Glossary on everything health insurance and rate review related.
Relating to the mathematics of insurance, including probabilities. Actuarial work involves analyzing data to predict with a reasonable degree of accuracy the amount of claims that will be paid. This work ensures that the risks are carefully evaluated and that the premiums charged are reasonable in relation to the benefits provided.
A document prepared as a formal means of conveying the appointed actuary’s professional conclusions and recommendations of an insurance filing. It records and communicates the methods and procedures, it assures that the parties addressed are aware of the appointed actuary’s opinion or findings, and it documents the analysis of the opinion.
Actuarial value represents the share of health care expenses the plan covers for a typical group of enrollees. The Patient Protection and Affordable Care Act (ACA) establishes various tiers of health insurance coverage. These tiers are used for three primary purposes: 1) To set the minimum amount of coverage many people must have to satisfy the requirement that they be insured or pay a federal tax penalty beginning in 2014. 2) To establish standardized levels of insurance individuals and small businesses can buy in health insurance purchasing Exchanges or in the outside market. 3) And, as benchmarks for premium and cost-sharing subsidies provided to lower and middle income people buying their own insurance in Exchanges.
Source: Henry J Kaiser Family Foundation
A person who computes premium rates, dividends, risks, etc., according to probabilities based on statistical records.
Administrative expenses include expenses associated with the general administration of the business. Examples include the salaries and fringe benefits of the company president, human resource personnel, accounting, information technology, the depreciation expense for equipment and space used in administration, as well as supplies, utilities, etc.
The federal health care reform law enacted in March 2010. The law was passed in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act" is used to refer to the final, amended version of the law.
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.
Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The law generally covers health plans maintained by private-sector employers with 20 or more employees, employee organizations, or state or local governments. Many states, including Minnesota, have "mini-COBRA" laws that apply to the employees of employers with less than 20 employees.
This is a comprehensive term referring to all the legislation and all the activities by both state and federal agencies to improve the health care system. It includes:
• changes in federal law such as the Affordable Care Act,
• changes in Minnesota statutes such as the comprehensive package of reforms passed in 2008, also called “Minnesota’s Vision for a Better State of Health”
• all regulations, rules and guidance issued by both state and federal agencies to implement the various health reform laws.
A health plan that provides coverage for individuals who have been denied coverage in the private market, usually due to a pre-existing health condition. Minnesota's high risk pool is the Minnesota Comprehensive Health Association (MCHA). The Affordable Care Act prevents companies from denying coverage for a pre-existing health condition after January 1, 2014.
The federal Affordable Care Act requires that at least 80 percent of the premiums that small groups and individuals pay be used to pay for medical care, rather than administrative cost, surplus, or profit. This relationship between what an insurer pays for medical care and the total premium paid is called the medical loss ratio.
A federal government program that provides health care coverage for all eligible individuals age 65 or older or under age 65 with a disability, regardless of income or assets. Eligible individuals can receive coverage for hospital services (Medicare Part A), medical services (Medicare Part B), and prescription drugs (Medicare Part D). Together, Medicare Part A and B are known as Original Medicare. Benefits can also be provided through a Medicare Advantage plan (Medicare Part C). These plans are regulated by the Center for Medicare and Medicaid Services (CMS).
If your plan was effective after the Affordable Care Act (ACA) was signed on March 23, 2010, or your plan existed before the ACA, but lost its grandfathered status at renewal, it is a non-grandfathered or “other” plan.
A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), other health care professional, or health care facility licensed, certified or accredited as required by state law.
Review by insurance regulators of proposed premiums and premium increases. During the rate review process, regulators will examine proposed premiums to ensure that they are sufficient to pay all claims, that they are not unreasonably high in relation to the benefits being provided, and that they are not unfairly discriminatory to any individual or group of individuals.
A process through which insurance plans that enroll a disproportionate number of sick individuals are reimbursed for that risk by other plans that enroll a disproportionate number of healthy individuals. The Affordable Care Act requires states to conduct risk adjustment for some non-grandfathered health insurance plans.
A period of time that an you must wait either after becoming employed or after applying for a health insurance plan before your plan becomes effective and claims may be paid.