Key terms and phrases

Affordable Care Act: Words or phrases I need to know

This glossary has many commonly used terms for the Affordable Care Act. The list will be updated frequently, so please check back often. The following information was provided by Kaiser Permanente and Healthcare.gov.

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.

Co-payment -
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Employer Responsibility - Under the Affordable Care Act starting in 2014, if an employer with at least 50 full-time equivalent employees doesn't provide affordable health insurance and an employee uses a tax credit to help pay for insurance through an Exchange, the employer must pay a fee to help cover the cost of the tax credits.

Four levels of Coverage – The four levels of coverage - bronze, silver, gold and platinum - are based on actuarial value, a measure of the level of financial protection a health insurance policy offers. It indicates the percentage of health costs that a health plan would pay for an average person.
  • Bronze: 60%
  • Silver: 70%
  • Gold: 80%
  • Platinum: 90%
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.

Individual Responsibility - Under the Affordable Care Act, starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren't, you may be required to pay an assessment. You won't have to pay an assessment if you have very low income and coverage is unaffordable to you, or for other reasons including your religious beliefs.

Insurance marketplace - The Marketplace is designed to help individuals and businesses find health insurance that fits their budgets. Every health insurance plan in the new Marketplace will offer comprehensive coverage, from doctors to medications to hospital visits.

Large Employer - Usually a company with over 50 employees (or full-time equivalent employees). May vary by state law.

Network - The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Pre-existing condition - Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.

Small employer - Usually a company with 50 or fewer employees (or full time equivalent employees). May vary by state law.

Summary of benefits and coverage - A plain-language summary of your benefits and coverage. In compliance with the ACA, every insurer must supply this document and a uniform glossary of common health terms to members and prospective members during open enrollment and/or upon request.

The SBC provides a brief summary of information such as the following:
  • Cost sharing for some common medical services such as office visits or lab tests
  • Deductibles and out-of-pocket limits
  • Services not covered by the plan
Qualified Health plan - Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an 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 Exchange in which it is sold.