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. Ohio 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.
Basic Health Plan. A health plan established by the state of Ohio to offer people the choice of buying coverage for a minimum set of specified benefits. The basic health plan imposes a high level of cost sharing, including a $1000 annual deductible, 50% coinsurance for most covered services, and an annual limit of $50,000 on all covered benefits. Benefits and cost sharing under the basic health plan vary somewhat, depending on whether you are purchasing coverage from an HIC. The basic health plan must be offered by all individual health insurance companies during their annual open enrollment periods. See HIC, Individual Health Insurance, Open Enrollment Period.
Breast and Cervical Cancer Prevention Project. A program which provides free screening for breast and cervical cancer to eligible Ohio residents. Eligible women diagnosed with breast or cervical cancer may be eligible for free health coverage through Medicaid for treatment of their condition.
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. Under Ohio rules, coverage is continuous if not interrupted by a break of more than 30 days in a row. Ohio rules apply when you are buying an individual health insurance policy and you are not HIPAA eligible. See also Creditable Coverage, HIPAA eligible.
Conversion Coverage. Your right, when leaving a fully insured group health plan in Ohio, to convert your policy to an individual health insurance policy. You will not face a new pre-existing condition exclusion period. Unless you are HIPAA eligible, you must be offered a hospital, surgical, or medical expenses policy currently being sold by the insurance company. If you are HIPAA eligible, you must be offered a choice between a standard and basic health plan. Conversion coverage also extends to surviving, divorced or separated spouses; dependent children; and children who lose their dependent status under their parent’s plan rules. See also HIPAA eligible.
Creditable Coverage. Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance in Colorado; Medicare; Medicaid; CHAMPUS and TRICARE (health coverage for military personnel, retirees, and dependents); the Federal Employees Health Benefits Program; Indian Health Service; the 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.
Elimination Rider. An amendment to an individual health insurance policies that permanently excludes coverage for a health condition, body part, or body system.
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. A health plan purchased by an employer from an insurance company. Fully insured group health plans are regulated by the state of Ohio. See also Self-Insured Group Health Plans.
Genetic Information (Group Health Plans). 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.
Genetic Information (Individual Health Insurance). Includes laboratory tests of a person’s genes or chromosomes that are linked to physical or mental disorders or impairments, or that indicate 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 insurance (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 Ohio are guaranteed issue. Standard and Basic individual health inurance policies must be sold on a guaranteed issue basis year-round to HIPAA eligible individuals, and to other people during annual open enrollment periods. 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 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.
Healthy Start. Healthy start 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 who live in families with qualifying incomes and pregnant women.
Healthy Families Healthy Families is Medicaid insurance intended to meet the needs of working families who cannot afford health insurance coverage.
HIC. Health Insuring Corporation. A term in Ohio law for several kinds of health insurance plans. Any insurance company that uses managed health care techniques must be registered as an HIC. HICs may require you to seek covered care from hospitals, doctors and other providers that they contract with, also known as network providers. Or they may require you to pay more for covered services provided outside the HIC network. HICs also often require you to get a referral from your primary care physician in order to see a specialist. All HICs must offer a state-defined package of health care services during a 30-day annual open enrollment period. See also HMO, Open Enrollment Period.
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 eligible confers greater protections on you than you would otherwise have in Ohio 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 Ohio can require affiliation periods in the group market. See also Affiliation Period.
Indemnity Health Plan. A kind of health plan that reimburses you or your health care provider on the basis of services rendered. Indemnity plans generally do not restrict you to a limited network of providers for covered care. However, indemnity plans often impose other restrictions on covered services. For example, plans can require prior authorization of hospital care or other expensive services.
Individual Health Insurance. Policies for people not connected to an employer group. This term also refers to coverage purchased by the self-employed for themselves (or their family members) but for no other employees. Individual health insurance policies are regulated by the state of Ohio. All residents without access to employer-sponsored or government-sponsored health insurance can buy such coverage for themselves and their families from a variety of private carriers during a plan’s annual open enrollment period, and may be able to purchase such coverage at other times as well. See Open Enrollment Period.
Kassebaum-Kennedy. See HIPAA.
Large Group Health Plan. One with more than 50 employees.
Late Enrollment. Enrollment in a health plan at a time other than a regular or special enrollment period. Ohio requires fully insured group plans to cover you if you are a late enrollee. However, insurance companies are only required to enroll you within 12 months of your request to enroll, and 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. See HIC.
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.
Ohio’s “Best Rx” Program. A prescription drug discount card program designed to lower the cost of prescription for Ohio’s eligible residents.
Open Enrollment Period (Individual Health Insurance). A period each year during which all private individual health insurers must accept individuals who apply for coverage. Individual insurers must offer you the same standard and basic health plans that are offered to small employers. An indemnity health plan open enrollment period begins in January of each year and remains open until the plan has enrolled a specified number of individuals required by law. To date, very few health plans have reached this maximum. An HIC must have an open enrollment period of at least 30 days in length each year, beginning on the anniversary date of receiving its license to operate in Ohio.
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. See also Genetic Information.
Pre-existing Condition (Individual Health Insurance). Any condition for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period immediately preceding enrollment in a health plan, or for which an ordinarily prudent person would have sought medical advice, care or treatment during that period. Under individual health insurance only, pregnancy can be counted as a pre-existing condition and a waiting period of up to 270 days can be imposed for maternity benefits. Newborns and newly adopted children covered within 30 days cannot be subject to pre-existing condition exclusions. Genetic information cannot be counted as a pre-existing condition in individual health insurance. See also Prudent Person Rule. HICs/HMOs may not use pre-existing condition exclusion periods for basic health services.
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 Rule. 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 in the 6 months prior to enrolling in an individual health insurance policy. See Pre-existing Condition (Individual health insurance).
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 Ohio.
Small Group Health Plan. Plans with at least 2 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.
Standard Health Plan. A health plan established by the state of Ohio that covers a specified set of benefits. Compared to the basic health plan, the standard health plan offers more extensive coverage with lower cost sharing. Standard health plans offered by HICs and HMOs have somewhat different benefits and cost sharing. The standard health plan must be offered by all individual health insurance companies during their annual open enrollment periods. See Basic Health Plan, HIC, HMO, Individual health insurance, Open Enrollment Period.
State Continuation Coverage. A program similar to COBRA. In Ohio, if you are eligible for unemployment insurance and in a fully insured group health plan sponsored by an employer with less than 20 employees, you also have rights to continue your health coverage for up to six months when your job ends. 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.
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. Employers with fully insured group health plans may not have a waiting period that exceeds 90 days. See also Pre-existing Condition Exclusion Period.
