Affiliation Period.  The time an HMO may require you to wait after you enroll and before your coverage begins.  HMOs that require an affiliation period cannot exclude coverage of pre-existing conditions.  Premiums cannot be charged during HMO affiliation periods. Delaware law allows for the use of HMO affiliation periods in group health plans.  See also HMO, Small Group Health Plan.

Alternative Trade Adjustment Assistance (ATAA). ATAA is a benefit for workers at least 50 years old who have obtained different, full-time employment within 26 weeks of the termination of adversely-affected employment. These workers may receive 50% of the wage differential (up to $10,000) during their 2 year eligibility period. To be eligible for the ATAA program, workers may not earn more than $50,000 per year in their new employment. Also, the firm where the workers worked must meet certain eligibility criteria.

Certificate of Creditable Coverage.  A document provided by your health plan that lets you prove you had coverage under that plan.  Certificates of creditable coverage will usually be provided automatically when you leave a health plan.  You can obtain certificates at other times as well.  See also Creditable Coverage.

COBRA.  Stands for the Consolidated Omnibus Budget Reconciliation Act, a federal law in effect since 1986.  COBRA permits you and your dependents to continue in your employer’s group health plan after your job ends.  If your employer has 20 or more employees, you may be eligible for COBRA continuation coverage when you retire, quit, are fired, or work reduced hours.  Continuation coverage also extends to surviving, divorced or separated spouses; dependent children; and children who lose their dependent status under their parent’s plan rules.  You may choose to continue in the group health plan for a limited time and pay the full premium (including the share your employer used to pay on your behalf) plus a two percent administrative fee.  COBRA continuation coverage generally lasts 18 months, or 36 months for dependents in certain circumstances.  See also State Continuation Coverage.

Continuous Coverage.  Under federal rules, health insurance coverage that is not interrupted by a break of 63 or more consecutive days.  Employer waiting periods and HMO affiliation periods do not count as gaps in health insurance coverage for the purpose of determining if coverage is continuous.  Federal rules apply to you if you are joining a group health plan and, if you are HIPAA eligible, when you buy an individual health insurance policy.  See also Creditable Coverage, HIPAA eligible.

Creditable Coverage.  Health insurance coverage under any of the following: a group health plan; individual health insurance; Medicare; Medicaid; CHAMPUS (health coverage for military personnel, retirees, and dependents); Federal Employees Health Benefits; Indian Health Service; Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); State Children’s Health Insurance Program; or a state health insurance high risk pool.  See also Continuous Coverage, Group Health Plan, Individual Health Insurance.

Delaware Cancer Treatment Program.  A state funded program which provides payment  for medical services related to the treatment of cancer for qualified Delaware residents.

Delaware Healthy Children Program.  Healthy Children insurance is intended to meet the needs of working families, who cannot afford health insurance coverage for their children, yet earn too much to qualify for Medicaid. Coverage is available for uninsured children age 18 and younger that live in families with qualifying incomes.

Elimination Rider.  An amendment permitted in individual health insurance policies issued by an insurer that permanently excludes health coverage for a health condition, body part, or body system.  See also Individual Health Insurance.

Enrollment Period.  The period during which all employees and their dependents can sign up for coverage under an employer group health plan.  Besides permitting workers to elect health benefits when first hired, many employers and group health insurers hold an annual enrollment period, during which all employees can enroll in or change their health coverage.  See also Group Health Plan, Open Enrollment Period, Special Enrollment Period.

Family and Medical Leave Act (FMLA). A federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness, to have or adopt a child, or to care for another family member.  When you qualify for leave under FMLA, you can continue coverage under your group health plan.

Fully Insured Group Health Plan. Health plan purchased by an employer from an insurance company.  Fully insured group health plans are regulated by the state of Delaware.  See also Self-Insured Group Health Plans.

Genetic Information. Includes information about family history or genetic test results indicating the risk of developing a health condition.  A health plan cannot consider pre-existing (and therefore exclude coverage for) a condition about which you have genetic information, unless that health condition has been diagnosed by a health professional.

Group Health Plan.  Health plan (usually sponsored by an employer, union or professional association) that covers at least 2 employees.  See also Fully Insured Group Health Plan, Self-Insured Group Health Plan.

Guaranteed Issue.  A requirement that health plans must permit you to enroll regardless of your health status, age, gender, or other factors that might predict your use of health services.  All health plans sold to small employers in Delaware are guaranteed issue.  Standard and Basic plans must be sold on a guaranteed issue basis to all small employers including self-employed individuals. Two state approved plans must be sold to HIPAA eligible individuals.  Plans that are guaranteed issue can turn you away for other reasons.

Guaranteed Renewability.  A feature in health plans that means your coverage cannot be canceled because you get sick.  Kassebaum-Kennedy requires all health plans to be guaranteed renewable. Your coverage can be canceled for other reasons unrelated to your health status.

Health Coverage Tax Credit (HCTC).  The Health Coverage Tax Credit (HCTC) is a program that can help pay for nearly two-thirds of eligible individuals’ health plan premiums.  In general, in order to be eligible for the credit, you must be 1) receiving Trade Readjustment Allowance (TRA) benefits or 2) will receive TRA benefits once your unemployment benefits are exhausted or 3) receiving benefits under the Alternative Trade Adjustment Assistance (ATAA) program or 4) aged 55 or older and receiving benefits from the Pension Benefit Guaranty Corporation (PBGC).

Health Insurance or Health Plan.  In this guide, the term means benefits consisting of medical care (provided directly or through insurance or reimbursement) under any hospital or medical service policy, plan contract, or HMO contract offered by a health insurance company or a group health plan.  It does not mean coverage that is limited to accident or disability insurance, workers’ compensation insurance, liability insurance (including automobile insurance) for medical expenses, or coverage for on-site medical clinics.  Health insurance also does not mean coverage for limited dental or vision benefits to the extent these are provided under a separate policy.

Health Plan Year.  That calendar period during which your health plan coverage is in effect.  Many group health plan years begin on January 1, while others begin in a different month.

Health Status.  When used in this guide, refers to your medical condition (both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability.  See also Genetic Information.

HIPAA.  The Health Insurance Portability and Accountability Act, better known as Kassebaum-Kennedy, after the two senators who spearheaded the bill.  Passed in 1996 to help people buy and keep health insurance, even when they have serious health conditions, the law sets a national floor for health insurance reforms.  Since states can and have modified and expanded upon these provisions, consumers’ protections vary from state to state.

HIPAA Eligible.  Status you attain once you have had 18 months of continuous creditable health coverage. To be HIPAA eligible, you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare, Medicaid, or a group health plan; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage.  When you are buying an individual health insurance policy, HIPAA eligibility confers greater protections on you than you would otherwise have in Delaware and in other states.  See also COBRA, Continuous Coverage, Creditable Coverage, State Continuation Coverage.

HMO.  Health maintenance organization.  A kind of health insurance plan.  HMOs usually require you to get care from doctors who work for or contract with the HMO.  They generally do not require deductibles, but often do charge a small fee, called a copayment, for services like doctor visits or prescriptions.  HMOs in Delaware can require affiliation periods in the group market. See also Affiliation Period.

Individual Health Insurance.  Policies for people not connected to an employer group. Individual plans are regulated by the state of Delaware.

Large Group Health Plan.  One for an employer with more than 50 employees.

Late Enrollment.  Enrollment in a health plan at a time other than a regular or special enrollment period. You may be subject to an 18-month pre-existing condition exclusion period upon enrollment. See also Special Enrollment Period.

Look Back.  The maximum length of time, immediately prior to enrolling in a health plan that can be examined for evidence of pre-existing conditions.  See also Pre-existing Condition.

Managed Care Plan.  A kind of health insurance plan.  Like an HMO, managed care plans can limit coverage to health care provided by doctors or hospitals who work for or contract with them.  Also called ‘network’ providers.  Often managed care plans will require you to get permission (a ‘referral’) from you family doctor before you receive care from a specialist in their network.  Some managed care plans will cover your care at a lower rate if you go to a non-network provider or if you get specialist care without a referral.

Medicaid.  A program providing comprehensive health insurance coverage and other assistance to certain low-income Delaware residents.  All other states have Medicaid programs, too, though eligibility levels and covered benefits will vary.

Nondiscrimination.  A requirement that group health plans not discriminate against you based on your health status.  Your coverage under a group health plan cannot be denied or restricted, nor can you be charged a higher premium, due to your health status.  Group health plans can restrict your coverage based on other factors (such as part time employment) that are unrelated to health status.  See also Group Health Plan, Health Status.

Pension Benefit Guaranty Corporation (PBGC). PBGC is a federal government corporation established by Title IV of the Employee Retirement Income Security Act of 1974 (ERISA) to encourage the continuation and maintenance of defined benefit pension plans, provide timely and uninterrupted payment of pension benefits to participants and beneficiaries in plans covered by PBGC. It currently guarantees payment of basic pension benefits earned by American workers and retirees participating in private-sector defined benefit pension plans. The agency receives no funds from general tax revenues. Operations are financed largely by insurance premiums paid by companies that sponsor pension plans and by PBGC’s investment returns.

Pre-existing Condition (Group Health Plans).  Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period immediately preceding enrollment in a group health plan.  Pregnancy cannot be counted as a pre-existing condition.  Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition.  Newborns, newly adopted children, and children placed for adoption covered within 30 days cannot be subject to pre-existing condition exclusions. Delaware does not limit the use of pre-existing conditions in individual health insurance policies.

Pre-existing Condition (Individual Health Insurance).  Any symptoms for which medical advice, diagnosis, care or treatment was ever recommended or received, or for which an ordinarily prudent person would have sought medical advice, care or treatment within a 5-year period preceding enrollment.  In Delaware, under individual health policies, pregnancy can be counted as a pre-existing condition. See also Prudent Person Rule.

Pre-existing Condition Exclusion Period.  The time during which a health plan will not pay for covered care relating to a pre-existing condition.  See also Pre-existing Condition.

Prudent Person Standard.  In individual health insurance only, a rule that permits insurers to exclude as pre-existing any condition for which - in the insurer’s judgment - most people would have sought care or treatment.

Screening For Life Program.  Program which provides free screening for breast and cervical cancer to eligible Delaware residents.  Eligible women diagnosed with breast or cervical cancer may be eligible for free health coverage through Medicaid for treatment of their condition.

Self-Insured Group Health Plans.  Plans set up by employers who set aside funds to pay their employees’ health claims.  Because employers often hire insurance companies to run these plans, they may look to you just like fully insured plans.  Employers must disclose in your benefits information whether an insurer is responsible for funding, or for only administering the plan.  If the insurer is only administering the plan, it is self-insured.  Self-insured plans are regulated by the U.S. Department of Labor, not by Delaware.

Small Group Health Plan.  Plans with at least 1 but not more than 50 employees.

Special Enrollment Period.  A time, triggered by certain specific events, during which you and your dependents must be permitted to sign up for coverage under a group health plan. Employers and group health insurers must make such a period available to employees and their dependents when their family status changes or when their health insurance status changes.  Special enrollment periods must last at least 30 days.  Enrollment in a health plan during a special enrollment period is not considered late enrollment.  See also Late Enrollment.

State Continuation Coverage.  A program similar to COBRA.  In some states, if you are in a fully insured group health plan sponsored by an employer with 2 to 19 employees, you also have rights to continue your health coverage when your job ends.  However, Delaware does not have a state continuation coverage requirement.  See also COBRA.

Supplemental Security Income (SSI).  A program providing cash benefits to certain very low income disabled and elderly individuals.  When you qualify for SSI, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time if your income increases so that you no longer qualify for SSI.  See also Medicaid.

Temporary Assistance for Needy Families (TANF). A program that provides cash benefits to low income families with children.  When you qualify for TANF, you generally also qualify for Medicaid.  In addition, Medicaid coverage often continues for a limited time or longer if you no longer qualify for TANF.  See also Medicaid.

Trade Adjustment Assistance (TAA) Program. A program authorized by the Trade Adjustment Assistance Reform Act of 2002.  This program provides aid to workers who lose their job or whose hours of work and wages are reduced as a result of increased imports.  The TAA Program offers six benefits and reemployment services to assist unemployed workers prepare for and obtain new suitable employment.  In addition, TAA offers a significant tax credit that covers 65% of health insurance premiums for certain plans.

U.S. Department of Labor.  A department of the federal government that regulates employer provided health benefit plans.  You may need to contact the Department of Labor if you are in a self-insured group health plan, or if you have questions about COBRA or the Family and Medical Leave Act.  See also COBRA, Family and Medical Leave Act.

Waiting Period.  The time you may be required to work for an employer before you are eligible for health benefits.  Not all employers require waiting periods.  Waiting periods do not count as gaps in health insurance for purposes of determining whether coverage is continuous.  If your employer requires a waiting period, your pre-existing condition exclusion period begins on the first day of the waiting period.  See also Pre-existing Condition Exclusion Period.