Glossary | Georgia Access

Term	Acronym	Definition
Actuarial Value	AV	The Actuarial Value (AV) is the percentage of total average costs for covered benefits that a plan will cover. For example, if your plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Advance Premium Tax Credit	APTC	Advance Premium Tax Credit (APTC) is a federal income tax credit you can take in advance to lower your monthly health insurance payment (or “premium”). The advanced tax credit amount is based on your household size and estimated income. You can use all or a portion of the credit in advance to lower your premium.
Affordability Exemption		An affordability exemption is an exemption to mandatory health coverage based on lack of affordable health coverage, either offered through an employer or through a health care exchange (such as the Federally-facilitated Exchange (FFE)). Coverage is considered unaffordable if costs are more than 8.17% of your projected annual household income in 2024. This exemption allows you to enroll in a Catastrophic health plan.
Affordable Care Act	ACA	The Patient Protection and Affordable Care Act (ACA) is a federal health care reform law enacted in March 2010 to ensure that affordable health care coverage is available across the country. Under the ACA, each state may either operate its own exchange or rely on the Federally-facilitated Exchange (FFE), HealthCare.gov, to operate an exchange in the state.
Agent		An agent is a trained professional who is licensed to sell health insurance products in Georgia; to sell on the Federally-facilitated Exchange (FFE), agents must receive certification from the Centers for Medicare & Medicaid Services (CMS). Agents can assist you with the consumer application and enrollment processes.
Annual Household Income		The annual household income is the total income for a family in a calendar year.
Appeal		An appeal is a request that a consumer, enrollee, employer, or Small Business Health Options Program (SHOP) employer can submit to have any eligibility determination or redetermination reviewed by the Federal Hearings entity within the Centers for Medicare & Medicaid Services (CMS). As a consumer, you may file an appeal if you believe an eligibility result [determination] was made in error regarding enrollment eligibility, financial assistance, or timing. You generally have 90 days from the date of your Eligibility Determination Notice (EDN) to file the appeal. For citizenship and immigration issues, you have 95 days from the date of your EDN to file the appeal. Employers may file an appeal if an employer does not provide minimum essential coverage (MEC) through an employer-sponsored plan, or if the employer does provide coverage to an employee, but the coverage is unaffordable.
Binder Payment		A binder payment is the first month’s premium for your new coverage through the Federally-facilitated Exchange (FFE). You must complete your binder payment to complete the enrollment process. If you do not make the payment, your policy will not take effect and you will not be enrolled in coverage. Note: If you are in the Open Enrollment Period (OE) (November 1 to January 15) and you have not completed your binder payment, you are still able to change the plan you enroll in.
Catastrophic Health Plan		A Catastrophic health plan is a qualified health plan (QHP) offered through the Federally-facilitated Exchange (FFE) that primarily covers major, unexpected medical expenses. While it often has lower premiums, it usually has higher out-of-pocket costs. You can only enroll in a Catastrophic health plan if you are under the age of 30; otherwise, you must have an approved health coverage exemption.
Center for Consumer Information and Insurance Oversight	CCIIO	The Center for Consumer Information and Insurance Insight (CCIIO) is the center within the Centers for Medicare & Medicaid Services (CMS) that implements, operates, and oversees provisions of the Patient Protection and Affordable Care Act (ACA).
Centers for Medicare & Medicaid Services	CMS	The Centers for Medicare & Medicaid Services (CMS) is the federal agency within the U.S. Department of Health and Human Services (HHS) that is responsible for overseeing Medicaid, the Children’s Health Insurance Plan (CHIP), Medicare, and the individual health insurance market.
Certified Application Counselor Designated Organizations	CDO	Certified Application Counselor Designated Organizations (CDOs) are public or private organizations that provide services to underserved consumer populations. CDOs may include hospitals, Federally Qualified Health Centers (FQHCs), health care providers, nonprofit organizations, and state or local government agencies.
Certified Application Counselors	CAC	Certified Application Counselors (CACs) are personnel affiliated with a Certified Application Counselor Designated Organization (CDO) (either employees or volunteers) who are licensed by the state and certified by a CDO to help you apply for and understand your health coverage options.
Children’s Health Insurance Program	CHIP	Children’s Health Insurance Program (CHIP) is a state-administered program that provides health coverage to eligible children through a combination of Medicaid and state-specific programs, such as Georgia’s PeachCare for Kids®.
Coinsurance		Coinsurance is a percentage of costs for a covered health care service or medication that you pay after you’ve met your deductible. For example, if the deductible has been met: You pay 30% of a $100 service which is $30. The insurance company pays the rest (70%). The percentage amount varies depending on the level of plan.
Consolidated Omnibus Budget Reconciliation Act	COBRA	Consolidated Omnibus Budget Reconciliation Act (COBRA) allows employees and their families who lose employer coverage as a result of a job loss, reduction in hours, death, or other qualifying event to choose to temporarily keep coverage for a fee. If you elect to use COBRA coverage, you pay up to 102% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Copayment		A copayment (commonly referred to as a copay) is a fixed amount ($50, for example) that you pay for a covered health care service before or after you’ve paid your deductible. Copays vary for different types of services within the same plan like drugs, lab tests, and visits to specialists.
Cost-Sharing Reduction	CSR	A cost-sharing reduction (CSR) is an income-based federal subsidy that lowers the out-of-pocket costs for health care services including deductibles, copayments, and coinsurances. CSRs can also help you lower your out-of-pocket maximums. To be eligible for a CSR you must be enrolled in a Silver qualified health plan (QHP).
Deductible		A deductible is the amount you pay, over the course of one calendar year, toward covered health care services before the health insurance company begins to pay a percentage of the total bill. Health plans vary on what is counted towards the deductible.
Dependent under the ACA		A dependent is a child or other individual for whom you financially support and claim a personal exemption as an annual tax deduction.
Disability		A disability is a limited ability in a range of major life activities. This includes, but is not limited to, activities such as seeing, hearing, and walking and on tasks such as thinking and working.
Direct Enrollment	DE	Direct Enrollment (DE) is a mechanism by which qualified health plan (QHP) insurance companies provide the ability for you to shop and enroll directly into your plans leveraging an Enhanced Direct Enrollment (EDE) Partner-certified platform.
Effective Date of Coverage		The effective date of coverage is the date your health insurance coverage begins. It is dependent on both the timing of enrollment and path used. If done through Open Enrollment (OE) it will be the first of the upcoming plan year. In some instances, such as a Special Enrollment Period (SEP) it will be the first day of a future month. For employer-sponsored coverage, it is often the first of the month following your enrollment.
Enhanced Direct Enrollment	EDE	Enhanced Direct Enrollment (EDE) is a service that private sector partners provide that is a user-friendly and seamless enrollment experience for you by allowing you to apply for, and enroll in, plans directly through an approved insurance company or web broker. EDEs are certified by CCIIO and serve as enrollment partners for the FFE.
Enhanced Direct Enrollment (EDE) Partner		An Enhanced Direct Enrollment (EDE) Partner is an organization that is certified to provide a technology platform for you to shop for and enroll in qualified health plans (QHPs) and stand-alone dental plans (SADPs).
Essential Health Benefits	EHB	Essential health benefits (EHBs) are services that health insurance plans must cover under the Patient Protection and Affordable Care Act (ACA). All insurance plans certified by Georgia Access are required by federal law to include EHBs. These include: ambulatory patient services; emergency services; hospitalization; pregnancy, maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventative and wellness services including chronic disease management; pediatric services, including dental and vision care; birth control coverage; and breastfeeding coverage.
Federal Data Services Hub	FDSH	The Federal Data Services Hub (FDSH) is a tool built and operated by the Centers for Medicare & Medicaid Services (CMS) to verify information to determine eligibility for enrollment in qualified health plans (QHPs) and Premium Tax Credits (PTCs)/Advance Premium Tax Credits (APTCs). The FDSH provides a single point of access for states to connect to the federal data sources to verify immigration, income, citizenship, access to minimum essential coverage (MEC), and other necessary information.
Federally-facilitated Exchange	FFE	The Federally-facilitated Exchange (FFE) is a federal health insurance exchange operated by the Centers for Medicare & Medicaid Services (CMS) pursuant to the Patient Protection and Affordable Care Act (ACA) that enables you as an individual or small-business employer to compare and shop for qualified health plans (QHPs) and stand-alone dental plans (SADPs). “FFE” may be used interchangeably with HealthCare.gov or Federally Facilitated Marketplace (FFM).
Federal Poverty Level	FPL	The Federal Poverty Level (FPL) is a benchmark published annually by the U.S. Department of Health and Human Services (HHS) that is calculated based on household size. OR The Federal Poverty Level (FPL) is published annually by the U.S. Department of Health and Human Services (HHS) and is calculated based on household size. FPL is used to determine your eligibility for premium tax credits (PTC) and cost-sharing reductions (CSR), as well as Medicaid and PeachCare for Kids®.
Flexible Spending Account	FSA	A Flexible Spending Account (FSA), sometimes referred to as a Flexible Spending Arrangement, is a special account that you can put money into (up to a pre-set limit), then use to pay for certain out-of-pocket health care costs such as deductibles, copayments, and prescriptions. This account is typically set up through your employer and is tax-free.
Full-time Equivalent	FTE	A full-time equivalent (FTE) calculation is used to determine employer size under the Patient Protection and Affordable Care Act (ACA). An employee who works at least 30 hours a week for more than 120 days in a year is considered full time. Part-time employees are defined as working an average of less than 30 hours per week.
Georgia Access Specialist Licensure		To operate as a Certified Application Counselor (CAC) in Georgia, individuals must obtain the Georgia Access Specialist License prior to receiving certification from their Certified Application Counselor Designated Organization (CDO). The Georgia Access Specialist License prepares Certified Application Counselors (CACs) to utilize Georgia Access and makes sure that these individuals are properly trained to provide accurate and adequate assistance.
Georgia Access Division		The Georgia Access Division is the division of Georgia’s Office of Commissioner of Insurance and Safety Fire that operates the Georgia Access State-based Exchange on the Federal Platform (SBE-FP).
Georgia Access Navigator Licensure		To operate as a Navigator in the State of Georgia, individuals must obtain the Georgia Access Navigator License. The Georgia Access Navigator License is intended to prepare Navigators to utilize Georgia Access and make sure these individuals are trained to provide accurate and adequate assistance to you. Navigator grantees are responsible for validating that their individual Navigators have obtained Georgia Access Navigator Licensure.
Small Business Health Options Program	SHOP	Small Business Health Options Program (SHOP) assists qualified employers in providing health insurance coverage to their employees. The Federally-facilitated Exchange (FFE) reviews and certifies small group plans as qualified health plans (QHPs) or stand-alone dental plans (SADPs), which insurance companies and agents offer to qualified employers as SHOP plans. Qualified employers may be eligible for the Small Business Health Care Tax Credit if they offer a SHOP plan to their employees.
Georgia Access Website		The Georgia Access website is a publicly available website (GeorgiaAccess.gov) providing information on Georgia Access programs and services, how to access health care coverage, and how to get assistance with applying for coverage.
Hardship Exemption		A hardship exemption is a type of exemption that you can apply for if you have experienced a financial hardship or other event that has prevented you from getting health coverage. If you are approved for a hardship exemption, you will have the opportunity to enroll in a Catastrophic health plan (CHP).
Health Coverage Exemptions		Health coverage exemptions help you get coverage if you are unable to meet the minimum essential coverage (MEC). Only individuals who are 30 years or older can apply for an exemption to enroll in a Catastrophic health plan (CHP). There were originally eight types of exemptions recognized by the Internal Revenue Service (IRS): A. Religious conscience B. Membership in a health care sharing ministry C. Incarceration D. Membership in an Indian tribe E. Hardship F. Affordability G. Medicaid Ineligibility based on a state’s decision not to expand
Health Reimbursement Arrangement	HRA	A Health Reimbursement Arrangement (HRA) is a type of account that an employer funds so that you can reimburse yourself for certain medical, dental, or vision expenses. These accounts are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. If your funds are not used, they may be rolled over to the next year.
Household		A household (also referred to as “Tax Household”) includes self, spouse if married, and tax dependents — those included on tax returns. This may be different than those actually living in the house. Eligibility for financial income is generally based on the income of all household members, even those who do not need insurance.
Individual Coverage Health Reimbursement Arrangement	ICHRA	An Individual Coverage Health Reimbursement Arrangement (ICHRA), established in 2020, is a type of Health Reimbursement Arrangement (HRA) that allows employers of any size to reimburse employees for some, or all, of their health insurance premiums that employees purchase on their own.
In-Network		In-network is defined as the facilities, providers, and suppliers such as doctors, hospitals, and pharmacies that a health insurance company or plan has contracted with to provide health care services. These are commonly referred to as a “provider network” or “preferred providers.”
Individual Market		The individual market i is the market where plans are sold to you as an individual, rather than to employers or groups. In the individual market, a plan year spans a calendar year, and you are automatically reenrolled for coverage for the next plan year unless you choose to enroll in another plan during Open Enrollment (OE) or terminate coverage.
Initial SHOP (Small Business Health Options Program) Enrollment Period		The initial SHOP (Small Business Health Options Program) enrollment period is the initial period of time during which qualified employees enroll in SHOP coverage. This period is determined by the qualified employer and issuer.
Internal Revenue Service	IRS	The Internal Revenue Service (IRS) is the revenue service for the United States federal government, which is responsible for collecting U.S. federal taxes, administering the Internal Revenue Code, and reconciling your estimated premium tax credit.
Limited English Proficiency	LEP	Someone described as having Limited English Proficiency (LEP) is not fluent in the English language, often because it is not their native language. If you or someone you know has limited English proficiency, review the accessibility services offered to you by Georgia Access.
Life Change Event		Commonly referred to as a Qualifying Life Event (QLE), a life change event is an event that makes you eligible to enroll in or change your health insurance coverage outside of the Open Enrollment Period (OE). Some examples of a life change event include getting married, moving, losing job-based health coverage, or having a child.
Medicaid (Medical Assistance)		Medicaid is a state-administered health insurance program that provides health coverage at little to no cost to people with disabilities, pregnant women, children and families, the elderly, and childless adults, whose household income is below a specific level and who meet additional eligibility requirements.
Medicare		Medicare is a federal health insurance program for those 65 and older or who have certain medical conditions. Medicare is not part of the Health Insurance Medicare coverage.
Metal Tiers		Metal tiers are four different levels of coverage that fit into a health insurance plan. These include Bronze, Silver, Gold, and Platinum, and serve to help you narrow down your options based on your budget and health needs. The levels are based on how you and your insurance company will split costs for that plan. The levels have no impact on the quality of care you receive. However, you must be enrolled in a Silver plan to be eligible for cost-sharing reductions (CSRs).
Minimum Essential Coverage	MEC	Minimum essential coverage (MEC), sometimes referred to as “qualifying health coverage,” is any type of insurance plan that meets the Affordable Care Act (ACA) requirement for having health coverage. Consumers must be enrolled in a plan that qualifies as MEC. Examples of plans that qualify include Marketplace plans, job-based plans, Medicare, Medicaid, and PeachCare for Kids®.
Minimum Participation Rate	MPR	The minimum participation rate (MPR) is calculated as the number of qualified employees who accept coverage under an employer’s group health plan, divided by the number of qualified employees offered coverage. The MPR to qualify for Georgia Access Small Business Health Options Program (SHOP) coverage is 70 percent of qualified employees who are offered insurance, not including employees with other health coverage.
Modified Adjusted Gross Income	MAGI	Modified adjusted gross income (MAGI) is your adjusted gross income after taking into account allowable deductions and tax penalties. This adjusted income is used to calculate your eligibility for premium tax credits (PTCs)/advance premium tax credits (APTCs) and other health plan savings.
National Association of Insurance Commissioners	NAIC	The National Association of Insurance Commissioners (NAIC) is a nonprofit, nonpartisan organization governed by the chief insurance regulators of the 50 states, the District of Columbia, and the five U.S. territories. NAIC sets standards and establishes best practices for the U.S. insurance industry and provides support to insurance regulators. NAIC also owns and operates the System for Electronic Rates & Forms Filing (SERFF).
Navigator Grantees		Navigator Grantees are organizations or a consortium of organizations that apply for and receive grants funded by Georgia Access to provide health insurance application support to Georgia consumers. Navigator Grantees are responsible for overseeing the work of individual Navigators, including training, day-to-day management, and activity monitoring.
Navigators		A Navigator is an individual affiliated with a Navigator Grantee Organization either as an employee or volunteer, who is trained and licensed by Georgia’s Office of the Commissioner of Insurance and Safety Fire (OCI) and certified by Georgia Access to assist consumers with applying for health coverage, but cannot offer advice on which QHP to select. Navigators are required to provide you with fair, accurate, and impartial information about health coverage options and available financial assistance.
National Insurance Producer Registry		The National Insurance Producer Registry (NIPR) maintains a database known as the Producer Database (PDB), which contains information about insurance agents and brokers (also known as producers) provided by state Departments of Insurance (DOI). The NIPR contains data on National Producer Numbers (NPNs), Lines of Authority (LOA), and state licensure.
National Producer Number	NPN	A National Producer Number (NPN) is a unique identification number that is assigned to insurance agents and web brokers by the National Association of Insurance Commissioner (NAIC). An NPN tracks individuals and ensures compliance with state licensing requirements.
Office of Commissioner of Insurance and Safety Fire	OCI	The Office of Commissioner of Insurance and Safety Fire (OCI) is an agency that licenses and regulates insurance companies, investigates reports of insurance fraud in Georgia, and provides you services including insurance financial oversight, insurance product review, agent licensing, insurance enforcement, and fraud investigation.
Open Enrollment Period	OE	The Open Enrollment Period (OE) is the annual period when you may enroll in an individual health insurance plan for the upcoming Plan Year. OE 2024 runs from November 1, 2023, to January 15, 2024.
Out-of-Pocket Costs		Out-of-pocket costs are expenses for medical care that are not reimbursed by insurance. These typically include deductibles, coinsurance, and copayments for covered services.
Personally Identifiable Information	PII	Personally Identifiable Information (PII) is any information that can be used to identify you by direct or indirect means.
Plan Year	PY	A Plan Year (PY) is the 12-month period of benefit coverage under a health plan. Note: This 12-month period may not always be the same as a calendar year.
Premium		A premium is the amount you are required to pay to the health insurance company each month in order to maintain coverage.
Premium Tax Credit	PTC	A premium tax credit (PTC) is a refundable tax credit that helps eligible individuals and family members cover the premiums for your health insurance. A PTC can be accepted as a one-time credit upon tax filing or spread throughout the year if taken upfront as an advance premium tax credit (APTC) and paid directly to your health insurance company to lower your monthly premium.
Qualified Employee		A qualified employee is an individual employed by a qualified employer who has been offered health insurance coverage by the qualified employer.
Qualified Employer		A qualified employer is a small business employer that is determined eligible to enroll in Small Business Health Options Program (SHOP) plans or provide SHOP plans to employees.
Qualified Small Employer Health Reimbursement Arrangement	QSEHRA	Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) is a type of Health Reimbursement Arrangement (HRA) that allows small employers (less than 50 employees) who do not offer group health insurance to their employees, to contribute up to the IRS limit toward their employees’ qualified medical expenses.
Qualified Health Plan	QHP	A Qualified Health Plan (QHP) is an insurance plan that is certified by Georgia Access that provides essential health benefits (EHBs) and follows established limits on cost sharing.
Recission		A recission is a retroactive cancellation of a health insurance policy. Under federal law, recission is illegal except in cases of fraud or intentional misrepresentation of facts as prohibited by the terms of the plan or coverage.
Small Business Health Options Program	SHOP	The Small Business Health Options Program (SHOP) insurance is generally available to employers with 1-50 full-time equivalent (FTE) employees that want to provide health and/or dental coverage at a cost that the small business can afford. SHOPs are either run by the state or the federal government.
Small Business Health Options Program (SHOP) Eligibility Period		A Small Business Health Options Program (SHOP) Employer eligibility period is a 12-month period, starting on the date of the SHOP Eligibility Determination Notice (EDN), during which a qualified employer is eligible to enroll in SHOP coverage with an agent or insurance company.
Small Business Health Options Program (SHOP) Employer Appeal		Employers who are either deemed ineligible for or terminated from Small Business Health Options (SHOP) may file an appeal to contest these decisions. SHOP appeals are reviewed by the Federally-facilitated Exchange (FFE).
Sircon/National Insurance Producer Registry Licensing Systems		The Sircon and National Insurance Producer Registry (NIPR) licensing systems are used by the State of Georgia to manage all licensure applications, approvals, renewals, and maintenance.
Small Business Health Care Tax Credit		The Small Business Health Care Tax Credit is a federal tax credit that may be available to employers with fewer than 25 employees who pay at least 50 percent of health insurance premiums on behalf of employees enrolled in qualified health plans (QHPs) through Georgia Access Small Business Health Options Program (SHOP).
Small Business Employer		A small business employer in Georgia refers to qualified employers with 50 or fewer full-time equivalent (FTE) employees.
Special Enrollment Period	SEP	A Special Enrollment Period (SEP) is a time outside of Open Enrollment Period (OE) when you can sign up for health insurance if you experience a Qualifying Life Event (QLE). You can qualify for an SEP if you’ve experienced certain life events such as moving, getting married, having a child, or losing your job-based coverage.
Stand-Alone Dental Plan	SADP	A stand-alone dental plan (SADP) is a dental plan that is not included as part of a health plan. SADPs are available for you to buy if you are purchasing a qualified health plan (QHP) at the same time.
State-based Exchange	SBE	A State-based Exchange is an online marketplace (sometimes referred to as “Exchange”) fully operated by a state where you can shop for, apply for, select, and enroll in health insurance plans.
State-based Exchange on the Federal Platform	SBE-FP	A State-based Exchange on the Federal Platform (SBE-FP) is an online marketplace that allows a state to take on some exchange functions but is supported by the Federal Platform (FP) for eligibility and enrollment and other necessary functions. Georgia Access will operate as an SBE-FP for Plan Year (PY) 2024.
Summary of Benefits and Coverage	SBC	A summary of benefits and coverage (SBC) is a standardized form that summarizes the benefits and coverage available for each health plan to help you compare different plans.
System for Electronic Rates and Forms Filing	SERFF	The System for Electronic Rates and Forms Filing (SERF) is the electronic system used by insurance companies and Office of Commissioner of Insurance and Safety Fire (OCI) to upload and review plan data. Plan certification and decertification decisions are recorded in SERFF.
U.S. Department of Health and Human Services	HHS	The U.S. Department of Health and Human Services (HHS) is the federal cabinet-level agency that oversees the legal authority of the Centers for Medicare & Medicaid Services (CMS).
Web Broker		A web broker is a private company that is certified by the Federally-facilitated Exchange (FFE) and partners with the State of Georgia to provide the same shopping and enrollment opportunities as the Federal Exchange. They also have agents who can help you pick the best plan to meet your needs.