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In the know: Navigating terms around health care reform

Rochester Business Journal
January 3, 2014

A vast and complex lexicon surrounds the Affordable Care Act.
Understanding the law and all its aspects is not for the faint of heart.
"We really have to help the employer and then the employees and the individuals understand the insurance rules and how the policies work and what the exchange can and cannot do," says Eric Lintala, a certified health consultant at Beltz Ianni & Associates LLC. "It's the opportunity for the brokers to really add value to this process, and ... it's very hard to be a generalist and cover health insurance in this current marketplace."
Here are explanations of some key terms:
Affordable Care Act: A federal statute signed into law in 2010 to usher in comprehensive health care reform. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name "Affordable Care Act" is used to refer to the final, amended version of the law. The program also is called Obamacare.
Appeal: A formal request for review of an eligibility determination made by New York's health insurance marketplace. The request may be made on behalf of a business, an individual or a household member who also applied for health insurance. Once a request is made, the marketplace sends information on how to submit an appeal in writing, called a "desk review," or how to schedule a telephone hearing.
Broker: A licensed professional or business that assists individuals, small businesses and their employees with the process of applying for help in paying for coverage and facilitates enrollment in a qualified health plan through a health insurance marketplace. If allowed by their state, brokers and agents agree to register with the marketplaces, complete training and adhere to privacy, security and other state and federal requirements. Brokers typically get payments or commissions from issuers of health insurance for enrollments.
Employer shared responsibility: The Affordable Care Act requires certain employers with at least 50 full-time employees or the equivalent to offer coverage to full-time employees that meets minimum standards or pay penalties called the ESRP. This provision, also known as the employer mandate, and its related penalties have been delayed until January 2015.
Health insurance marketplace: A resource for learning about health insurance coverage options; comparing plans based on cost, benefits and other features; choosing a plan; learning about cost assistance; and enrolling. The marketplaces, also known as exchanges, encourage competition among private health plans. States such as New York, California and Connecticut operate their own marketplaces. Residents and small businesses in states that do not operate exchanges must rely on the federal marketplace.
Individual shared responsibility: A provision in the Affordable Care Act that applies to the self-employed and had required that each individual, beginning in January 2014, have basic health insurance coverage for each month, qualify for an exemption or pay a penalty. Last month, the Obama administration temporarily exempted people whose insurance plans had been canceled this year from individual shared responsibility, also known as the individual mandate.
Metal tier: Plans are offered in the marketplace on four tiers, from lowest to highest: bronze, silver, gold and platinum. Each tier is associated with an actuarial value, meaning the percentage of total average costs for covered benefits that a plan will cover.
Navigator: A certified individual or organization trained to help individuals, small businesses and their employees as they look for health coverage options in the marketplace, including completing eligibility and enrollment forms. Navigators are required to be unbiased and provide services for free.
Preventive services: All state and federal marketplace plans and many other plans must cover certain preventive services without charging co-payments or co-insurance, even if a yearly deductible has not been met. This applies only when a network provider delivers the services.
The Affordable Care Act classifies dozens of services as preventive, including anemia screening for pregnant women, one-time abdominal aortic aneurysm screening for men of specified ages who have smoked, HIV screening for people ages 15 to 65 and others at increased risk, blood pressure screening and various immunizations.
"I think people are very fuzzy about preventive services, and they're very surprised-even though it's been out there-that (they) are free," says Christine Wagner, executive director of St. Joseph's Neighborhood Center Inc. "I think that's something that has not been presented well to the public."
Since health care reform's rollout, Nancy Adams, executive director of the Monroe County Medical Society, has fielded many questions about preventive services.
"(They) include things like mammography and colonoscopy. However, if a problem is found-i.e., lump in the breast-the service is no longer considered preventive, and co-pays (and) deductibles apply," she says.
Small-business health care tax credit: Criteria that employers must meet to receive this credit, which is available through use of the marketplace, include having fewer than 25 full-time-equivalent employees and covering at least 50 percent of the cost of single, not family, coverage for each employee. The employees also must have average wages of less than $50,000 per year, adjusted for inflation beginning in 2014.
For tax years 2010 through 2013, the maximum credit is 35 percent of premiums paid for small employers and 25 percent of premiums paid for small tax-exempt employers. For tax years beginning in 2014 or later, the maximum credit will increase to 50 percent of premiums paid for small employers and 35 percent of premiums paid for small tax-exempt employers.
Sheila Livadas is a Rochester-area freelance writer.

1/3/14 (c) 2014 Rochester Business Journal. To obtain permission to reprint this article, call 585-546-8303 or email

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