Typically the 30 days before the group policy renews (i.e. policy renews on 1/1 then open enrollment would be 12/1-1/1)
Allows changes to be made to the group policy
Employees can change plan and add/remove dependents
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
Only applies to health plans offered by private-sector employers with 20 or more employees as well as to state and local governments. It doesn’t apply to the federal government, churches, or some church-related organizations. The events that may qualify an employee or their family for COBRA coverage include voluntary or involuntary job loss, reduction in hours worked, the death of the employee, or the divorce or legal separation of the employee and their spouse. COBRA coverage generally lasts for a maximum of 18 months but may be extended to 36 months under certain circumstances.
Click Here for the Department of Labor’s guide on COBRA calculations
ERISA (Employee Retirement Income Security Act of 1974)
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. ERISA requires plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.
FF SHOP Group Health Plans
Not avalible in Oregon (As of published date)
SHOP insurance is generally available to employers with 1-50 full-time equivalent employees (FTEs). If you have fewer than 25 employees, you may qualify for the Small Business Health Care Tax Credit, if you buy SHOP insurance.
To qualify for the tax credit, all of the following must apply:
You have fewer than 25 full-time equivalent (FTE) employees
Your average employee salary is about $50,000 per year or less
You pay at least 50% of your full-time employees’ premium costs
You offer SHOP coverage to all of your full-time employees. (You don’t have to offer it to dependents or employees working fewer than 30 hours per week to qualify for the tax credit.)
The insurance plan must be approved by the government as tax-credit eligible.
The Family and Medical Leave Act of 1993 (FMLA) is a United States labor law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons.
The Family and Medical Leave Act (FMLA) guarantees eligible employees up to 12 weeks of unpaid leave each year with no threat of job loss. It also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working. Applies to companies with 25 or more employees.
GMA / MGA
Group Master Application or Master Group Application captures business information when applying for new coverage
The ICHRA is an employer-funded, tax-free health benefit used to reimburse employees for individual health insurance and other medical expenses.
Employees must attest to their company that they have individual coverage before they can collect reimbursements through the ICHRA.
The federal government requires employees participating in the ICHRA to have individual health insurance. Employees covered by a spouse’s group health insurance plan, employees participating in a health care sharing ministry, or employees who choose to go without insurance coverage cannot participate in the ICHRA.
State continuation rules apply to groups with fewer than 20 employees
Coverage can be extended for up to nine months, as long as the employee had coverage (not necessarily from the same employer) for at least three months prior to loss of eligibility for the employer-sponsored plan
TPA / Third Party Administrator
A third-party administrator is a company that provides operational services such as claims processing and employee benefits management under contract to another company. Insurance companies and self-insured companies often outsource their claims processing to third parties.
Annual Open Enrollment for Medicare
From October 15th to December 7th
Annual time to apply and make changes to Medicare Advantage or Prescription plans.
Centers for Medicare & Medicaid Services is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards.
End Stage Renal Disease
Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $5,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.
Dual Eligible (Medicare + Medicaid)
Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits.
Medicare Advantage / MA / MAPD
Medicare Advantage plan is a health plan option approved by the Centers for Medicare & Medicaid Services (CMS) and operated by a private insurance company. Sometimes, you will hear a Medicare Advantage plan called a Medicare Part C plan or a Medicare Health plan. Medicare Advantage plans provide a combination of your Medicare Part A (hospital coverage) and Medicare Part B (out-patient or medical coverage). Medicare Part D (drug coverage) is also included in most plans. These plans may also include other services such as vision coverage, dental coverage, transportation, and recreational coverage (such as a “Silver Sneakers” membership).
Must maintain Parts A and B to enroll in a Medicare Advantage plan
Medicare Supplement / Medigap / Med Supp
A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover.
The standardized Medigap policies were designed by the Federal Government so medical benefits will be identical from company to company. Generally speaking, the difference between Medigap policies sold by different insurance companies is the cost, customer service, and whether they include a gym membership.
Must maintain Parts A and B to enroll in a Medicare Supplement plan
Open Enrollment Period (OEP)
New as of 1/1/2019 the Medicare Open Enrollment Period allows you to make a one-time change.
January 1st – March 31st
You can change from one Medicare Advantage plan to another Medicare Advantage plan. You can also leave a Medicare Advantage plan and return to Original Medicare (and a Part D drug plan).
Oregon Birthday Rule
This only applies to Medicare – Medigap plans. Clients who want to change to another Medigap Company can only do so beginning on their birthday and for 30 days thereafter. Applies to same or lesser plan (can’t upgrade plans).
Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
Not available in Lane County as of the date of this publishing
Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.
To qualify for PACE, you must:
Be 55 or older
Live in the service area of a PACE organization
Need a nursing home-level of care (as certified by your state)
Be able to live safely in the community with help from PACE
You usually don’t pay a monthly premium for Medicare Part A (Inpatient Hospital Insurance) coverage if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called “premium-free Part A.”
In general, Part A covers:
Inpatient care in a hospital
Skilled nursing facility care
Inpatient care in a skilled nursing facility (not custodial or long-term care)
Home health care
Nearly everyone must pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:
Railroad Retirement Board
Office of Personnel Management
Most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA).
Part B covers things like:
Durable medical equipment (DME)
Medicare Part C is another name for Medicare Advantage. Medicare Part C is administered by private insurance companies contracted with Medicare. Medicare Part C covers everything that Original Medicare (Part A and Part B) cover and may cover extra benefits as well.
Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.
A prescription drug plan (PDP) is one option for individuals who want to enroll in the Medicare Part D prescription drug coverage, which helps pay the cost of prescription drugs for enrollees. A prescription drug plan (PDP) is a stand-alone plan, covering only prescription drugs.
You must be enrolled in Part A and/or Part B in order to purchase a PDP.
Enrollees pay a co-pay for each prescription, a monthly premium and an annual deductible.
Individual, Affordable Care Act, aka ‘Obamacare’ Plans
Annual Open Enrollment for Individuals
November 1st to December 15th
Only time to apply for new coverage or change carriers/plans without a Special Enrollment Period
The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
Christian Sharing Ministries
An exempt option under the Affordable Care Act (Obamacare), these Christian sharing ministries are not insurance and are not offered through insurance companies.
Procedures that are perceived as controversial or against the ministry’s beliefs (such as contraception, sterilization, genetic testing, etc.) will not be part of the plan, and pre-existing conditions may be excluded or limited.
Direct / Non-FFM
Individuals who do not qualify for a Tax Subsidy can apply directly with an insurance carrier.
FFM / HealthCare.gov / Marketplace
Online system for individuals who qualify for a Tax Subsidy to apply for individual health plans
Established by the Affordable Care Act
Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.
Some states have expanded their Medicaid programs to cover all people below certain income levels.
OHP / The Oregon Health Plan
Oregon’s Medicaid program
Offers year-round open enrollment
Tax Subsidy aka Tax Credit
A subsidy is financial assistance that helps you pay for something. It’s not a loan; you don’t pay it back. The Advanced Premium Tax Credit lowers your monthly health insurance payment, or premium.
Based on household size and household income
Income is estimated for the coming year. Final tax credit is calculated when you file your tax return; you will be owed a refund or you may owe money to the government if your original estimate was incorrect.
The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.
A co-pay is a fixed out-of-pocket amount paid by an insured for covered services. It is a standard part of many health insurance plans. Insurance providers often charge co-pays for services such as doctor visits or prescriptions drugs.
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay coinsurance for covered services.
EPO Exclusive Provider Organization
Hybrid between HMO and PPO network
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the Secretary of the U.S. Department of Health and Human Services (HHS) to develop regulations protecting the privacy and security of certain health information.
Establish a national set of security standards for protecting certain health information
HMO Health Maintenance Organization
An HMO gives you access to certain doctors and hospitals within its network. A network is made up of providers that have agreed to lower their rates for plan members and also meet quality standards. Unlike PPO plans, care under an HMO plan is covered only if you see a provider within that HMO’s network. There are few opportunities to see a non-network provider.
LTC Long-Term Care
Long-term care insurance is an insurance product, sold in the United States, United Kingdom and Canada that helps pay for the costs associated with long-term care. Long-term care insurance covers care generally not covered by health insurance, Medicare, or Medicaid.
Another name for the Affordible Care Act
Out of Pocket Maximum / OOPM
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
P & C
Property and Casualty Insurance
Think Home and Auto insurance
PHI / ePHI
PHI stands for Protected Health Information
ePHI stands for electronic Protected Health Information
The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.
Personally identifiable information, or PII, is any data that could potentially be used to identify a particular person. Examples include a full name, Social Security number, driver’s license number, bank account number, passport number, and email address.
PPO Preferred Provider Organization
PPO plans provide more flexibility when picking a doctor or hospital. They feature a network of providers, but there are fewer restrictions on seeing non-network providers.
You can see the doctor or specialist you’d like without having to see a PCP first.
You can see a doctor or go to a hospital outside the network and you may be covered. However, your benefits will be better if you stay in the PPO network.
Amount that the member is responsible for paying for their coverage
Typically billed monthly
Abbreviation of prescriptions
Special Enrollment Period / SEP
You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the event to enroll in a plan.
Short Term Medical / STM
Short Term Health Insurance has many different names like temporary health insurance, short term medical, short term insurance, short-term health plans, term insurance, or STM health plans. Short term health plans offer major medical type benefits in the case of unexpected accidents and illnesses. They are used for individual and family healthcare coverage.
Oregon law limits short-term plans to three months, including renewals.
A subsequent short-term plan purchased within 60 days of the termination of a short-term plan is considered a renewal.