Avenue H Glossary of Terms

Avenue H Health Glossary

The federal government has created a Universal Health Glossary that concisely defines many terms you may encounter when shopping for health insurance.  For your convenience, we have included a condensed glossary of perhaps unfamiliar words you may encounter while browsing the Avenue H site.

 

Benefit Mandate

Laws requiring all insurance policies sold to offer coverage for a particular treatment (e.g., in vitro fertilization, hair prostheses) or access to a particular type of medical provider (e.g., dentists, massage therapists). Federal group policies regulated under ERISA are exempt from State benefit mandates.

CHIP

Acronym describing the state Children's Health Insurance Program, a state health insurance plan for children. Depending on income and family size, working Utah families who do not have other health insurance may qualify for CHIP.

Community Rating

A requirement that carriers charge all individuals the same rates, with few variations.

Coordination of Benefits

When a patient has more than one health plan that covers their medical expenses, a "coordination of benefits" divides the responsibility of payment between the health plans so that together they will pay up to 100%.

Defined Contribution

Defined contribution health benefit plans are employer-sponsored health plans that allow individual employees full control over their plan choice. In a defined contribution arrangement, rather than promising or providing a certain level of health benefit, the employer offers a pre-determined level of funding that the employee then controls and uses to purchase their choice of health insurance.

Delivery System Reform

A general term for efforts to slow the growth of health costs by reforming the way health care is delivered in order to generate efficiencies.

Employee Exclusion

An Internal Revenue Service ruling that all health and related fringe benefits provided by an employer are excluded from income for purposes of both payroll and income taxes without limit. (Note however that for the employer, both wages and health benefits are tax-deductible business expenses.)

Employer Mandate

Proposals requiring employers to provide health insurance benefits to their employees.

ERISA

Acronym describing the Employee Retirement Income Security Act of 1974, which enacted rules regarding employee benefit plans. Section 514 of ERISA pre-empts "any and all State laws insofar as they relate to any employee benefit plan," permitting employers who self-insure their group health plans from complying with (potentially conflicting) State benefit mandates and other regulatory requirements. Small employers who "fully insure" - that is, purchase coverage from another company without assuming insurance risk - remain subject to State regulatory requirements.

Premium

The monthly contribution made to the insurance company to pay for coverage.

Group Insurance

Health coverage provided by employers. Coverage is offered to all eligible employees within a given classification and can be self-insured or fully-insured by an employer - in the latter instance, the employer purchases coverage from a carrier and assumes no insurance risk. States and the federal government also divide the group market into small and large groups, with the small groups classified as those with 2-50 employees.

Guaranteed Issue

A requirement that insurance carriers accept all applicants, regardless of health status.

Health Savings Account

A Health Savings Account is an alternative to traditional health insurance; it is a savings product that offers a different way for consumers to pay for their health care. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. You must be covered by a High Deductible Health Plan (HDHP) to be able to take advantage of HSAs. An HDHP generally costs less than what traditional health care coverage costs, so the money that you save on insurance can therefore be put into the Health Savings Account. You own and you control the money in your HSA. Decisions on how to spend the money are made by you without relying on a third party or a health insurer. You will also decide what types of investments to make with the money in the account in order to make it grow.

High-Risk Pools

A form of coverage for the medically uninsurable. Coverage is generally extended to those rejected for coverage on the individual market. Premiums are higher than rates for healthy individuals, but lower than the actual cost of most participants' health care - State general fund appropriations, grants from the federal government, and/or surtaxes on insurance premiums finance the pools' operating losses.

Individual Insurance

Health coverage purchased for an individual (or family) outside the group setting. Individual insurance is subject to State regulation (including benefit mandates), and must generally be purchased with after-tax dollars.

Mandates, Individual

A requirement that all individuals have health insurance, subject to some type of enforcement by the State.

Medicaid

A State-federal partnership providing health coverage to certain vulnerable populations. Eligibility requirements vary by State, but often include low-income women and children as well as elderly and disabled populations. The federal government finances Medicaid through the Federal Medical Assistance Percentage (FMAP), a match rate linked to States' relative income level that has averaged 57% of total Medicaid spending in recent years. While low-income individuals and children constitute the majority of Medicaid beneficiaries, most Medicaid spending funds long-term and related care to elderly and disabled enrollees.

Avenue H

An internet-based information portal with three core functions: 1) provide consumers with helpful information about their health care and health care financing, 2) provide a mechanism for consumers to compare and choose a health insurance policy that meets their needs, and 3) provide a standardized electronic application and enrollment system. In addition, Avenue H will allow for premium aggregation from multiple sources (for example, premiums from multiple employers for an individual, from multiple employers for different family members, or from state premium assistance programs) for a single policy.

Utah Premium Partnership (UPP)

A state insurance premium subsidy program designed to help make health insurance more affordable for working individuals and families.