ACA
A skinny medical plan that satisfies a requirement and avoids the larger penalty for employers to offer coverage.
Minimal Essential Coverage (MEC)
This type of medical funding plan where the employer pays a defined monthly premium to the insurance carrier.
Fully Insured
The statement sent to a member explaining how a claim was processed.
EOB (Explanation of Benefits)
It's indemnification coverage for employers to limit their financial liability on each member individually
Specific Stop Loss
HIPAA
Health Insurance Portability and Accountability Act
A form that covers the medical benefits and is required to be given to each member at least once a year.
Summary of Benefits and Coverage.
A type of medical plan where the employer sets aside a certain amount of money each year for the member to use for medical expenses (typically deductible and coinsurance).
HRA
These are the two main reports that any self-funded group can get on a monthly basis.
Aggregate report and 50% report.
Term for the portion of the monthly costs that is the same every month.
Fixed costs
ERISA
Employee Retirement Income Security Act
The only remaining fee/tax from the ACA that is imposed on employers.
PCORI Fee.
A type of plan with fixed monthly payments and a potential refund if claims are lower than expected.
Level Funded
The process of reviewing medical necessity before a service is performed.
Preauthorization
Self-funded employers sometimes partner with this type of vendor to manage pharmacy benefits.
PBM (Pharmacy Benefit Manager)
COBRA
Consolidated Omnibus Budget Reconciliation Act
The ACA (aka Obamacare) mandates what free services for EEs enrolled in benefits?
Preventive care (Annual check-up)
The entity that processes claims and maintains eligibility for level-funded or self-funded plan.
*Hint, three letter acronym.
TPA
The process of comparing a claim against eligibility, plan rules, and provider contracts before payment.
Adjudication
This federal agency enforces ERISA compliance.
Department of Labor
PCORI
Patient-Centered Outcomes Research Institute
What is a control group under ACA guidelines and IRS Code?
A controlled group exists when any two or more entities are connected through common ownership. (i.e. in a parent-subsidiary, a brother-sister, or a combination of the two controlled groups)
The “I” in ICHRA stands for this.
Individual
The maximum amount a plan will pay for a covered service.
Allowed Amount
This type of stop-loss protects when total claims for all employees exceed expectations.
Aggregate
EOI
Evidence of Insurability