ACA Lingo: Terms and Definitions

Learn the Lingo

A                                                                                                                                                         

Accountable Care Organization (ACO) – ACOs allow healthcare providers to coordinate care among a group of patients. Through our ACO, Bellin-ThedaCare Healthcare Partners, we work with 23,000 Medicare patients to improve health outcomes by coordinating care across all settings – including doctor’s offices, hospitals and long-term care facilities. We were chosen as one of 32 healthcare systems across the county to participate in this ACO program. Today, we have the second highest quality scores and the lowest costs among those systems. Our motivation for all of this is you, our patients.

Affordable Care Act (ACA) – The Affordable Care Act is most commonly called Obamacare. Sometimes it is called the Patient Protection and Affordable Care Act (PPACA). The ACA is a federal law that took effect March 23, 2010. It changed, and is changing, many parts of health care. The ACA requires all Americans to have health insurance coverage. The law also requires health insurance companies to offer the same rates regardless of pre-existing conditions. Additionally, the law targets improved healthcare outcomes.  

After Visit Summary – The document you receive when you leave an appointment with your ThedaCare doctor. ThedaCare’s After Visit Summary guides your care, with information about medications, future appointments, and the doctor’s instructions for you. It’s especially helpful for caregivers. You can find a copy of your Health Summary (After Visit Summary) in your MyThedaCare.org account under Medical Record.

B                                                                                                                                                         

BadgerCare  Plus —Medicaid is a federal/state partnership. Individual states design, manage and name the program. In Wisconsin, Medicaid is currently called BadgerCare. it provides access to healthcare services to families with income at or above a percentage of the federal poverty guidelines, who do not receive insurance through an employer or who cannot afford to purchase coverage on their own. Check dhs.wisconsin.gov for changes to BadgerCare.

BadgerCare Plus Core Plan— Wisconsin’s BadgerCare Plus Core Plan provides access to health care services for uninsured adults.  If your income is at or below 100% of the federal guidelines and you are age 19 through 64 without children or you do not have dependent children under age 19 living with you, you may be able to enroll in the BadgerCare Plus Core Plan. Check dhs.wisconsin.gov for changes to this plan.

C                                                                                                                                                         

Catastrophic Health Insurance Plan – These plans provide “safety net” coverage in case of an accident or serious illness. Although their premium costs may be lower than other plans, they have very high deductibles. Out-of-pocket costs often reach thousands of dollars before full coverage kicks in.

Children’s Health Insurance Program (CHIP) – CHIP is an insurance program for low-income children in families who earn too much to qualify for Medicaid (more than $15,510 a year for a family of four) but who cannot afford to purchase private health insurance.

Co-insuranceCo-insurance is a health plan provision in which you and the insurance company share the total cost of covered medical services after the deductible has been met, set as fixed percentages. For example, if your health insurance plan has an 80%/20% co-insurance requirement (and does not have any additional co-payment or deductible requirements), then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80.

Co-payment A fixed amount (for example, $40) you pay for a covered health care service, such as a doctor visit, usually paid at the time you get the service. The amount can vary by the type of covered healthcare service.

Cost sharing—The portion of health care costs not covered by insurance that patients pay out-of-pocket, including deductibles, coinsurance and copayments, or similar charges. Cost sharing for Medicaid and CHIP patients also includes premiums.

D                                                                                                                                                         

Deductible – The amount you owe for healthcare services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your insurance plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible. Under the ACA, the deductible may not apply to all services.

E                                                                                                                                                         

Electronic Medical Record (EMR) – EMR is a digital version of your health history. Sometimes it is called EHR, or Electronic Health Record.  An EMR allows providers to track your medical care over time, identify when you are due for preventive visits and screenings, monitor your health and share important information confidentially with other doctors. ThedaCare uses Epic – the #1 EMR system used by providers throughout the country. All providers employed by ThedaCare Physicians are on our EMR system, along with more than 700 of our specialist partners.

Episode of Care – All of the services you receive for a specific illness or medical problem during a defined period of time.

Essential Health Benefits (EHB) – A set of 10 healthcare service categories that must be covered by certain health insurance plans starting in 2014. EHBs include emergency services, hospitalization, maternity and newborn care, preventive care and chronic disease management. Insurance plans offered in Wisconsin’s health insurance exchange must cover these benefits.

Exchange Navigator – Trained guides who help you compare health insurance options on Wisconsin’s health insurance exchange and determine your eligibility for public assistance programs. Navigators are not allowed to provide you with advice on which health plans to choose and are not allowed to sell insurance.

F                                                                                                                                                          

Federal Poverty Level (FPL) – Levels of income set by the federal government to determine whether or not you qualify for Medicaid or subsidized coverage under the Affordable Care Act. For 2013, the annual FPL for one person is $11,490 and is $23,550 for a family of four. Depending on your income, you may be eligible for a tax credit or subsidy if you purchase a health plan on Wisconsin’s health insurance exchange.

H                                                                                                                                                         

Habilitation Services - Healthcare services that help a person learn skills and functioning for daily living for the first time. Rehabilitation helps a person re-learn those skills. Services include physical and occupational therapy, speech-language pathology and other services for people with disabilities. The Affordable Care Act requires certain health plans to cover habilitation services.

Healthcare Network – A healthcare network is a list of doctors, hospitals and other healthcare providers who provide medical care to members of a specific health plan for an agreed-upon price. If you use a doctor or facility that isn’t in your plan’s network, you may have to pay the full cost of the services provided.

Health Maintenance Organization (HMO) – An HMO is a narrow network health insurance plan that typically limits coverage only to providers in its network. HMO members usually have a primary care doctor and must get a referral to see a specialist.

Health Savings Account (HSA) – An HSA is a medical savings account for people enrolled in a high-deductible health plan. The funds in the account allow individuals to pay for qualified, out-of-pocket medical expenses. Deposits in the account are not subject to federal income tax, and unspent funds accumulate over time. Withdrawals for non-medical expenses may provide tax advantages after retirement age.

High Deductible Health Plan (HDHP) – An HDHP usually offers lower premiums and higher deductibles than traditional insurance plans. As of 2013, HDHPs are plans with a minimum deductible of $1,250 per year for individual coverage and $2,500 for family coverage. If you have an HDHP you can use a health savings account (HSA) or a similar account to pay for many out-of-pocket costs. Doing so can reduce your federal income taxes.

I                                                                                                                                                          

Individual Mandate – Beginning in 2014, individuals will be required to maintain minimum essential health insurance coverage for themselves and their dependents. If you do not maintain coverage, you will have to pay a penalty, unless you are exempt from the mandate. Penalties in 2014 are $95 for an adult and $47.50 for a child, or 1% of family income, whichever is greater. Penalties increase in 2015 and beyond. Don’t worry if you purchase health insurance through Wisconsin’s exchange. ThedaCare accepts most major insurance plans.  To understand how the individual mandate affects you, see the flowchart called Does the ACA Require Everyone to Buy Health Insurance? [insert the location for this graphic].

Insurance Exchange – A health insurance exchange is an online store or marketplace where individuals and small businesses can buy health insurance plans that meet certain benefits and cost standards. When looking at plans, you can get help from a trained navigator, an application assister or a certified application counselor. Insurance agents and brokers can also help you with your application and choices. The Help Center at healthcare.gov will help direct you to the right resource.  

M                                                                                                                                                         

Medical Assistance—The umbrella name for Medicaid.

Medical Home – You may hear your insurance company use the term “medical home.” At ThedaCare, we don’t use that insurance term, but ThedaCare providers act just like your medical home base. This includes using a team approach, attention to mind, body and spirit, plan of care and enhanced access to care. In addition, ThedaCare offers FastCare locations for urgent care situations, especially during evenings and weekends, and MyThedaCare.org, for secure online access to personal health information. All your providers, whether in a doctor’s office, online, or at FastCare, are connected through our EMR.

MedicareSee BadgerCare Plus

Medicare Advantage—Medicare Advantage, often called Medicare Part C, is offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Traditional Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

MyThedaCare.orgThe ACA emphasizes more opportunities for patients to connect with their doctors using technology. MyThedaCare.org is an online patient portal, offering you personalized and secure access to portions of your medical records. You can request login information from your physician to set up your own secure online account. Once activated, you can request appointments, email your provider, refill a prescription, check your immunization records and more to take control of your healthcare.

O                                                                                                                                                         

Out-of-pocket Costs – In health insurance, out-of-pocket costs refer to any expenses you must pay directly to a health care provider, without any contribution from the insurer. Your health plan may require you to pay out-of-pocket copays for prescription medication or a visit to the doctor’s office. A deductible that you must pay before insurance kicks in is also an out-of-pocket cost.

Out-of-pocket Spending— The most you pay during a policy period before your health insurance plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance plan doesn’t cover. Some health insurance plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.

P                                                                                                                                                         

Payment Bundling – Payment bundling is a way to compensate all the healthcare providers involved in your care a single amount, rather than being paid for each individual treatment, test or procedure. In payment bundling, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments.

Preferred Provider Organization (PPO) – A PPO is a health insurance plan that gives you a choice of getting care within or outside of a provider network. With a PPO, you may use out-of-network doctors and facilities, but you’ll have to pay more than if you use in-network doctors. In a PPO, you can visit any doctor without a referral.

Q                                                                                                                                                         

Qualified Health Plan (QHP) – An insurance plan is certified under the Affordable Care Act as a QHP if it provides essential health benefits, follows established limits on cost-sharing (e.g. deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.

S                                                                                                                                                         

Small Business Health Options Program (SHOP) – A health insurance exchange that offers small businesses and their employees a variety of Qualified Health Plan options to fit their needs and their budget. To see plans offered on Wisconsin’s SHOP exchange, visit healthcare.gov.

V                                                                                                                                                         

Value – Getting the most for your money is important with any purchase. Value is an individual assessment, typically calculated as the quality received for the dollars paid. In healthcare, value is receiving the best quality care at a reasonable price.