Delta Dental of Kentucky

ACA Definitions

ACA – Affordable Care Act – The health care reform law was enacted in March 2010. The first part (The Patient Protection and Affordable Care Act, or PPACA) was signed into law on March 23, 2010. The second part (the Health Care and Education Reconciliation Act) was passed on March 30, 2010. Both parts together are called the ‘Affordable Care Act’ (ACA).

EHB – Essential Health Benefits –10 benefit categories that must be covered by certain plans:

  • Ambulatory patient services
  • Prescription drugs
  • Emergency services
  • Rehabilitative and habilitative services and devices
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Preventive and wellness services and chronic disease management
  • Mental health and substance use disorder services, including behavioral health treatment
  • Pediatric services, including oral and vision care

For a plan to be sold in the Exchange, or to be Exchange-certified, it must cover these 10 categories. Also, for the most part, plans cannot impose lifetime maximums (aka lifetime limits) on these services.

EHBCompliant Pediatric Dental Benefits– Under the Affordable Care Act (ACA), pediatric dental benefits must be covered as an Essential Health Benefit (EHB) at one of two benefit levels (determined actuarially). These benefits are certified as Pediatric EHB-compliant plans by the Kentucky Department of Insurance. In Kentucky, they are for covered subscribers or dependents under age 21.  There is no annual or lifetime maximum benefit and there is an annual maximum limit on how much out-of-pocket the member pays each year.

Health Plan Benefit Level Categories – The level—Bronze, Silver, Gold, or Platinum—given to each plan in the Exchange to describe what percentage of benefits the insurance will pay. Standalone Dental Plans will only have two levels, Low and High. The higher the plan level, the more expenses it will cover, and the more it may cost in premium.

FFM (Federally Facilitated Marketplace) – A transparent and competitive health insurance marketplace where individuals and small businesses can buy (qualified) insurance plans.   All plans must meet certain benefits and cost standards, and you’ll be easily able to compare one to the other.  Also referred to as kynect. 

Medically-Necessary – Services needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms, and that meet accepted standards of medicine. (U.S. Centers for Medicare and Medicaid Services at HealthCare.gov)

OOP – Out-of-Pocket Limit – The most you will pay during a policy period (usually a year) for Essential Health Benefits received from an in-network provider before your insurance starts paying 100% of the allowed amount. This limit doesn’t include your premium, balance-billed charges, or care you receive that’s not covered by your insurance.

Premium Tax Credit – A new tax credit provided by the ACA intended to help those with earnings less than 400% of the poverty level afford coverage purchased through the Exchange. These credits can be received in advance to help pay for coverage.

Qualified Individual – A person who:

  • Lives in an Exchange’s service area
  • Is a U.S. citizen or national OR is a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought
  • Is not incarcerated

QHP – Qualified Health Plan – A plan that is allowed to offer products in the Exchange. It must:

  • Be offered by a company that is licensed by the state and in good standing
  • Cover Essential Health Benefits
  • For dental, offer at least one plan at the “low” level and one at the “high” level of cost-sharing
  • Follow limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximums)
  • Agree to charge the same premium whether offered inside or outside the Marketplace

SHOP – Small Business Health Options program – The government Exchange for small businesses and their employees.

Standalone Dental Plan – Dental insurance plans that are offered and purchased separately from other health coverage.

 

Don’t see what you’re looking for?

Click here to see more definitions about healthcare reform
 

More Definitions:

A–D (Abscess—Dependents)
E–L (Gingivitis—Limitations)
M–R (Malocclusion—Root Canal Therapy)
S–Z (Scaling—Waiting Period)

 

 

 

 

 

 


Disclaimer: This information is not intended to serve as legal advice and only constitutes Delta Dental of Kentucky’s opinion on this subject. Please consult your attorney and/or accountant for more information about how the ACA may impact you or your business.