Health Care Exchange (Marketplace) Glossary

actuarial value
The ratio of covered services in a policy that are paid for by a carrier over total cost of benefits covered by the plan. Medical and dental EHB plans are generally offered at specified actuarial values, depending on their tier for medical (bronze, silver, gold or platinum), or for stand-alone dental, if they are high (85%) or low (70%).
Affordable Care Act/ACA
The ACA is the comprehensive Health Care Exchange (Marketplace) law, enacted in March 2010. Provisions of the ACA ensure Americans access to reasonably priced, comprehensive health insurance.
This refers to a medical plan and a dental plan that are sold together, but as two separate policies. Both policies could be administered by the same company or by different companies. Within a bundled policy, the out-of-pocket maximums and deductibles are accumulated separately and each plan has its own actuarial value. This type of policy is not available in all states and is never available through a public exchange.
cost sharing
This refers to the enrollee’s annual out-of-pocket costs for health care within limits that are set by the ACA. Medical cost sharing cannot exceed $6,600 for an individual and $13,200 for families. Cost sharing for pediatric essential benefits offered under a separate dental policy cannot exceed $350 for a single pediatric member or $700 for multiple children.
When one insurance policy includes both medical coverage and pediatric dental coverage, the pediatric dental is considered to be “embedded” into the policy and is therefore subject to the combined deductible and out-of-pocket maximums, without actuarial value limits for the dental.
essential health benefits/EHB
The ACA defines essential health benefits (EHBs) as 10 categories of health care services, including pediatric oral care, which provide the basic level of care and must be included in health benefits plans offered through exchanges and in the small group and individual market outside of exchanges.
The 10 essential health benefits include:
  1. Pediatric services, including oral and vision care
  2. Ambulatory patient services
  3. Emergency services
  4. Hospitalization
  5. Maternity and newborn care
  6. Mental health and substance use
  7. Disorder services, including behavioral health treatment
  8. Prescription drugs
  9. Rehabilitative and habilitative services and devices
  10. Laboratory services and preventive and wellness services and chronic disease management
Each state determines the specific scope of services included in its package of essential health benefits in accordance with HHS guidelines.
excepted benefit
Stand-alone pediatric dental coverage is an “excepted” benefit, which means that it generally is not subject to the ACA’s market reforms, though select reforms are applied by federal regulation to pediatric dental sold inside exchanges, and outside to small groups and individuals wanting ACA-compliant coverage. Fully insured commercial dental products that are not sold as ACA compliant are considered to be “excepted benefits.”
exchange/exchange (marketplace)
An exchange is a state- or federally-facilitated competitive insurance marketplace where individuals and businesses can compare and purchase qualified health plans. Each state has a health care exchange (marketplace).
This term describes health plans that state and federal regulators determine meet the federally prescribed EHB requirements and certification standards, and these plans therefore are approved to be offered for purchase both inside and outside state- and/or federally-facilitated health care exchanges (marketplaces).
grandfathered plan
Health plans that were in effect as of March 23, 2010 (and that meet specific conditions) are considered to be grandfathered, which means they are exempt from many health reform mandates. Because Delta Dental specializes in dental-only plans, our plans are excepted benefits and therefore are exempt from ACA requirements. Grandfathering is therefore inapplicable to dental plans.
Health Care Exchange (Marketplace)
An exchange is a state- or federally-facilitated competitive insurance marketplace where individuals and businesses can compare and purchase qualified health plans. Each state has a health care exchange (marketplace). See ACA.
Health and Human Services/HHS/U. S. Department of Health and Human Services/CMS
This is the federal agency that oversees the ACA.
minimum essential coverage/MEC
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, employer-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
open enrollment
The time period in which individuals and businesses may enroll in plans through their state or federally facilitated exchange marketplace. Visit for more information on open enrollment.
out-of-pocket maximum
This is the amount an enrollee pays for services (a total of annual deductibles and copayment/coinsurance amounts) before the plan begins to pay 100% for covered in-network services. A contractual out-of-pocket maximum with an embedded plan could be up to $6,600 per individual and $13,200 for families annually. For exchange-certified dental plans, the out-of-pocket maximum for covered pediatric essential dental benefits cannot exceed $350 for a single child and $700 for multiple children. An out-of-pocket maximum is different from an annual maximum, which is a limit on how much the insurance company pays. Annual maximums will no longer be allowed in exchange-certified pediatric dental plans for small groups and individuals beginning in 2014.
qualified health plan/QHP
A QHP is certified by each exchange marketplace in which it is sold to provide essential health benefits, follow the ACA’s established limits on deductibles, copayments and out-of-pocket maximums, and meet other requirements.
reasonable assurance
This is a declaration from a health policy purchaser that verifies that the purchaser either has or will obtain an exchange-certified pediatric stand-alone plan to satisfy the required pediatric dental EHB for small groups and individuals. This declaration allows a medical carrier to write a policy or contract for an individual or small group that does not include pediatric dental benefits. There is variation in what state regulators will accept as reasonable assurance, and at least one state (California) won’t accept reasonable assurance at all. Its purpose is to provide flexibility for small groups and individuals to obtain pediatric EHB from a stand-alone dental plan, rather than just from a health plan that embeds or bundles its pediatric EHB.
Small Business Health Insurance Options Program/SHOP
SHOP is each state’s health care exchange (marketplace) for small businesses.
A stand-alone plan is offered and may be purchased separately from other coverage.
subsidy/federal subsidy
This is a tax credit (also known as the Advance Premium Tax Credit – APTC) to help individuals with the cost of premiums for plans purchased in the public exchange marketplace. Subsidies are applied to the medical coverage first, and only if there is carryover can subsidies be used to also cover dental benefits premiums. Small businesses may receive a tax credit subsidy for medical coverage only.