Terminology

Terminology Definition
Affordable Care Act Federal law passed in 2010, requires most individuals to have health insurance or face a tax penalty.
Copayment A form of cost sharing. Copayments or "copays" refer to a specific dollar amount that an individual will pay for a particular service, regardless of the price charged for the service. The payment may be collected at the time of service or billed later. The HIP Basic plan requires copayments for most services, ranging from $4 to $8 for a doctor visit or prescription to $75 for a hospital stay.
Cost sharing The costs a member is responsible for paying for health services when covered by health insurance.
Deductible A form of cost sharing. A deductible is a dollar amount that is paid for initial medical costs before health insurance starts to pay. HIP 2.0 has a $2,500 deductible that is funded by a POWER Account, which includes a combination of state and member contributions.
Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Federal Health Insurance Marketplace Individuals with incomes above the federal poverty level can purchase health coverage through the federal government's Health Insurance Marketplace. Those with incomes between 138 percent and 400 percent FPL may receive federal tax subsidies to help pay for coverage.
Federal Poverty Level (FPL) Determined annually by the federal government. The federal poverty level for 2017 is $1,005 per month for an individual and $2,050 per month for a family of four.
HIP Basic HIP members who do not pay their POWER account contributions are disenrolled from HIP Plus. Those with incomes in 2017 of $1,005 or less per month for an individual or $2,050 per month for a family of four will receive HIP Basic benefits. HIP Basic benefits meet the requirements of minimum essential coverage but do not provide vision or dental services. In HIP Basic, copayments are required for most health services including visiting the doctor, filling a prescription and staying in the hospital. These payments may range from $4 to $8 per doctor visit or prescription filled and may be as high as $75 per hospital stay.
HIP Basic Benefits HIP Basic provides basic benefits that meet the minimum coverage requirements. HIP Basic does not provide coverage for vision or dental services, bariatric surgery or Temporomandibular Joint Disorders (TMJ). HIP Basic benefits also allow for fewer visits to physical, speech and occupational therapists.
HIP Plus HIP Plus is the preferred plan for all HIP Members. HIP Plus provides the best value coverage and includes vision and dental services. In HIP Plus members pay affordable monthly contributions based on income and do not pay any other costs unless they visit the emergency room when they don’t have an emergency health condition. Members who do not pay their contribution may not receive HIP Plus services.
HIP Plus Benefits HIP Plus provides comprehensive coverage including vision and dental services. Like the coverage offered by employers, HIP Plus covers all of the essential health benefits required by federal law. HIP Plus has higher annual visit limits to see physical, speech and occupational therapists than the HIP Basic program, and coverages for additional services like bariatric surgery and Temporomandibular Joint Disorders (TMJ) treatments are included.
HIP State Plan The HIP State Plan ensures that if you are otherwise eligible for Medicaid or have a qualifying health condition, you will receive enhanced benefits. Additional benefits offered under the HIP State Plan include non-emergency transportation services, chiropractic services and Medicaid Rehabilitation Option (MRO) services. HIP State Plan members still have a POWER Account and can pay an affordable monthly contribution for these benefits as if you were in HIP Plus. If you do not pay your affordable monthly contribution you will be disenrolled from the State Plan Plus option. If your income in 2017 is at or below $1,005 per month for an individual or $2,050 per month for a family of four, you will still have access to the HIP State Plan enhanced benefits, but will be required to pay a HIP Basic copayment for most health services. These payments may range from $4 to $8 per doctor visit or prescription filled and may be as high as $75 per hospital stay.
Medically Frail Individuals who are determined to be medically frail receive coverage for some additional benefits including non-emergency transportation and chiropractic services. An individual is medically frail if he or she has one or more of the following:
  • Disabling mental disorder;
  • Chronic substance abuse disorder;
  • Serious and complex medical condition;
  • Physical, intellectual or developmental disability that significantly impairs the individual’s ability to perform one or more activities of daily living; or
  • Disability determination from the Social Security Administration.

However, your access to these services is temporary while your health plan confirms your status as medically frail. If your health plan confirms your status as medically frail, you will continue receiving State Plan benefits. If your health plan does not confirm your status as medically frail, you will no longer receive these additional benefits. You must make your first POWER account payment in order to access these temporary State Plan Plus benefits.

You must contact us in order to confirm your health condition.

If your health condition cannot be confirmed, you will still receive full benefits including coverage for vision and dental through HIP Plus, as long as you continue to make your monthly POWER account payment. However, the additional benefits of non-emergency transportation and chiropractic services are not available in HIP Plus.

Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Power Account In the HIP program, the first $2,500 of medical expenses for covered services are paid through a special savings account called a Personal Wellness and Responsibility (POWER) account. The state will pay most of this amount, but you will also be responsible for paying a small portion of your initial health care costs. Your portion is paid through an affordable, monthly contribution to your POWER account based on income.
Preventive Services Health care services recommended to identify health conditions so they can be treated before they become serious.
Prior Authorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Your health plan may require prior authorization for certain services before you receive them, except in an emergency.
Rollover Managing your account well and getting preventive care can reduce your future costs. If your annual health care expenses are less than $2,500 per year, you may roll over your remaining contributions to reduce your monthly payment for the next year. You can also have this reduction doubled if you complete preventive services. Your health plan will inform you what preventive care services are recommended for you.