Glossary: Employer-Sponsored Health Coverage

Health coverage offered by your employer that:

• Would cost you, for your policy alone, less than 8.39% of your income for the monthly premium, and
• Meets a certain benefits standard.

If you have an option that meets these standards, you cannot qualify for government subsidies to get private insurance on Covered California. If your income is low enough, you may still qualify for Medi-Cal.

A health coverage plan that generally has a lower premium and provides most benefits only after a large deductible has been paid. This sort of plan is most useful for people who do not have regular medical expenses but wish to be covered in case of an accident or other sudden and significant medical needs. These plans may allow you to see your primary care provider up to 3 times per year and get preventive care without paying the deductible.

If you are under 30, you can sign up for a catastrophic plan on Covered California.

The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%. That 20% is known as "co-insurance."

A conversion insurance policy is something you can buy when your employer-sponsored group health insurance policy ends. It lets you keep buying insurance through the same insurance company. You may have to use up all your COBRA coverage first, before you can get a conversion policy, depending on the regulations in your state.

A set amount you have to pay when you receive medical services. For example, you may have to pay $30 every time you visit the doctor or $20 to get a prescription refilled. This is also known as a "copay."

The date an individual is enrolled in coverage. The effective date is usually not the same as the date of hire.

A person, usually a child, who is economically dependent on another person. Different programs have different definitions of when someone is a dependent.

A level of impairment that causes private insurers to provide benefits to people who have paid a monthly premium for coverage.

There are two common levels of disability according to private insurers:

1. Own-Occupation Disability (or “Own Occ” ) means your disability prevents you from performing your own occupation, which means you cannot do the work or job you have been trained to do and have experience in
2. Any-Occupation Disability (or “Any Occ”) means your disability prevents you from performing any occupation:
   • Sometimes Any Occ means that your disability prevents you from performing any occupation that pays at least a specified percentage of what you earned before your disability

Own-occupation insurance policies pay you if you are unable to perform your own occupation, even if you are able to get a different type of job. They have higher premiums than policies that require you to be unable to perform any occupation. Check with your insurer to see which definition of disability your plan has.

A part of the Affordable Care Act (ACA) that requires most employers with 100 or more employees to offer affordable insurance to their employees, or pay a fine.

Benefits that federal law requires all individual and small group health coverage plans provide. These benefits include:

• Ambulatory patient services (care you get without being admitted to the hospital)
• Emergency services
• Hospitalization
• Maternity and newborn care (care before and after your baby is born)
• Preventive and wellness services and chronic disease management, including:
  • Immunization vaccines for many diseases
  • Screening for different conditions
  • Counseling for some health issues
  • Women’s preventive care
  • Children’s preventive care
• Prescription drugs
• Laboratory services
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Pediatric services for children, including oral and vision care

A law that protects the privacy and confidentiality of your health information, such as medical records and test results. It regulates how health care providers are allowed to handle and share your protected health information.

HIPAA also prevents group health plans from denying you coverage based on your health condition and provides protections for those buying individual health coverage. However, these parts of HIPAA are protections that are no longer needed, since the Affordable Care Act provides all the same protections, plus more.

A common type of health care coverage plan. HMOs require that you only see certain doctors and that your primary care physician decides when you need to see a specialist.

A health coverage plan with a relatively low premium that usually doesn’t pay for the first few thousand dollars of health care expenses (this is your deductible) but will typically cover your expenses after you pay a certain set amount.

Private health insurance an individual or family purchases. The individual or family pays a monthly premium and the plan agrees to pay a portion of the cost of approved medical services when needed, like for preventive care, lab tests, surgery, or prescription drugs. The easiest way to purchase an individual plan is through Covered California.

The government may help individuals and families with low to middle income who get their coverage through Covered California pay for their monthly premiums and a portion of the cost of approved medical services.

The individual mandate was a part of the Affordable Care Act (ACA) that required most Americans to have health coverage or pay a fine. This fine was sometimes called the ACA “tax penalty.”

Starting in 2019 there is no tax penalty if you don't have coverage.

Note: The state of California has its own individual mandate. Learn more about the California individual mandate and tax penalty.

The first time an individual is eligible to enroll in a group’s benefits programs.

Any medical care that you receive for a medical condition. Some examples include being prescribed medication, visits to the doctor, and therapy for a mental health problem.

The health care related costs you pay yourself without help from Medicare, Medi-Cal, or other health insurance.

The maximum amount of money that you have to spend on health costs in a year. After you reach the out-of-pocket maximum, your policy will pay the entire cost of covered services. The out-of-pocket maximum does not count the premiums you pay, and certain other costs may or may not be counted.

Government-run insurance plans for people who couldn’t get insurance because of pre-existing medical conditions, PCIPs ended on January 1, 2014. Now, insurance companies cannot deny people health coverage because of pre-existing conditions. People who don’t have health insurance can get coverage through Covered California.

A type of health insurance plan. You pay a monthly premium and — when you use medical services — copayments and deductibles. PPOs have networks of physicians. You can see any doctor in the network without getting prior authorization from a primary care physician. Seeing a doctor outside of the network is more expensive.

A regularly scheduled payment to an insurer or health care plan.

The doctor, nurse practitioner, or other medical service provider who is in charge of your medical care in a Health Maintenance Organization (HMO). In HMOs, you have to see a PCP in order to get a referral to see a specialist. Other types of health coverage might not have PCPs, or might charge you more if you see a specialist without getting a referral from a PCP.

A health plan process of reviewing medical services or medications before they give you permission to go ahead with the service or use the medication. This is done to ensure that the service or medication is appropriate and necessary before the plan pays for it.

The care of clients by nurses. Most nurses who provide private duty care are working one-on-one with individual clients. Sometimes such care is provided in the client's home, or an institution, such as a hospital, nursing home, or other such facility.

Health coverage through a private company that pays for medical expenses. A monthly premium must be paid for this coverage by the individual or family covered, by an employer, or by an association. The individuals covered by private health plans must also make payments such as copayments or coinsurance each time they use certain medical services.

In some cases, the federal government may help low to middle-income families pay for private health coverage through tax subsidies if they are in very specific situations and do not have other affordable health coverage alternatives.

The period of time an individual is required to be employed by a company or be a member of an association before becoming eligible to enroll for the group’s health coverage. Also known as the minimum service requirement.

When you get private group health coverage through your employer, you can only sign up for, or make changes to, an insurance plan during the open enrollment period. However, under certain circumstances, such as marriage, birth of a child, or loss of other insurance, a group health plan offers a special enrollment period. This special enrollment period lets you sign up for group health insurance, or make changes to your plan, without having to wait for an open enrollment period.

A support provided by the government that helps people and families with low to middle income pay for their health coverage when they purchase it through Covered California. This support means that individuals and families may qualify to get health plans with lower premiums and other expenses. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG for federal subsidies and 600% of FPG for state subsidies.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

Premiums are lowered with a federal tax credit called the Premium Tax Credit (PTC). To get this credit, you must qualify and file your federal taxes with Form 8962.

In addition, families with income at or below 250% of FPG, $37,650 for an individual ($78,000 for a family of four), may also qualify to get health coverage with lower expenses, such as reduced copayments, coinsurance, or deductibles, as long as they choose to get a silver plan.