Accountable Care Organization (ACO)
A group of healthcare providers that gives coordinated care for chronic disease management with the goal of improving the quality of patient care. The “organization’s” payment is tied to achieving healthcare quality goals and outcomes that result in cost savings. ACOs can include various types of doctors – primary care, specialists, etc. – as well as other medical providers (nurses, physician’s assistants, etc.) and institutions (hospitals, multi-physician practices).
If a health plan provided in the Marketplace/Exchange is approved, this is the “seal of approval” given to the plan by an independent organization to show that the plan meets national quality standards.
Affordable Care Act (ACA)
Also known as the Patient Protection and Affordable Care Act (PPACA), healthcare reform (HCR), and Obamacare, it is the comprehensive healthcare reform law enacted in March 2010. The law was enacted in two parts: PPACA was signed into law on March 23, 2010. It was amended by the Healthcare and Education Reconciliation Act on March 30, 2010. Affordable Care Act refers to the final, amended version of the law.
Discounted fees that insurers will recognize and pay for covered services. Insurers negotiate these discounts with providers in their health plan network. Network providers agree to accept the allowed charge as payment in full. Each insurer has its own schedule of allowed charges.
A cap on the benefits your insurance company will pay in a year while you’re enrolled in a health insurance plan. Annual caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits for a particular service. After the annual limit is reached, you must pay all associated healthcare costs for the rest of the year.
A request for a health insurer or plan to review a decision or a grievance again. See information on how to file an appeal.
The healthcare items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
A biologic (also known as a biological product) is a type of medication such as a vaccine, blood or blood product, or other treatment that mimics biological substances naturally present in the body. Rather than being created chemically like drugs, biologics are created from biological sources, such as donated plasma, cell culture, or bone marrow. Biologics can be composed of sugars, proteins, or nucleic acids or complex combinations of these substances, or may be living entities such as cells and tissues. Immunoglobulin (Ig) replacement therapy, administered intravenously or subcutaneously, is a biologic. Gene therapy products are also biologics.
Biosimilar Biological Products
A biosimilar is the “follow-on” or subsequent version of a biologic. Biosimilars and biologic products have the same relationship that generic drugs have with brand name drugs, with an important distinction that due to their complexity, biosimilars are not identical to the original biologic product.
Bronze Health Plan
A plan in the health insurance Marketplace/Exchanges where the percentage the plan pays of the average overall cost of providing essential health benefits to members is 60%.
The process of organizing your treatment across several healthcare providers. Medical homes and Accountable Care Organizations (see definition) are two common ways to coordinate care.
A healthcare plan that only covers certain types of expensive care, like hospitalizations. May also include plans that have a high deductible, so that your plan begins to pay only after you’ve first paid up to a certain amount for covered services. You must be under 30 years old to purchase a catastrophic plan through a Marketplace/Exchange.
The federal agency responsible for protecting health and promoting quality of life through the prevention and control of disease, injury and disability.
The federal agency that administers the Medicare, Medicaid, and Children’s Health Insurance Programs (CHIP), and implements many provisions of the Affordable Care Act (ACA) related to private health insurance Marketplaces/Exchanges.
Certified Application Counselor (CAC)
An individual (affiliated with a designated organization) who is trained to help consumers, small businesses, and their employees as they search for and enroll in health insurance options through the Marketplace/Exchanges created by the ACA. CAC services are free to consumers.
Insurance program jointly funded by state and federal government that provides health insurance to low-income children. In some states, it covers pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage.
A request for payment that you or your healthcare provider submits to your health insurer after you receive covered items or services.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that may allow you to temporarily keep health coverage if your employment ends, you lose coverage as a dependent of the covered employee or if there is another qualifying event. COBRA requires you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage (rather than a set dollar amount) of medical expenses after the deductible amount, if any, was paid.
Community Health Centers (CHC)
Public and private, nonprofit organizations providing comprehensive, culturally competent, quality primary and related healthcare services to medically underserved communities and vulnerable populations. The centers are managed and governed by a community board, which is primarily comprised of patients and community members. There are several different types of CHCs: Federally Qualified Health Centers; non-grant supported health centers; and outpatient health programs/facilities operated by tribal organizations.
Consumer Assistance Program (CAP)
State programs available to assist consumers with problems or questions concerning healthcare coverage. Consumers with questions can usually access the programs through phone or e-mail. See https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.
Consumer Operated Oriented Plan (CO-OP)
A non-profit health insurance organization for which its insured people are also the owners. Cooperatives can be formed at a national, state, or local level and can include doctors, hospitals, and businesses as member-owners. Co-ops will offer insurance through the Marketplace/Exchange.
Coordination of Benefits (COB)
A way to figure out who pays first when two or more health insurance plans are responsible for paying the same medical claim.
Copayment or Copay
A flat dollar amount you must pay for a covered program. Example: you may have to pay a $15 copayment for each covered visit to a primary care doctor.
The share of costs covered by your insurance that you pay out of pocket. This share is commonly referred to as out-of-pocket (OOP) costs. Cost sharing includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
Cost-Sharing Reduction (CSR)
A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace/Exchange, your income is below a certain level, and you choose a Silver Health Plan (See “Metal Tiers” and “Silver Health Plan”). If you are a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.
The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. Example: under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage.
Department of Health and Human Services (HHS)
The federal agency charged with protecting the health of all Americans. Its agencies include the Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA).
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
Insurance coverage for family members of the policyholder, such as spouse, children or partners.
A limit in action, restriction, or impairment that can be physical and/or mental. Different state, federal, or private programs may have different disability standards. A legal definition of disability can be found at: http://www.ada.gov/pubs/ada.htm.
Donut Hole, Medicare Prescription Drug: Most plans with Medicare prescription drug coverage (Part D) have a coverage gap, called a donut hole. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again. The donut hole is being phased out and will be closed entirely by the ACA in 2020.
Drug List: Also referred to as a formulary, it is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Durable Medical Equipment (DME): Equipment and supplies ordered by a healthcare provider for everyday or extended use. Typically DME may be considered a separate category under a health insurance plan. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Early Periodic Screening, Diagnostic & Treatment Services (EPSDT): The comprehensive set of benefits covered for children in Medicaid.
Electronic Medical Record (EMR): A digital version of a paper chart that contains all of a patient’s medical history from one practice.
Employer Mandate: The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to their full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment.
Employer-Sponsored Insurance (ESI): Sometimes called group health insurance, this is health insurance provided by an employer, who typically covers a portion of the costs. Plan options include HMOs, PPOs, and EPOs, among others.
Employee Retirement Income Security Act of 1974 (ERISA): A federal law that establishes standards for some employer-sponsored health insurance, particularly for self-insured employer-sponsored plans (See Employer Sponsored Insurance and Self-Insured Plan). ERISA plans can only be regulated by federal law; state health insurance laws don’t apply to them. In the context of the ACA, ERISA plans are exempt from some of the private health insurance reforms.
Essential Community Providers (ECP): The ACA designates certain providers as Essential Community Providers, those that are included in section 340B(a)(4) of the Public Health Service Act. Plans offered through the Marketplace/Exchanges are required to include some ECPs in their networks.
Essential Health Benefits (EHB): A set of healthcare service categories that must be covered by certain plans starting in 2014. The Affordable Care Act defines essential health benefits to “include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.’’
EHB services are defined differently in each state, based on what is covered by a typical plan that existed in the state in 2011. Private health insurance policies must cover these benefits in order to be certified and offered in Marketplaces/Exchanges.
Non-grandfathered health plans are no longer able to impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, were required to begin phasing out annual dollar spending limits for these services starting with plan/policy years that began on or after September 23, 2010. For the majority of health insurance plans, annual dollar limits on essential health benefits were completely phased out by 2014.
Exclusions: Items or services that are not covered under a contract for insurance and which an insurance company won’t pay.
Exclusive Provider Organization (EPO) Plan: A managed care plan in which services are covered only if you go to doctors, specialists or hospitals in the plan’s network (except in an emergency).
Explanation of Benefits (EOB): A form sent by an insurance company to an insured that includes such items as a summary of the claims processed for an insured since their last claim, a summary of what the insurer paid for the claim and what the insured’s responsibility may be, and a summary of the person’s year-to-date costs in the plan.
External Review: A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn’t yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of a covered benefit; when the plan determines that the care is experimental and/or investigational; or for rescissions of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The plan must accept this decision.
Federally-Facilitated Marketplace/Federally-Facilitated Exchange (FFM/FFE): One of the three types of Marketplace/Exchange options for states under the Affordable Care Act. States opting for an FFM/FFE will have a Marketplace/Exchange that is run by the federal government.
Federal Poverty Level (FPL): A measure of income level issued annually by the Department of Health and Human Services. FPL is used to determine eligibility for certain programs and benefits. For more information on FPL please visit: http://aspe.hhs.gov/poverty/index.cfm. Many public health insurance programs set eligibility based on a percentage of the FPL.
Federally Qualified Health Centers (FQHC): Federally-funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee.
Fee for Service (FFS): A reimbursement plan in which doctors and other healthcare providers are paid for each service performed, such as for tests and office visits.
Flexible Benefits Plan: Also known as a Cafeteria Plan or IRS 125 Plan, these plans offer employees a choice between various benefits including cash, life insurance, health insurance, vacations, retirement plans and child care. Although a common core of benefits may be required, you can choose how your remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes you can contribute more for additional coverage.
Flexible Spending Account (FSA): Accounts offered and administered by employers that allow employees to set aside pre-tax dollars out of their paycheck to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. The employer may also make contributions to a FSA. Typically, benefits or cash must be used within the given benefit year or the employee loses the money. Employers can choose whether they want to allow any amount to be rolled over to the following year. Flexible spending accounts can also be provided to cover childcare expenses, but those accounts must be established separately from medical FSAs.
Formulary: Sometimes referred to as a “drug list,” it is a list of drugs your insurance plan covers and may include how much you pay for each drug. If the plan categorizes drugs into different groups with different co-pays, also known as tiers, then the formulary may list drugs by these tiers. Formularies may include both generic drugs and brand-name drugs.
Fully Insured Employer Plan: A plan in which the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.
Grandfathered Health Plan: As defined in the Affordable Care Act, a group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act.
Plans or policies may lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials if it is a grandfathered plan. It must also advise consumers how to contact the U.S. Department of Labor or HHS with questions. (See New Plan).
Grievance: A complaint an insured communicates to his or her health insurer or plan.
Guaranteed Issue: A requirement that health plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services. Except in some states, guaranteed issue doesn’t limit how much you can be charged if you enroll.
Guaranteed Renewal: A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums. Except in some states, guaranteed renewal doesn’t limit how much you can be charged if you renew your coverage.
Habilitative/Habilitation Services: Healthcare services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Habilitative services are one of the 10 essential health benefits (EHBs).
Health Insurance Exchange (HIE): Also known as a Health Insurance Marketplace, these are new transparent and competitive health insurance Marketplaces/Exchanges where individuals and small businesses can buy qualified health plans that meet certain benefit and cost standards. Every state has a Marketplace/Exchange, effective 2014.
Health Insurance Marketplace (HIM): Also known as a Health Insurance Exchange (HIE), these are new transparent and competitive health insurance Marketplaces/Exchanges where individuals and small businesses can buy qualified health plans that meet certain benefit and cost standards. Every state will have a Marketplace/Exchange in 2014 and beyond.
Health Insurance Portability and Accountability Act (HIPAA): HIPAA is a 1996 law that eliminated discrimination by health insurers for those with pre-existing medical conditions. It also sets important privacy and security standards for healthcare entities so that consumers’ health information is protected.
Health Maintenance Organization (HMO): An insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. Generally won’t cover out-of-network care except in an emergency, and may require you to live or work in its service area to be eligible for coverage.
Health Resources and Services Administration (HRSA): An agency of the U.S. Department of Health and Human Services that works to improve access to healthcare services for people.
Health Savings Account (HSA): A medical savings account available to taxpayers who are enrolled in a High-Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
Health Status: Refers to your medical conditions (both physical and mental health), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability and disability.
High-Deductible Health Plan (HDHP): A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
High-Risk Pool (HRP) Plan (State): High-risk pool plans offer health insurance coverage that is subsidized by a state government. Not all states offer high-risk pools, and those that do have distinct rules in terms of cost, eligibility and benefits. Many high-risk pools have been phased out following the implementation of plans in the ACA’s Marketplaces/Exchanges.
Home and Community-based Services (HCBS): Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing. Covered when provided by care workers or, if your state permits it, by your family.
Home Healthcare: Healthcare services and supplies in your home that a doctor prescribes.
Hospital Readmission: A return by a patient to the hospital following discharge for the same or related care within 30, 60 or 90 days. Hospital readmissions are often used in part to measure the quality of hospital care.
Individual Health Insurance Policy: Policies for people who aren’t connected to job-based coverage. Individual health insurance policies are regulated under state and federal law. Note that the phrase “individual policies” when used in this way – policies that are unconnected to employment – can be used for policies that cover a single person or multiple people (families, mother and dependent child, husband and wife, etc.).
Individual Mandate: Also known as “individual responsibility,” under the Affordable Care Act. Starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay a penalty. Exempt from this are people with very low income for whom coverage is unaffordable, or for other reasons, including religious beliefs.
In-Network Coinsurance: The percent (for example, 20%) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.
In-Network Co-payment: A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
In-Network Provider: A physician, certified nurse midwife, hospital, skilled nursing facility, home healthcare agency, or any other duly licensed or certified institution or health professional under contract with your insurance provider.
In-Person Assisters (IPA): Individual or organizations that are trained to provide help to consumers, small businesses, and their employees as they look for health coverage options through the Marketplace/Exchanges. IPAs help consumers complete eligibility and enrollment forms and are required to be unbiased. Their services are free to consumers.
Lifetime Limit: A cap on the total lifetime benefits your insurance policy will cover (also known as a lifetime cap). Before passage of the ACA, many insurers set a lifetime dollar limit on benefits (like $1 million) and would not pay for covered services once the limit was hit. As of September 2010, non-grandfathered health plans can no longer set lifetime dollar limits on the Essential Health Benefits (EHBs). Plans can continue to limit specific benefits by number (for example, covering only a certain number of visits).
Long-Term Care (LTC): Medical and nonmedical services provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.
Managed Care Plan: A plan that generally provides comprehensive health services to its members, and offers financial incentives for patients to use the providers who belong to the plan. Examples include: health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs) and point of service plans (POSs).
Managed Care Provisions: Features within health plans that provide insurers with a way to manage the cost, use and quality of healthcare services received by group members. Examples of managed care provisions include:
- Preadmission certification - Authorization for hospital admission given by a healthcare provider to a group member prior to hospitalization. Failure to obtain a preadmission certification in nonemergencies reduces or eliminates the healthcare provider’s obligation to pay for services rendered.
- Utilization review - The process of reviewing the appropriateness and quality of care provided to patients. Utilization review may take place before, during or after the services are rendered.
- Preadmission testing - Requirement designed to encourage patients to obtain necessary diagnostic services on an outpatient basis prior to nonemergency hospital admission. The testing is designed to reduce the length of a hospital stay.
- Nonemergency weekend admission restriction - A requirement that imposes limits on reimbursement to patients for nonemergency weekend hospital admissions.
- Second surgical opinion - A cost-management strategy that encourages or requires patients to obtain the opinion of another doctor after a physician has recommended that a nonemergency or elective surgery be performed. Programs may be voluntary or mandatory in that reimbursement is reduced or denied if the participant does not obtain the second opinion. Plans usually require that such opinions be obtained from board-certified specialists with no personal or financial interest in the outcome.
Medicaid: A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding and sets guidelines. States also have choices in how they design their program, so Medicaid programs and eligibility vary from state to state, and may have a different name in your state.
Medical Loss Ratio (MLR): A financial tool that measures the percentage of premium dollars taken in by a health insurer that are spent on customers’ medical claims and quality improvement activities as compared with money spent on overhead expenses, including salaries, administrative costs and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws. If your plan does not meet an applicable MLR, then you or your employer could receive a refund.
Medically Necessary: Services or supplies that are needed for the diagnosis or treatment of your health condition and meet accepted standards of medical practice.
Medical Underwriting: A process used by insurance companies that uses your health status when you’re applying for health insurance coverage to determine whether to offer you coverage, at what price and with what exclusions or limits.
Medicare: A federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-State Renal Disease (ESRD)/Medicare is composed of four parts:
- Medicare Part A: Hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospice and home care. Most beneficiaries are enrolled in Part A automatically.
- Medicare Part B: Medical coverage that helps to cover medically necessary services like doctors’ services, outpatient care, home health services and other medical services. Part B also covers some preventive services, and physician-administered drugs like immunoglobulin replacement therapy for patients with most kinds of primary immunodeficiency diseases. Most beneficiaries are enrolled in Part B automatically. It covers all approved services up to 80% after the deductible has been met.
- Medicare Part C/Medicare Advantage (MA): A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. There are many types of Medicare Advantage Plans (MAP) include HMOs, PPOS, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans. If you’re enrolled in an MA plan, Medicare services are covered through the plan and aren’t paid for under Parts A and B. Most Medicare Advantage Plans offer prescription drug coverage. If you choose an advantage plan, you are not eligible to obtain a secondary policy.
- Medicare Part D: An optional program that provides prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.
- Medicare Part F or G (medigap): A secondary health plan to Medicare Part B that helps with the remaining 20% that Medicare Part B does not cover.
Make sure you know the coverage before enrolling. Since Medicare plans vary from state to state and even by counties within a state, you need to research what plans you are eligible for. You can contact your State Health Insurance Assistance Program (SHIP) to find trained counselors who can tell you the plans you are eligible for and assist you in finding the answers to your questions regarding coverage. To find your state’s SHIP program contact information, go to http://bit.ly/SHIPprograms.
Minimum Essential Coverage: 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, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
Minimum Value: A health plan meets this standard if it’s designed to pay at least 60% of the total cost of medical services for a standard population. Starting in 2014, individuals offered employer-sponsored coverage that provides minimum value and that’s affordable won’t be eligible for a premium tax credit if they choose to purchase health insurance through the Marketplace/Exchange.
Modified Adjusted Gross Income (MAGI): The figure used to determine eligibility for lower costs in the Marketplace/Exchange and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.
Navigator: An individual or organization that’s trained to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace/Exchanges established pursuant to the Affordable Care Act. Navigators assist consumers with completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased and their services are free to consumers.
New Plan: As referenced in the Affordable Care Act, a health plan that is not grandfathered and therefore subject to the reforms in the Affordable Care Act. In the individual health insurance market, this is a plan that your family is purchasing for the first time. In the group health insurance market, this is a plan that your employer is offering for the first time. New employees and new family members may be added to existing grandfathered group plans – so a plan that is new to you and your family may still be a grandfathered plan.
In both the individual and group markets, a plan that loses its grandfathered status will be considered a new plan. This happens when it makes significant changes to the plan, such as reducing benefits or increasing cost-sharing for enrollees (See Grandfathered Plan).
Open Enrollment Period (OEP): The time period set up to allow you to choose from available plans, usually once a year.
Out-of-Network Coinsurance: The percentage (for example, 40%) you pay of the allowed amount for covered healthcare services to providers who don’t contract with your health insurance or plan. Out-of-network (OON) coinsurance usually costs you more than in-network coinsurance. The amount of coinsurance you pay may be more when you use an out-of-network provider.
Out-of-Network Co-payment: A fixed amount (for example, $30) you pay for covered healthcare services from providers who don’t contract with your health insurance or plan. Out-of-network (OON) co-payments usually are more than in-network co-payments. The co-payment you pay may be more when you use an out-of-network provider.
Out-of-Network Providers: A duly licensed or certified institution or health professional not under contract with your insurance provider.
Out-of-Pocket (OOP) Limit: The maximum amount you will be required to pay for covered services in a year, before the plan covers 100% of all costs. Generally, this includes the deductible, coinsurance, and co-payments (varies from plan to plan), but not premiums. Plans can set different out-of-pocket limits for different services.
Patient-Centered Outcomes Research Institute (PCORI): Institute authorized by the Affordable Care Act (ACA) to conduct comparative effectiveness research (CER).
Pharmacy Benefit Manager (PBM): Health plans and sponsors contract with Pharmacy Benefit Managers to handle the claims processing and administrative functions involved with prescription drug programs. In addition to processing and paying claims, PBMs develop and maintain a program drug formulary, contract with participating pharmacies and negotiate discounts and rebates with drug manufacturers.
Plan Year: A 12-month period of benefits coverage under a group health plan. This 12-month period might be different than the calendar year, depending on when your health plan renews.
Policy Year: A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period might be different than the calendar year.
Point-of-Service Plan (POS) Plan: A type of plan in which you pay less if you use doctors, hospitals and other healthcare providers that belong to the plan’s network. POS plans may also require you to get a referral from your primary care doctor in order to see a specialist.
Preauthorization: A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. This is sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Pre-Existing Condition: With certain limited exceptions, a pre-existing condition is any condition (physical, mental or a disability) for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period before you enrolled in a health insurance plan. Before passage of the ACA, insurers could either not offer health insurance to you if you had a pre-existing condition or could refuse to cover any services related to a pre-existing condition (known as a pre-existing condition exclusion). As of September 23, 2010 (for children) and as of January 1, 2014 (for adults), health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition. Coverage for pre-existing conditions begins immediately.
Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers who belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost.
Premium: A monthly or annual payment you make to your insurer to get and keep insurance coverage. Premiums can be paid by employers, unions, employees or individuals or shared among different payers.
Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.
Preventive Services: Routine healthcare that includes screenings, checkups, and patient counseling to prevent illnesses, disease or other health problems.
Primary Care: Health services that cover a range of prevention, wellness and treatment options for common illnesses. Primary care providers (PCP) include doctors, nurses, nurse practitioners and physician assistants. They often maintain long-term relationships with you, and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.
Qualified Health Plan (QHP): Under the Affordable Care Act, an insurance plan that is certified by a Marketplace/Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts) and meets other requirements. A qualified health plan will have a certification by each Marketplace/Exchange in which it is sold.
Qualifying Event: Any event or occurrence such as death, termination of employment, divorce or a terminal illness that changes an employee’s eligibility status and permits an acceleration or continuation of benefits or coverage under a group health plan. The term is most frequently used in reference to COBRA eligibility.
Rate Review: A process that allows state insurance departments to review rate increases before insurance companies can apply them to you.
Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Rehabilitative/Rehabilitation Services: Healthcare services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Rescission: The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Rider (Exclusionary Rider): An amendment to an insurance policy. Some riders add coverage while other riders exclude coverage (known as exclusionary rider). Example: You buy a maternity rider to add coverage for pregnancy to your policy. An exclusionary rider is an amendment permitted in individual policies that permanently excludes coverage for a health condition, body part or body system (such as a certain disease state or disability). Beginning January 1, 2014, no exclusionary riders are permitted in any health insurance plan.
Self-Insured Plan: Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.
Skilled Nursing Facility (SNF) Care: Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Example: Physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
Small Business Health Options Program (SHOP): The Marketplace/Exchange available to small businesses under the Affordable Care Act. Small businesses buying plans in the SHOP select the plan and decide how much they pay toward employee premiums. Participating small businesses may qualify for a small business health tax credit worth up to 50% of their premium costs.
Social Security Disability Income (SSDI): Income payable by the federal government to individuals who are determined to be totally disabled.
Special Enrollment Period (SEP): A time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status (such as marriage or birth of a child) or loss of other job-based health coverage.
Special Healthcare Need: The healthcare and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally.
Specialty Pharmacy Provider (SPP): A pharmacy that is designated to provide specialized medication for complex, genetic, rare, and chronic health conditions. Specialty pharmacy providers may provide home health or nursing services.
State Based Marketplace/State Based Exchange (SBM/SBE): One of the three types of Marketplace/Exchange options for states under the Affordable Care Act. States opting for an SBM/SBE will manage their own Marketplace/Exchange in accordance with applicable federal laws.
State Continuation Coverage: A state-based requirement similar to COBRA that applies to group health insurance policies of employers with fewer than 20 employees. In some states, state continuation coverage rules also apply to larger group insurance policies and add to COBRA protections. Example: in some states, if you’re leaving a job-based plan, you must be allowed to continue your coverage until you reach the age of Medicare eligibility.
State Partnership Marketplace/State Partnership Exchange (SPM/SPE): One of the three types of Marketplace/Exchange options for states under the Affordable Care Act. States opting for an SPM/SPE will have a Marketplace/Exchange that is run by the federal and state government jointly.
Summary of Benefits and Coverage (SBC): The Affordable Care Act requires plans to offer this easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
Supplemental Security Income (SSI): A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits are different than Social Security retirement or disability benefits.
Third Party Administrator (TPA): An individual or firm hired by an employer to handle claims processing, pay providers and manage other functions related to the operation of health insurance. The TPA is not the policyholder or the insurer. The TPA may often be a company you associate with health insurance, such as Aetna or Blue Cross, but in this role it is not the actual insurer but simply managing the plan on behalf of the employer.
TRICARE: A healthcare program for active-duty and retired uniformed services members and their families.
Urgent Care: Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Usual, Customary and Reasonable (UCR) Charges: A healthcare provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount. Conventional indemnity plans typically operate based on UCR charges.
Veteran’s Health Benefits: Veterans may be eligible for a broad range of services, including healthcare benefits, through the Veteran’s Administration.
Waiting Period (Employer Coverage): The time that must pass before coverage can become effective for an employee or dependent, who is otherwise eligible for coverage under a job-based health plan. Applies to all new employees, and is not based on health status. This is different than a pre-existing condition exclusion period, which is applied to individual employees and is based on health status.
Well-Baby/Well-Child Visits: Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services include physical exam and measurements, vision and hearing screening, and oral health risk assessments.
Wellness Programs: A program intended to improve and promote health and fitness that’s usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships and other incentives to participate. Examples: programs to help you stop smoking, diabetes management programs, weight loss programs and preventive health screenings.
Other Healthcare and Insurance-Related Acronyms
CCIIO: Center for Consumer Information and Insurance Oversight
COB: Coordination of Benefits
CSR: Cost-Sharing Reduction
DME: Durable Medical Equipment
ECP: Essential Community Provider
EHB: Essential Health Benefits
EMR: Electronic Medical Record
EOB: Explanation of Benefits
EPO: Exclusive Provider Organization
ERISA: Employee Retirement Income Security Act
FFM/FFE: Federally Facilitated Marketplace/ Federally Facilitated Exchange
FPL: Federal Poverty Level
FQHC: Federally Qualified Health Center
FSA: Flexible Spending Account
HCR: Healthcare Reform
HCBS: Home and Community-Based Services
HHS: U.S. Department of Health and Human Services
HIPAA: Health Insurance Portability and Accountability Act
HIM/HIX: Health Insurance Marketplace/ Health Insurance Exchange
HMO: Health Maintenance Organization
HRP: High Risk Pool
HRSA: Health Resources and Services Administration
HSA: Health Savings Account
HDHP: High Deductible Health Plan
IPA: In-Person Assisters Program
LTC: Long-term Care
MA: Medicare Advantage
OEP: Open Enrollment Period
PBM: Pharmacy Benefit Manager
PCIP: Pre-existing Condition Insurance Plan
PCORI: Patient-Centered Outcomes Research Institute
PCP: Primary Care Provider
POS: Point-of-Service Plan
PPO: Preferred Provider Organization
QHP: Qualified Health Plan
SBC: Summary of Benefits and Coverage
SBM/SBE: State Based Marketplace/State Based Exchange
SEP: Special Enrollment Period
SHOP: Small Business Health Options Program
SNF: Skilled Nursing Facility
SPP: Specialty Pharmacy Provider
SSDI: Social Security Disability Income
SSI: Supplemental Security Income
TPA: Third Party Administrator