Affordable Coverage – applies to employer-sponsored plans – For employer-sponsored insurance plans to meet the minimum essential coverage standard under the ACA, the employee’s portion of the annual premium must be no more than 9.5% of the employee’s household income.
Dependent Coverage – Health insurance for a plan policyholder’s dependents.
Employer Mandate – Employers with more than 50 full-time equivalent employees must provide a health insurance option for its full-time employees or be subject to penalties. This large employer mandate is effective on January 1, 2015.
Exchange – The Marketplace maintained by the state or the federal government, depending on the state, which offers a choice of health insurance plans. Plans in the Exchange must meet benefit and affordability standards. Plans purchased from the exchange are often called individual market plans.
Family Size – The total number in a family. This may include the taxpayer, spouse, and dependents.
Government-Sponsored Plans – plans like Medicare, Medicaid, CHIP, TRICARE, and Veteran Affairs Health Benefits. These plans are subsidized by the federal government.
Health Insurance Premiums – The monthly fee that a health insurance policyholder paid for coverage during the benefit period.
Household Income – The total amount of modified adjusted gross income (MAGI) for the taxpayer, spouse (if applicable), and dependents (if applicable). This amount can make several determinations including how much of a subsidy that a family may qualify for or what is considered “affordable coverage” for a household. This includes wages, salaries, tips, net income from any self-employment or business, unemployment compensation, social security payments, rental income, interest, dividends, capital gains, annuities, alimony, and some retirement and pensions.
Individual Penalty – An additional penalty that individuals will have to pay if they don’t have a qualified insurance plan which meets minimum essential coverage and are not eligible for an exemption to the requirement. This penalty is calculated monthly and paid on the individual’s annual tax return. An individual or family is allowed 90 days per year without coverage before they have to pay the fine. Other names: Shared responsibility penalty
January 1, 2014 – The individual mandate begins. On this date, most people that do not have employer-based coverage must purchase health insurance or be subject to a tax penalty.
Minimum Essential Benefits – All individual plans and those sold to small business must offer a comprehensive package that includes: emergency services, lab services, mental health and substance abuse treatment, hospitalizations, pediatric care, preventative care, maternity care outpatient or ambulatory care, vision, and dental care for children.
Minimum Essential Coverage – The type of health insurance that individuals must have in order to meet ACA requirements and avoid tax penalties. Types include: employer-sponsored plans, employer-sponsored retiree health plan, Medicare, Medicaid, CHIP, TRICARE, coverage from a health plan purchased in the Exchange.
Minimum Value – applies to employer-sponsored plans – The standard that an employer-sponsored plan must cover in order to meet the ACA’s minimum essential coverage requirement. The ACA states that the plan must cover at least 60% or more of the plan’s share of the total cost of benefits covered under the plan.
Open Enrollment – The annual period when an insurance company allows individuals to make changes to their existing plans or enroll in coverage.
Out-of-Pocket Costs – Costs for medical care that is not paid by the insurance plan. Common out-of-pocket expenses are co-pays, deductibles, and services that are not covered by the insurance plan.
Plan Year – The 12-month period of defined by the insurance provider. This typically begins on the date that the plan was purchased for the group or individual, but varies depending on insurance provider. Other names: policy year
Qualified-Health Plan – A health insurance plan that meets requirements provisioned under the ACA. This includes key characteristics like (but is not limited to) minimum essential coverage and limits on deductibles, copayments, and out-of-pocket maximum amounts.
Subsidy – For taxpayers who purchase health insurance through the health insurance exchange because they are not offered affordable health insurance through their employer, this is the amount of the taxpayer’s monthly premium that the government will pay to help taxpayer afford health insurance. This is determined on a household income and family size basis. Other names: premium tax credit (PTC) or premium assistance.