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This glossary covers common health insurance terms & acronyms used in the Affordable Care Act (ACA). Additional glossary resources are available here.

In this article we'll cover:

The Affordable Care Act (ACA) is a federal law enacted in 2010 that established rules for health insurance coverage, created the Marketplace, and introduced protections such as coverage for pre-existing conditions and required coverage of essential health benefits.

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees the Marketplace, Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

Enhanced Direct Enrollment (EDE) is a CMS-approved technology that creates a secure backend connection to the Marketplace. EDE allows agents to complete the full Marketplace enrollment process directly on HealthSherpa.

An Affordable Care Act (ACA) Marketplace is an official health insurance exchange where consumers can shop for ACA health plans, apply for coverage, & find out whether they’re eligible for financial assistance.

On-exchange plans are purchased through the Marketplace and are subsidy eligible. Consumers complete a subsidy application where the Marketplace asks for information about the consumer’s tax household to determine eligibility for coverage and financial assistance. All ACA-compliant plans must cover the same essential health benefits, whether the plan is purchased on-exchange or off-exchange

Off-exchange plans do not go through the Marketplace and are not subsidy eligible. Consumers do not complete a subsidy application. All ACA-compliant plans must cover the same essential health benefits, whether the plan is purchased on-exchange or off-exchange.

A subsidy is federal financial assistance designed to lower the cost of health insurance purchased through the Marketplace. Subsidy eligibility can consist of both advance premium tax credit (APTC) and cost-sharing reductions (CSR).

An advance premium tax credit (APTC) is a dollar amount that may be applied on a consumer's behalf to their monthly health insurance premium. APTC can be applied to all metal levels.

Cost-sharing reductions (CSR) are discounts applied to silver level plans that lower deductibles and out-of-pocket costs for care and prescription drugs. Consumers who are eligible for APTC may also be eligible for CSR. Consumers who are not eligible for APTC are not eligible for CSR.

The federal poverty level (FPL) is a measure of income updated each year that is used to determine eligibility for certain programs and benefits, such as ACA subsidies, Medicaid, and CHIP. Subsidy eligibility for a tax household is based, in part, on the FPL.

A tax household is everyone included on one federal income tax return: the tax filer, their spouse if filing jointly, and anyone claimed as tax dependents. The Marketplace uses tax household information from the subsidy application to determine eligibility for coverage and financial assistance.

A premium is the monthly amount a consumer pays to a carrier in order to maintain health insurance coverage, regardless of whether benefits are used.

A deductible is the amount a consumer pays for covered services before their plan begins to pay. The deductible may not be required for all services.

A copayment, also called a copay, is a fixed amount a consumer pays each time they receive a covered service.

Coinsurance is a percentage of the cost a consumer pays each time they receive a covered service.

The out-of-pocket maximum is the most a consumer will pay for covered, in-network care in a plan year. After this amount is reached, the plan covers 100% of costs. The out-of-pocket maximum includes deductibles, copays, and coinsurance, but does not include premiums.

ACA health plans are categorized into metal levels that include bronze, silver, gold, and platinum. Metal levels indicate how costs for covered, in-network services will typically be shared between the plan and the consumer. Catastrophic plans are also available to certain consumers.

Enrollment periods determine when consumers can enroll in ACA coverage or change ACA plans. Enrollment periods consist of the Open Enrollment Period (OEP) and Special Enrollment Periods (SEPs).

The Open Enrollment Period (OEP) is the annual window when consumers can enroll in an ACA plan for the upcoming plan year.

Special Enrollment Periods (SEPs) are additional enrollment windows available during the plan year. SEPs allow a consumer to enroll in or change their ACA coverage when a qualifying life event (QLE) occurs.

Qualifying life events (QLEs) are specific life events that can open an SEP. Common examples include losing health coverage, moving, or having a baby. Not every change a consumer could experience during the year is a QLE, and a QLE must meet specific rules for SEP eligibility.

A Marketplace Eligibility Notice is an official letter from the Marketplace that is generated each time a consumer’s subsidy application is submitted. This notice explains coverage eligibility for each applicant, financial assistance the household qualifies for, along with any follow-up actions needed to satisfy Data Matching Issues (DMIs) & SEP Verification Issues (SVIs).

A Data Matching Issue (DMI) means the information entered on a consumer’s subsidy application does not match what is on file with the government, or is not available within their records, and needs to be verified. If a DMI is not resolved, the consumer may lose their subsidy eligibility or eligibility for coverage.

A Special Enrollment Period (SEP) Verification Issue (SVI) occurs when a consumer is eligible for an SEP and is asked to verify they experienced the qualifying life event (QLE). If an SVI is not resolved, the consumer may lose SEP eligibility.

Group insurance is employer-sponsored health coverage offered to employees and, in many cases, their dependents. Group plans are not sold through the Marketplace. Consumers who have access to affordable employer-sponsored coverage may not qualify for Marketplace subsidies, depending on the plan offered by the employer.

COBRA (Consolidated Omnibus Budget Reconciliation Act) is a federal law that allows consumers who lose job-based health coverage to continue that coverage for a limited period of time. COBRA coverage is usually more expensive than employer-sponsored coverage because the consumer pays the full premium, including any portion the employer previously covered.

Short-term medical (STM) plans are limited-duration health plans that are not ACA-compliant. STM plans may not cover pre-existing conditions or essential health benefits.

Indemnity plans, sometimes called reimbursement plans, pay a set benefit amount for specific covered services regardless of the actual cost of care.

Ancillary plans are additional insurance products that complement health coverage. Common examples include dental, vision, and hearing.

For help using HealthSherpa or for other assistance, contact Agent Support. Agent Support is available by phone at (888) 684-1373, by email at Agent_Support@HealthSherpa.com, or by chat directly from your account.