Gross Income: your total income from all sources minus any
adjustments, i.e. specific deductions (including contributions to deductible
retirement accounts, alimony paid by you); but not including standard
and itemized deductions (on Federal Tax forms" 1040-find line 37;
For Form 1040A-find line 21; For Form 1040EZ-find line 4; if you use
other Federal Tax forms check with your accountant/tax preparitor to
find the correct line for adjusted gross income).
Health Insurance: health plans that only cover "major
medical" expenses, usually through high deductibles and low monthly
premiums. These plans typically cover only major hospital and medical
expenses above a certain deductible, while the insured pays out-of-pocket
for everything else, such as routine doctor visits and prescription
in some health care literature people receiving medical care are referred
to as consumers.
a flat dollar amount paid for a medical service by an insured person.
Insurance companies use co-payments to share health care costs although
the co-pay is often only a small portion of the actual cost of the
the portion of any medial claim that is not covered by the insurance
provider. It is normally quoted as a fixed amount and is a part of
most policies covering losses to the policy holder. The deductible
must be "met", that is, paid by the insured, before the
benefits of the policy can apply.
Medical Equipment: Medical equipment that is ordered by a
doctor for use in treatment. DME's are covered separately from prescription
drugs. Examples are walkers, wheelchairs, or insulin pumps.
HIRD form (Health Insurance Responsibility Disclosure): The
form an employer with more than 11 Full time Equivalent Employees
will have an employee fill out who declines to enroll in the employer's
sponsored subsidized health plan (ie the employer is paying part of
the premium cost) and/or that employee declines to participate in
the employer's Section 125 Plan. When completing the HIRD form the
employee must indicate whether they have an alternative source of
Sponsored Insurance (ESI): The term used to denote the health
insurance an employer offers their employees.
Poverty Line (FPL): The set minimum amount of income that
a family needs for food, clothing, transportation, shelter and other
necessities. FPL varies according to family size. The number is adjusted
for inflation annually. Public assistance programs, such as Medicaid,
define eligibility income limits as some percentage of FPL. These
amounts are adjusted annually in April. (They are increased to keep
pace with the standard of living)
Income: your total income from all sources (pre-taxes -i.e.
before taxes are taken out- social security, Medicaid, etc.).
type of Managed Care Organization (MCO) that provides a form of health
insurance coverage fulfilled through hospitals, doctors, and other
providers with which the HMO has a contract. Under this model, providers
contract with an HMO to receive more patients and in return usually
agree to provide services at a discount. This arrangement allows the
HMO to charge a lower monthly premium. The providers and organizations
that the HMO has a contract with are referred to as 'in their network."
Safety Net (HSN): was formerly called the Uncompenstated
Care Pool or the Free Care Pool. The HSN, like the Free Care pool
was, is administered by the Division of Health Care Finance and Policy
(DHCFP). This program helps to pay for some medical services for low
and lower income people (with incomes up to 400 percent of the Federal
Poverty Level (FPL) who sought care at a Hospital or a Community Health
Center. Note there are new eligibilty requirements for the HSN. See
Beginning on July 1, 2007, Massachusetts residents age 18 and older
are required to have health insurance that is deemed affordable
to them at their income level or they risk being fiscally
penalized on their income taxes. It is important to be
aware that starting on January 1, 2009, individuals will have to have
health insurance that is deemed affordable to them at their income
level AND meets "Minimal Creditable Coverage" standards set by the
Connector. The Department of Revenue (DOR) will be policing this part
of the law.
There is a waiver process from the individual mandate.
those who have health insurance.
Care: an effort to control escalating health care costs by
the health insurance industry, which defines a reasonable maximum
fee that health care providers may charge for any given service. Providers
are bound to accept these maximum fees if they wish to be listed in
directories of specific insurance companies, which are provided to
their policy holders as referral directories of "approved"
physicians. (Administered primarily by private companies called "Managed
Benefit Request (MBR): the form that is required to determine
if an individual or family is eligible for a the Health Safety Net
(HSN), a MassHealth Program, Commonwealth Care, or the Insurance Partnership.
Modified Adjusted Gross Income (MAGI) is now the measure used to see if individuals are eligible for subsidies/tax credits to pay for their insurance. This is very helpful for those who are self-employed or have 1099 income. To learn what MAGI is: http://laborcenter.berkeley.edu/pdf/2013/MAGI_summary13.pdf
Creditable Coverage (MCC) also referred to as creditable and affordable
coverage or creditable coverage: The Connector set the standards
that define what "creditable and affordable" health insurance
coverage is. This is also referred to as minimum creditable coverage
or MCC. Please see our section
of Pocket Medical Expenses: medical expenses that are not
covered by insurance and paid for directly by the individual.
-a monthly amount paid by insured persons toward the costs of their
(preferred provider organization): insurance plans in which
the policy-holder is free to choose his/her own physician, although
they will generally receive greater benefits returns if they see a
pre-approved "in-network" caregivers and facilities. These
"network" caregivers and facilities are independent
of insurance company ownership, and may hold contracts for reimbursement
with multiple insurers.
(Point of Service Plan): POs plans are almost a hybrid of
HMO and PPO plans. Like an HMO, the individual designates an "in-network
physician" to be their primary care provider. However, like a
PPO, a POs plan lets the individual go "out-of-network".
But when the individual goes out-of network, they will have to pay
most of the cost, unless your primary care physician refers them to
an out-of-network doctor. Then, the health plan will pick up the tab.
125 Cafeteria Plans an individual deposits funds into an
account (usually the account is offered by their employer) to pay
for their health insurance premiums. These accounts are tax exempt.
Payer Health Care: a health care system in which a single
entity, typically a government-run organization, acts as the administrator
(or "payer") to collect all health care fees, and pay out
all health care costs.
Care Pool/ Free care pool: reimbursed hospitals and community
health centers that provide care to eligible low-income uninsured
and uninsured people. It was adminstered by the Division of Health
Care Finance and Policy (DHCFP).Due to the health care reform law,
it is now called the Health Safety Net and there are new eligibility
an individual with health insurance that is inadequate to meet their
health care needs.
an individual with no health insurance-approximately 550,000
Health Care: a health care system in which all residents
of a geographic or political entity have their health care paid for,
regardless of medical condition or financial status.