Advance Premium Tax Credit (APTC): The federal government offers a tax credit to help pay for private health insurance for individuals and families within certain income limits who also meet certain other requirements. The tax credit can either be automatically applied towards your insurance premiums to lower your monthly payment, or you can claim it when you file your federal tax return. You must apply for financial assistance to confirm eligibility and to receive the tax credit.
Affordable Care Act (ACA): The name used to refer to the federal health laws that require most Americans to have health insurance that provides Minimum Essential Coverage. The name refers to two distinct pieces of legislation- the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).
Agent: Another word for a Broker.
American Indian & Alaska Native (AIAN): A member of a federally recognized tribe, or Alaska Native tribe, band, nation, Pueblo, village, or community that the Department of the Interior acknowledges as an Indian tribe, including Alaska Native Claims Settlement Act (ANCSA) regional village corporations.
Appeal: If you don’t agree with a decision about your eligibility for enrollment in coverage, or assistance in paying for coverage, you have a right to appeal the decision and receive a hearing before an independent administrative law judge.
Assister: Another term for Maine Enrollment Assister.
Authorized Representative: Someone you choose to act on your behalf. The person could be a family member, a Broker or other person you trust, or someone who has legal authority to act on your behalf.
Broker: Brokers are licensed under Maine law to sell health insurance to individuals, families, small businesses and their employees. Brokers can recommend plans or plan types, and perform activities on behalf of their clients. Only Brokers who have been trained and certified by CoverME.gov are authorized to assist consumers using the Marketplace. A directory of trained and certified Brokers can be found on our Find Local Help Tool. There is no cost to use a Broker.
Bronze Health Plan: Bronze Health Plans pay about 60 percent of in-network expenses for an average population of consumers. The premiums are typically among the lowest but the deductible and out-of-pocket limit of what you'll pay before the plan starts paying are among the highest. Metal levels only focus on what the plan is expected to pay, and do NOT reflect the quality of health care or service providers available through the health insurance plan. Once you meet your in-network out-of-pocket limit for the plan year, plans pay 100 percent of the allowed amount for covered services.
Catastrophic Plan: A health plan with low monthly premiums and high annual deductibles designed to protect consumers from worst case situations like a serious illness or an accident. Catastrophic plans are only available to people under 30 or people with a hardship exemption. Catastrophic plans provide essential health benefits and count as having coverage for tax purposes. Plans cover at least 3 primary care visits during the plan year and certain preventive services at no cost. Consumers pay all other medical costs until the annual deductible is met. Then the plan pays 100 percent for covered services for the rest of the plan year. Advance premium tax credits and cost-sharing reductions can’t be used with this plan type.
Centers for Medicare and Medicaid Services (CMS): The federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs, and the federally facilitated marketplace.
Children’s Health Insurance Program (CHIP): An insurance program that provides no cost or low cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private health insurance. In Maine, you can apply for CHIP coverage (referred to as Cub Care) any time of the year through the Office for Family Independence.
Coinsurance: Your share of the costs for covered services that you pay when you receive them. Coinsurance is calculated as a percent of the total fee. For example, if your health insurance plan’s allowed amount to visit your doctor is $100, a coinsurance payment of 20 percent would be $20. Some plans require that you pay up to the plan's deductible amount before coinsurance begins. Once you reach your out-of-pocket limit, you no longer have to pay coinsurance for the rest of the plan year.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA): The acronym for the Consolidated Omnibus Budget Reconciliation Act, a federal law that may allow you to keep employer-sponsored health insurance if you lose your job. In most cases, you'll pay the full costs every month plus a small administrative fee if you elect to continue the coverage. COBRA coverage is typically available up to 18 months (longer only in special circumstances). You may want to compare the cost of continuing your COBRA coverage with private health plans available through CoverME.gov. If you live in Maine and leave your job for any reason, you have 60 days from the date you lost coverage to either enroll in COBRA (if eligible) or sign up for a private plan through CoverME.gov. However, if you enroll in a COBRA plan, and then voluntarily drop it, or stop paying the premiums, you can’t enroll in a private plan through CoverME.gov until the next annual open enrollment.
Copayment: A fixed dollar amount you pay for a covered service, usually when you receive the service. The amount can vary depending on the type of service. (For example, $25 to visit your doctor, $10 for prescription drugs). Once you reach your out-of-pocket limit, you no longer have copays for the rest of the plan year.
Cost Sharing Reductions (CSR): A discount that lowers your costs for deductibles, coinsurance, copayments, and also lowers what you have to pay to reach your out-of-pocket limit. To get these savings, you must apply for financial assistance. CoverME.gov will help you determine if you qualify as part of the application process. Then you can enroll. Customers must enroll in a Silver Health Plan to receive cost-sharing reductions. Native Americans receive additional cost-sharing reductions regardless of a plan's metal level.
Coverage: Another word for health insurance (through the Marketplace, an Employer, or a program like MaineCare or Medicare).
Covered Services: The health care services you’re entitled to receive based on the terms of your health insurance plan. All plans available through CoverME.gov cover essential health benefits. Other covered services or excluded services will vary among plans. Each plan available through CoverME.gov includes a Summary of Benefits and Coverage, but it's only a summary. You'll need to see your plan documents for all benefits information. You can also call the insurance company directly if you have questions.
Deductible: The amount you must pay during the plan year for covered services you use before your insurance company begins to contribute towards costs. For example, if your annual in-network deductible is $1000, your health insurance company may not pay anything for covered services until you reach this amount. The deductible may not apply to all services. For example, most plans include certain preventive services at no cost even before you meet your deductible. Some plans also have separate deductibles for specific benefits like prescription drugs.
Dependent (also referred to as Tax Dependent): A person (other than you or your spouse) such as a child, parent or other relative, for whom you're entitled to claim a personal exemption on your federal tax return. If you're unsure, the IRS has a tool to help determine who you can claim as a dependent.
Effectuated Date: This is the date that your health coverage goes into effect. Typically, this happens after the first payment is made (sometimes called a binder payment).
Enrollee: A person enrolled in a Qualified Health Plan (QHP) or off-Marketplace plan.
Essential Health Benefits (EHBs): All health insurance plans available through CoverME.gov are required by federal law to include what are called essential health benefits. These include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitation services and habilitative services and devices; laboratory services; preventive services and chronic disease management; and pediatric services, including dental and vision care for children. This doesn’t mean that all plans are the same. Some plans may offer a higher level of service or additional services beyond the minimum required, or exclude other optional services that may be important to you. It’s important to understand these differences when comparing and choosing a plan to meet your needs and budget.
Exchange: Another word for a Health Insurance Marketplace.
Federal Poverty Level (FPL): A measure of income used to determine eligibility for certain financial assistance programs. The guidelines are issued each year by the US Department of Health and Human Services. Learn more about this year's FPL guidelines.
Federally Qualified Health Center (FQHC): Nonprofit health centers or clinics that receive federal funding to serve medically underserved areas and populations. The centers provide low cost to no cost primary care services on a sliding scale fee, based on your ability to pay. There are several federally qualified health centers in Maine.
Federally Recognized Tribe: An American Indian or Alaska Native tribal entity that is recognized as having a government-to-government relationship with the United States. Members are eligible for enhanced savings, benefits and protections through CoverME.gov, and should apply for financial assistance prior to choosing a health plan to determine eligibility and the savings, benefits and protections available.
Financial Assistance: An umbrella term used by CoverME.gov to describe Medicaid, and federal programs that help you pay for private health insurance like advance premium tax credits and cost-sharing reductions. In Maine, there are many other financial assistance programs for health care and other services. You can learn more about these programs from Maine's Department of Health and Human Services.
Gold Health Plan: Gold Health Plans pay 80 percent of in-network expenses for an average population of consumers. The premiums are typically higher but the deductible and out-of-pocket limit of what you'll pay before the plan starts paying are lower. Metal levels only focus on what the plan is expected to pay, and do NOT reflect the quality of health care or Service providers available through the health insurance plan. Once you meet your in-network out-of-pocket limit for the plan year, plans pay 100 percent of the allowed amount for covered services.
Group Health Plan: An umbrella term generally used to describe a health plan offered by either an employer or an employee organization (such as a union) that provides medical coverage to plan participants.
Hardship Exemption: If you are 30 or older and want to buy a Catastrophic health plan, you must apply for a hardship exemption to qualify. Hardship Exemptions are filed through HealthCare.gov, not CoverME.gov. Learn about hardship exemptions and Catastrophic plans.
Health Insurance Marketplace: A state-based or federally-facilitated exchange where individuals, families, small businesses and their employees can get quality, affordable health insurance. Maine's health insurance marketplace is available at CoverME.gov.
Health Insurance Portability and Accountability Act: A federal law that sets rules about who can see, use or share your health information and provides other protections to consumers. Commonly referred to as HIPAA, the law gives you rights over your health information, and requires doctors, pharmacists, other health care providers, and your health plan to explain your rights. The law has specific privacy and security requirements to safeguard your electronic health information, and to notify you if there's ever a breach.
Health Maintenance Organization: An HMO (Health Maintenance Organization) is a type of health plan that usually only covers care from in-network Service providers. It generally won't cover out-of-network care except in an emergency, and may require you to live or work in its service area to be eligible for coverage. You may be required to choose a primary care physician.
Health Reimbursement Arrangement (HRA): An optional, employer-sponsored benefit funded by the employer that reimburses plan participants for qualified medical expenses up to a fixed amount. The reimbursements are tax free, and any unused funds can be rolled over for use in future years.
Health Savings Account (HSA): If you have a High Deductible Health Plan, you may be eligible for a Health Savings Account (HSA) where you can deposit pre-tax dollars to pay for qualified medical expenses like your deductible, copayments and coinsurance. There's an annual limit on contributions established by the IRS, but any funds deposited can be used in future years. If you have an HSA through your employer, the funds belong to you and can rollover into another qualifying account if you ever leave.
High Deductible Health Plan: A feature of some health plans. HDHPs have a higher annual deductible and typically lower monthly premiums. You pay more for health care up front before your insurance company starts to pay. With an HDHP, you're eligible to open a tax deductible Health Savings Account to pay for qualified medical expenses like your annual deductible, copayments or coinsurance. The IRS defines the limits for plans that qualify as HDHPs and the deductible and out-of-pocket limit may be adjusted annually for inflation.
In-Network: The service providers and suppliers your health insurance company has contracted with to provide health care services. Some health insurance plans will only let you use in-network (sometimes called preferred service providers), and only cover out-of-network providers on a limited basis. It also costs less to use in-network service providers. If you have a doctor or other service provider that you want to keep using, make sure they are in-network for the health insurance plan you choose.
Life Changes: Also called a Qualifying Life Event, certain life changes may make you eligible to enroll in health insurance coverage outside of the annual open enrollment period in what's called a special enrollment period, or make changes to your plan during the year.
Maine Enrollment Assister (MEA): Maine Enrollment Assisters (or MEAs) provide in-person help to individuals, families, and small businesses shopping for health plans through CoverME.gov. Assisters have been trained by CoverME.gov and are required to provide fair and impartial information to help with eligibility, and facilitate enrollment in health plans. There is no cost to use an Assister.
Medicaid (also known as MaineCare): Medicaid is a joint federal-state health program that provides health care coverage to low-income and disabled adults, children and families. Medicaid in Maine is referred to as MaineCare. To be eligible for MaineCare, you must be a Maine resident and must meet non-financial and financial eligibility requirements. MaineCare covers many services, including doctor visits, hospital care, prescription drugs, mental health services, transportation and many other services at little or no cost to the individual. Currently, 1 out of every 3 Maine residents receives quality health care coverage through the MaineCare program.
Medical Loss Ratio (MLR): The Affordable Care Act requires health insurance companies to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medial Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases. If an issuer fails to meet the applicable MLR standard in any given year, as of 2012, the issuer is required to provide a rebate to its consumers. The financial performance of CoverME.gov carriers, including MLR can be found on the state of Maine, Bureau of Insurance website here under Company Health Insurance Reports.
Medicare: A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). The program helps with the cost of health care, but it doesn't cover all medical expenses or the cost of most long-term care. The program is administered through the Social Security Administration, not through CoverME.gov. Learn more about when and how to apply for Medicare.
Metal Levels: Plans are assigned metal levels to indicate how generous they are in paying expenses. Metal levels only focus on what the plan is expected to pay, and do NOT reflect the quality of health care or Service providers available through the health insurance plan. Bronze Health Plans pay 60 percent of medical expenses for the average population of consumers, Silver Health Plans 70 percent, Gold Health Plans 80 percent, and Platinum Health Plans 90 percent. Bronze and Silver plans generally have lower premiums, but you pay more when you get covered services. Gold and Platinum plans generally have higher premiums, but you pay less when you get covered services.
Minimum Essential Coverage: Health coverage that meets the requirement of the Affordable Care Act that most Americans have health insurance and certain other standards. All private health plans available through CoverME.gov meet or exceed this standard. MaineCare and Medicare also qualify. If you get your medical coverage outside of CoverME.gov or through another government program, find out what kind of health coverage qualifies as minimum essential coverage.
Minimum Value: A standard applied to employer-sponsored health insurance. A plan meets the standard if it pays at least 60 percent of the total cost of medical services for a standard population of consumers and offers substantial coverage of hospital and doctor services. If your employer’s plan meets this standard and is considered affordable, you won’t be eligible for an advance premium tax credit if you buy a private plan through CoverME.gov's Individual & Family marketplace instead.
Modified Adjusted Gross Income (MAGI): The way your income is calculated to see whether or not you qualify for MaineCare or an advance premium tax credit. MAGI is your household's Adjusted Gross Income (as calculated when you file your taxes) plus any non-taxable Social Security benefits, tax-exempt interest, and foreign income.
Network: Doctors, specialists, other Service providers, facilities and suppliers that a health insurance company contracts with to provide health care services to plan members.
Notice: Once you sign up for health insurance, from time to time, you may receive important information about your health insurance in the mail or an alert by email that a new notice is available when you login to your CoverME.gov account. Notices are time sensitive and may impact your health insurance, so it’s important that you read them and take action, if required.
Open Enrollment (OE) Period: A limited period of time every year when people can enroll in a health insurance plan for the next plan year. For individuals and families, Open Enrollment for 2025 coverage will run from November 1 through January 15. If your employer offers health insurance, the open enrollment time will be shorter and at a different time, so you should check with your employer on when you can enroll. You can apply for and enroll in MaineCare any time of the year.
Out of Pocket Costs: Expenses you incur for medical services that your insurance company doesn't pay including deductibles, copayments, and coinsurance along with any costs you incur for excluded services.
Out of Pocket Limit: The most you'll have to pay in a plan year for covered services before your health insurance company pays 100 percent. After you spend this amount on deductibles, copayments, and coinsurance, your health insurance pays 100 percent of the allowed amount for covered services. premiums don't count towards your out-of-pocket limit.
Plan Year (PY): A 12-month period during which the benefits and premium rates for insurance plans stay the same. The plan year for the Individual & Family marketplace is the same as the calendar year, even if you’re not enrolled for the whole calendar year. If you’re enrolled in a group health plan through an employer, your plan year may not be on a calendar year basis.
Platinum Health Plan: Platinum Health Plans pay 90 percent of in-network expenses for an average population of consumers. The premiums are typically among the highest, but the out-of-pocket limit of what you'll pay before the plan starts paying is usually the lowest and the plan may not have a deductible at all. Metal levels only focus on what the plan is expected to pay, and do NOT reflect the quality of health care or Service providers available through the health insurance plan. Once you meet your in-network out-of-pocket limit for the plan year, plans pay 100 percent of the allowed amount for covered services.
Preferred Provider Organization (PPO): A PPO (Preferred Provider Organization) plan covers care from in-network and out-of-network providers. You pay less if you use providers that belong to the plan’s network. You can use providers outside of the network for an additional cost.
Qualified Health Plan (QHP): A plan purchased through a Health Insurance Marketplace, such as the private plans available through CoverME.gov.
Qualifying Life Event (QLE): If you have a life change, such as but not limited to getting married, having a baby or losing your employer-sponsored insurance, you may be able to get health insurance coverage outside of the annual open enrollment period, or make changes to your plan during the year. This is called a special enrollment period, or “SEP”.
Remote Identity Proofing (RIDP): RIDP is the process of verifying a consumer’s identity. This may be done based on answers about your credit history, demographics, or other information. If this cannot be done electronically or over the phone with Experian, a consumer may be required to provide documentation to establish identity. This is a required step in applying for coverage.
Second Lowest Cost Silver Plan (SLCSP): The premium you would be charged for the second lowest cost Silver health plan available through CoverME.gov is used to calculate the amount of any advance premium tax credit you could be eligible to receive, even when this isn’t the plan in which you enroll. Following enrollment, this amount is reported on IRS Form 1095-A.
Silver Health Plan: Silver Health Plans pay 70 percent of in-network expenses for an average population of consumers. The premiums are typically lower, but the out-of-pocket limit of what you'll pay before the plan starts paying is higher. If you qualify for cost-sharing reductions and choose a silver plan, you'll have very low out-of-pocket expenses. metal levels only focus on what the plan is expected to pay, and do NOT reflect the quality of health care or Service providers available through the health insurance plan. Once you meet your in-network out-of-pocket limit for the plan year, plans pay 100 percent of the allowed amount for covered services.
Social Security Administration: The federal agency that assigns social security numbers; administers the retirement, survivors, and disability insurance programs known as Social Security; and administers the Supplemental Security Income program for the aged, blind, and disabled.
Special Enrollment Period (SEP): Outside the open enrollment season, you can enroll in a health insurance plan only if you qualify for a special enrollment. You qualify if you have certain Qualifying life events, like moving to Maine, getting married, having a baby, losing other health coverage and other circumstances.
Standalone Dental Plan (SADP): A dental insurance plan not included in your health plan. Dental care for adults is typically not included in medical plans.
Subsidy: An informal name for the advance premium tax credit or cost-sharing reductions.
TTY: A telephone and text communications protocol for people with hearing loss or speech disabilities.
Yearly Cost Estimate for Health Coverage: A feature of CoverME.gov’s Plan Compare tool that shows the estimated amount you might pay in a given year for premiums, deductibles, copayments and coinsurance based on the number of people covered, your health status and any expected medical procedures.
Zero Cost Sharing Plan: Federally recognized Tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is at or below 300 percent of the Federal poverty level are eligible for a zero cost sharing plan. With this plan, there are no copayments, deductibles or coinsurance when care is received from Indian health care providers, which include health programs operated by the Indian Health Service, tribes and tribal organizations, and urban Indian organizations. This is also true when receiving essential health benefits through a CoverME.gov plan, and you won't need a referral from an Indian health care provider to receive these benefits. Zero cost sharing is available for any metal level plan.