance organization that is not an insurance company, or as some other type of entity.

Continuation coverage: COBRA coverage, or similar health coverage obtained using a similar state-law program.

Continuing education unit: A measurement of how much content a class aimed at professionals appears to contain. Managers of HealthCare.gov and other ACA exchanges may require agents, brokers and other people who work with consumers to take a certain number of classes on exchange-related topics on a periodic basis.

CO-OP carrier: A health coverage provider that’s part of the ACA Consumer Operated and Oriented Plan program. A CO-OP carrier is a kind of nonprofit, member-owned health insurance provider created with startup loans provided by the Affordable Care Act. A CO-OP could be organized as an insurance company, as a health maintenance organization that is not an insurance company, or as some other type of entity.

Copper plan: A type of proposed major medical plan, not yet available, that would covers about 60 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.

Cost-sharing: A health plan provision that requires an individual or family that has plan coverage to pay part or all of the cost of the coverage. Plan managers may use the cost-sharing mechanisms both to reduce use of unnecessary care and to reduce the amount spent on the claims that do come in.

Cost-sharing reduction (CSR) subsidy: An ACA subsidy system that helps reduce what exchange plan users with income from 100 percent to 250 percent of the federal poverty level spend on exchange plan deductibles, co-payments, coinsurance amounts and other cost-sharing provisions. The subsidy is supposed to keep out-of-pocket costs from keeping poor people from getting necessary medical care.

Cost shifting: Efforts by health care providers to get some types of entities, such as commercial health insurance companies, to pay more for care, to make up for low profit margins or losses on care provided for patients who are uninsured, underinsured or covered by low-paying coverage providers. Traditionally, U.S. commercial insurers have accused providers using cost shifting to make up for low Medicare and Medicaid payment rates.

Creditor order of precedence: The official rules that govern which types of people and organizations that are owed money by an insolvent individual or an insolvent entity, such as a failed health plan, come first when rehabilitators or liquidators are deciding who to pay first.

Critical illness insurance: An insurance policy that pays benefits only when an insured suffers from a serious illness, or type of serious illness, described in the policy.

CSR subsidy: The ACA cost-sharing reduction subsidy system. The system helps reduce what exchange plan users with income from 100 percent to 250 percent of the federal poverty level spend on exchange plan deductibles, co-payments, coinsurance amounts and other cost-sharing provisions. The subsidy is supposed to keep out-of-pocket costs from keeping poor people from getting necessary medical care.

Culturally and Linguistically Appropriate Services (CLAS): Federal standards for efforts to help health system users who have trouble with English.

Continue reading… 

Data-matching issue: Conflicts between the information an exchange plan user has given an exchange or exchange plan issuer and the information in another data source, such as an Internal Revenue Service database or credit bureau database, used to verify the information provided by the consumer.

Deductible: The amount a coverage holder must spend on specified types of covered events or services before the issuer begins to pay a significant percentage of the bills related to the covered events or services.

Dependent: The HealthCare.gov glossary gives this definition: “A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.”

Domestic partnership: A household such that two people live together and share a domestic life but aren’t married or joined by a civil union.

Effective rate review program: A state entity that meets federal ACA standards for collecting information about proposed major medical insurance issuer rate changes and assessing how reasonable the proposals are. The ACA and ACA regulations call for HHS to handle rate reviews for states that are unable or unwilling to meet the federal rate review standards.

Effectuated enrollment: A move by a consumer to activate the exchange plan health coverage chosen through an ACA exchange by paying for the coverage.

EHB package: The essential health benefits package, or what the ACA defines as the core collection of goods and services that a solid major medical plan should cover.

Eligible: Capable of meeting federal government standards, exchange standards, issuer standards or other standards for ACA programs.

Eligibility assessment: In the ACA exchange context, this is the review agencies in some states do to see whether an exchange applicant qualifies to get Medicaid benefits.

Employer mandate: The ACA Employer Shared Responsibility provision, which exposes some employers that fail to provide affordable coverage with a minimum value to the possibility of having to pay penalties.

Employer shared responsibility payment: The employer mandate program, which exposes some employers that fail to provide affordable coverage with a minimum value to the possibility of having to pay penalties.

Enrollee: A health plan member. Usage: Maybe preferred by agents and brokers who think “member” sounds like an overly positive term for the relationship between a consumer and a health plan.

Essential health benefits (EHB): What the ACA defines as the core collection of goods and services that a solid major medical plan should cover.

Excepted benefit: A benefit that falls outside the scope of most or all of the provisions of the ACA, and of earlier health insurance, health care and employee benefits laws, such as the Employee Retirement Income Security Act of 1974 (ERISA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Excess advance payment: For exchange plan advance premium tax credit subsidy users, this is what the Internal Revenue Service says is the gap between the high amount the government paid for the subsidy and the lower amount the government should have paid. In many cases, the IRS will want the tax credit user to pay the extra help received back.

Exchange: A program that tries to use websites and other mechanisms to help users compare products on an apples-to-apples basis and buy the products as if they were buying airline tickets from Travelocity, or stock from the New York Stock Exchange.

Exclusive provider organization: A health plan that covers only care from in-network providers, except in emergencies, but does not require enrollees to get permission from a primary care doctor to see a specialist.

Family size: The number of people on an exchange application. Managers of HealthCare.gov describe who applicants can include on an application here. 

FAQ: Frequently asked question. Federal agencies often present batches of informal advice about how ACA rules and programs work as answers to FAQs.

Federal data services hub: A system ACA exchange program managers use to share the sensitive information used in ACA exchange application and eligibility review processes, such as information from tax returns and information about criminal records.

Federal poverty level (FPL): The measure of income, published every year by HHS, that determines whether people using ACA programs or other federal health programs are officially classified as having a low or moderate income. For 2016, in most of the country, the federal poverty level for a one-person household is $11,880 in income per year.

Federal Register: A publication the government uses to share draft regulations, final regulations and other official documents.

Federally facilitated marketplace (FFM): HealthCare.gov.

Fee for service: A system for paying doctors, hospitals or other medical care providers for each service provided.

FFM: The Federally Facilitated Marketplace, or HealthCare.gov.

FFM producer and assister help desk: The HealthCare.gov operations that’s supposed to help agents and brokers.

Flexible spending account (FSA): A mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.

Flexible spending arrangement (FSA): This is another term for flexible spending account, or a mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.

Formulary: A list of drugs that a prescription drug plan covers.

Formulary tiers: A mechanism managers of drug benefits use to impose higher out-of-pocket costs on some types of drugs and lower out-of-pocket costs on others. A drug plan might require a $5 co-pay for an inexpensive antibiotic, and a $50 co-pay for an expensive brand-name drug.

FPL: The federal poverty level. This is the measure of income, published every year by HHS, that determines whether people using ACA programs, or other federal health programs, are officially classified as having a low or moderate income. For 2016, in most of the country, the federal poverty level for a one-person household is $11,880 in income per year.

Frequently asked question (FAQ): This is a term federal agencies often use when presenting batches of informal advice about how ACA rules and programs work. The agencies pose a question, and then give an answer to the question.

FSA: A flexible spending account, or flexible spending arrangement. This is a mechanism that lets people keep some cash they want to spend on health care products and services from taxable income. A taxpayer can use an FSA together with an ordinary, low-deductible insurance but faces restrictions on how much unused account value can be carried over to the following year.

FTE: Full-time equivalent. This is a measure used to incorporate some or all part-time workers, seasonal workers, and other workers who work less than a full schedule in employee counts for ACA program purposes or other purposes.

Full-time equivalent employee (FTE): This is a measure used to incorporate some or all part-time workers, seasonal workers, and other workers who work less than a full schedule in employee counts for ACA program purposes or other purposes.

Gold plan: A major medical plan that covers about 80 percent of the actuarial value of the ACA core benefits package, or essential health benefits package.

Grace period: The time between when a payment for ACA exchange plan coverage or other coverage is due and when the coverage is canceled due to the coverage holder’s failure to pay the premium.

Grandfathered coverage: Health coverage in effect on or before March 23, 2010, when President Obama signed the bill that created the Patient Protection and Affordable Care Act of 2010 into law. The ACA exempts a grandfathered plan that normally would be subject to ACA major medical coverage rules from most ACA major medical coverage rules.

Grandmothered coverage: Federal regulators, state regulators and insurers have used “grandmothering,” or transitional rules, to let consumers and employers keep some major medical plans that are not eligible for ACA grandfathering and are not fully compliant with the ACA major medical rules.

Guaranteed issue: A system for requiring a coverage issuer to sell coverage to all applicants within a designated class of people or entities, without regard to those applicants’ apparent level of risk.

Guaranteed renewability: A system for requiring a coverage issuer to keep an insurance arrangement in force as long as the coverage holder pays the premiums, unless the issuer discontinues the product involved for all holders of that type of coverage in a given market.

Guaranty fund: A mechanism that’s supposed to protect coverage holders against the insolvency of a coverage issuer. In many states, a guaranty fund collects assessments from surviving issuers when an issuer fails. Before an issuer fails, the fund may have little or no assets on hand.

Guidance: Government agency advice about how to interpret laws or regulations, or how to run or participate in government programs.

HAFA: Health Agents for America, a Baton Rouge, Louisiana, group for health insurance agents and brokers.

Hardship exemption: Permission from the government or an ACA exchange to avoid complying with an ACA provision because of unusual difficulties.

HCERA: The Health Care and Education Reconciliation Act of 2010, one of the two laws in the ACA package.

HDHP: A high-deductible health plan, or health insurance arrangement that requires enrollees to have high medical costs before the insurance pays for all or designated types of care.

Health Agents for America (HAFA): A Baton Rouge, Louisiana, group for health insurance agents and brokers.