Health Reform Glossary
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Accountable care organization – A group of health care providers that have entered into a formal arrangement to assume collective responsibility for the care of a specific group of patients and that receive financial incentives to improve the quality and efficiency of health care. .
ACO – See Accountable care organization.
Actuarial value– A mathematical calculation used to determine the monetary value of benefits.
Acute episodes of care – A period of time related to a major health event that requires medical intervention. An episode of care may include tests performed prior to surgery, a surgical procedure, and post-operative treatment or follow-up care.
Administrative expenses — The expenditures by health insurance companies or public insurance programs other than payments for clinical services. These include may include fraud prevention, verification of provider credentials, and other expenses that are not directly related to patient care.
Administrative transactions – The exchange of health care information between health plans and providers to determine eligibility, coverage, and payment for health services.
Advanced care planning – A process in which a patient and physician discuss treatment options and develop a treatment or care plan. This is helpful for patients who choose to make their preferences known to family members and providers in case they are incapacitated, as well as for those with a terminal illness.
Affordability – See Affordable coverage.
Affordable coverage – A term used in the health reform law to designate both the types of coverage arrangements available to individuals and the level of family income that is considered available to pay health insurance premiums. The term is used to describe an individual who lacks access to coverage below 8 percent of household income for the purposes of being eligible for a free choice voucher and below 9.8 percent of income for purposes of allowing the purchase of a catastrophic health insurance plan. Medicaid, employer-sponsored coverage, coverage secured through state health insurance exchanges, and the Children’s Health Insurance Program (CHIP),all are considered forms of coverage. The health reform law also directs the HHS Secretary to conduct a study of affordable coverage.
Agency for Healthcare Research and Quality – The federal agency within the United States Department of Health and Human Services that has lead responsibility for efforts to improve the quality of health care and the promotion of health services research.
AHRQ – See Agency for Healthcare Research and Quality.
American Health Benefit Exchanges — The name given by the health reform law to the state-based insurance exchanges through which individuals will be able to purchase health insurance starting in 2014.
American Recovery and Reinvestment Act of 2009 — The American Recovery and Reinvestment Act of 2009, Pub. L. 111-5, commonly known as the stimulus bill. It provided funds for, among other matters, investments in health information technology, expansion of community health centers, and comparative effectiveness research.
Annual limits – Limits imposed by insurers or employer sponsored health benefit plans on the amount of covered treatment or services that will be considered covered during a single plan year. Limits may be expressed in dollar or quantitative terms (e.g., no more than $1000 annually; no more than 30 treatments annually). The health reform law addresses dollar limits but not quantitative treatment limits.
Antitrust law – A body of federal laws whose purpose is to promote market competition and to prevent anticompetitive, monopolistic, and collusive conduct. Health insurers are exempt from certain aspects of antitrust law, but not others. Antitrust laws also cover health care providers.
Appeals – The process by which health insurance beneficiaries can dispute a denial, reduction, or delay in covered treatments and services.
ARRA — See American Recovery and Reinvestment Act of 2009.
Basic health programs – An option under the Patient Protection and Affordable Care Act that permits a state to establish and oversee a health insurance program for low-income persons who are ineligible for Medicaid and whose family incomes do not exceed twice the federal poverty level. States electing this option would cover the low-income population directly, rather than through a health insurance exchange. States would receive direct federal assistance for the cost of establishing and administering such programs equal to the premium support available were low-income individuals to enroll into an exchange-qualified health plan.
Benchmark coverage –Benefit plans defined under Section 1937 of the Social Security Act that states may use in lieu of Medicaid mandatory and optional benefits, for newly eligible Medicaid beneficiaries, who gain eligibility as a result of the provisions of the health reform law.
Bundled payment – A single payment for all health care services related to a specific course of treatment or condition over a period of time.
Bundled payment system – Under a bundled-payment system, providers are not reimbursed for each discrete service, interaction, or procedure. Instead, a single payment is made for each episode of care for a single patient, which is divided appropriately amongst the providers involved in his or her care.
Bundling – A health insurance payment arrangement under which which providers are paid a set amount for the treatment they furnish for a particular condition or for an “episode of care.” In contrast to fee-for-service payments, which can encourage a high volume of treatment, “bundling” is thought to incentivize more cost-effective care.
Cadillac health plan – A term used to describe health coverage available through employee health benefit plans where the value of the coverage exceeds a stated annual dollar threshold. See also Excise tax.
Cafeteria plan – A benefit plan sponsored by an employer under which employees may set aside pre-tax wages to be used for various expenses, including medical expenses not otherwise covered by their health insurance, such as copayments and deductibles, or uncovered medical costs, such as dental care. The special accounts that hold these pre-tax wages to be spent on health care are known as Flexible Spending Accounts (FSAs). Health reform legislation limits employee contributions to FSAs to $2,500 annually (indexed for inflation) and reverses previous policy by prohibiting their use for over-the-counter medications.
CDC – See Centers for Disease Control and Prevention.
Center for Medicare and Medicaid Innovation – A unit within the Centers for Medicare and Medicaid Services that under the health reform law is responsible for overseeing demonstrations and pilot programs aimed at increasing the efficiency and quality of Medicare, Medicaid, and CHIP.
Centers for Medicare and Medicaid Services – The federal agency within the United States Department of Health and Human Services that administers Medicare, Medicaid, CHIP, and innovations in federal insurance programs. CMS also oversees state demonstration programs under §1115 of the Social Security Act as well as other demonstration and pilot programs involving Medicare, Medicaid, and the Children’s health Insurance Program (CHIP)
Centers for Disease Control and Prevention – The CDC is a federal agency within the Department of Health and Human Services charged with disease prevention, education, and public health activities.
CER – See Comparative Effectiveness Research.
Children’s Health Insurance Program– A program established in 1997 and reauthorized in 2009, which is administered by states and funded through a combination of federal and state payments. CHIP allows states to provide health insurance (known as child health assistance) to uninsured “targeted” low-income children. States also may provide coverage to targeted low-income pregnant women. State CHIP programs can establish state CHIP plans as separately administered programs, Medicaid expansions, or a combination of the two. Unlike Medicaid, the CHIP program caps federal funds available to states and must periodically be reauthorized.
CHIP – See Children’s Health Insurance Program.
CLASS Act – A federal program of voluntary long-term care insurance.
CMS – See Center for Medicare and Medicaid Services.
COBRA – The nickname for a law, enacted as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), that allows individuals to continue to purchase employee health benefits for a period of 18 to 36 months following a “qualifying event” such as unemployment, death of a wage earner, divorce, or termination of minor dependent coverage.
Coinsurance – Cost-sharing for covered health insurance benefits and services, expressed as a percentage of the approved payment amount for the benefit or service (e.g., 20 percent of the payable amount).
Community health centers – Non-profit clinics established under the Public Health Service Act and that provide or arrange for a broad range of primary health care services. Health centers must meet a series of federal criteria related to the scope of care they furnish, the prospective adjustment of charges in accordance with the ability to pay, location in or service to medically underserved communities and populations, and governance by a community board, 51% of whom must be patients of the clinic. See also, Federally Qualified Health Centers.
Comparative effectiveness research– A specific type of health services research that compares different approaches to treating medical conditions in order to determine which methods are most likely to produce the best outcomes.
Comptroller General of the United States – See Government Accountability Office.
CO-OP Program – A special program established under the Patient Protection and Affordable Care Act that allows for the development of qualified non-profit health plans selling essential health benefit plans through state exchanges.
Coordination of benefits – The process of reconciling health care that is covered by more than one form of health insurance. For example, if a child is insured through both parents, one insurer is generally considered the primary policy, and the secondary policy reimburses for services not covered under the primary policy.
Copayments– Cost-sharing for covered health insurance benefits, expressed as a flat dollar payment (e.g., $5.00 for a prescription drug).
Cost-sharing – A requirement that insured patients pay a portion of their medical costs, either as a deductible, or a flat dollar copayment, or as coinsurance (i.e., a percentage of the total paid claim for a covered benefit or service).
Creditable coverage– A term that encompasses public and private health insurance as well as coverage under certain other arrangements such as the Indian Health Service. The term is defined in §2701(c) of the Public Health Service Act.
Culturally and linguistically appropriate and competent services – A federal standard designed to assure better access and quality of care in order to eliminate ethnic and racial disparities in health care.
Current coverage – A health insurance policy in effect before the effective date of the Patient Protection and Affordable Health Care Act. Current coverage is “grandfathered” under the law. Certain new requirements, such as a prohibition on excessive waiting periods, limits on lifetime coverage, prohibitions against rescissions, and extension of dependent coverage, would apply to grandfathered plans.
Deductible– The amount patients must pay out of pocket before coverage begins.
Department of Defense– The federal cabinet-level agency that administers health care programs for active military and their dependents. Coverage is furnished through a publicly funded and privately administered health program called TriCare. The DOD also administers federal military health care facilities.
Department of Health and Human Services – The federal cabinet-level agency that administers federal health, welfare, and human services programs and activities. HHS has lead agency responsibility for significant aspects of the Patient Protection and Affordable Care Act and is home to the Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the National Institutes of Health, the HHS Inspector General, the HHS Office for Civil Rights, the HHS Office of Minority Health, the Substance Abuse and Mental Health Services Administration, the Indian Health Service, and other federal agencies that oversee the Patient Protection and Affordable Care Act.
Department of Labor – The federal cabinet-level agency responsible for administration and enforcement of the Employee Retirement Income Security Act (ERISA), a federal law that sets requirements for private employer-sponsored health benefit plans, both those that are self-insured as well as plans that are fully insured.
Dependent coverage – Health insurance coverage of a spouse, child, or domestic partner of an insured individual.
Diagnosis related group – A system of patient care classification based on diagnosis, which is used to establish payment rates to hospitals. Certain further adjustments are made to the payment based on patient age, geographic location and severity of illness.
Discrimination based on health status – Insurer practices that deny coverage either prior to or following enrollment. Discrimination at the point of enrollment can encompass the total denial of enrollment or the imposition of waiting periods or pre-existing condition exclusions following enrollment. Post enrollment discrimination can involve the use of flat limits on treatment (expressed either on a dollar or quantitative basis) that are aimed at limiting coverage for costlier conditions. For example, a child born with cerebral palsy might be denied coverage entirely; alternatively an insurer might impose waiting periods, exclusions on coverage, or limits on the amount of coverage available for certain treatments (e.g., only $10,000 annually for physical therapy or only 20 physical therapy sessions annually, or a total exclusion of physical therapy for conditions related to birth injuries). .
Discrimination in health care – Differences in patient treatment by health care providers based on race, gender, age, ability to pay for care, disability, language, or severity of illness. Under federal civil rights laws, discrimination may be intentional or de facto.
Disproportionate share hospital – A hospital whose patients are disproportionately low-income as measured by federal standards under the Medicare and Medicaid programs. DSH hospitals receive additional payments to offset the greater severity of illness present among low-income patients.
DOD– See Department of Defense.
DOL – See Department of Labor.
DRG – See Diagnosis related group.
DSH – See Disproportionate share hospital.
Dual Eligibles — Low-income individuals who meet the eligibility requirements for both the Medicaid and Medicare programs.
Early retiree – Early retirees are defined under the Patient Protection and Affordable Care Act as individuals aged 55 and over who are not yet eligible for Medicare.
EHR – See Electronic Health Record.
Elder Justice Act – Provisions included the health reform law to authorize services and supports aimed at protecting elderly persons from the knowing infliction of physical or psychological harm.
Electronic Health Record – An evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems.
Eligible individual – A term used in the health reform law to describe an individual who meets the eligibility criteria for a program or service authorized under federal law. Program or benefit criteria vary based on the program.
Emergency Medical Treatment and Labor Act – A federal law that obligates all Medicare-participating hospitals with emergency departments to furnish an “appropriate” screening, stabilization care, or a medically appropriate transfer. ETMALA obligations are triggered for individuals who come to an emergency department and on whose behalf a request for screening is made. EMTALA duties are not limited to uninsured or medically indigent persons.
Employee Retirement Income Security Act – A law passed by Congress in 1974, which establishes federal standards governing both pension plans and employer-sponsored “health and welfare benefit plans,” offered by private employers. Church plans are exempt, as are public employee health benefit plans. The health reform law establishes additional federal standards for ERISA-governed health benefit plans.
Employer mandate – See Employer responsibility.
Employer responsibility– A requirement that certain employers assist in the cost of coverage for workers and their dependents, either through the provision of a health plan or through contribution toward coverage via a payment on the individual’s behalf to a state health insurance exchange. This is also referred to as an “employer mandate.”
Employer sponsored insurance– A health benefit plan offered by an employer to employees and dependents. Health insurance coverage is optional for employers. Employers may opt to purchase an insurance policy for their employees, offer coverage on a self-insured basis, or a combination of the two.
EMTALA – See Emergency Medical Treatment and Labor Act.
Episode of care– A concept that focuses on a health condition from its inception through treatment as a means of measuring both the quality of care received and the efficiency of the care provided. For example, an episode of care in the context of a stroke would include a specified period of time preceding the stroke, the acute hospitalization episode, and aftercare aimed at helping an individual recover from the stroke and its effects. Episodes of care are the unit by which bundled payment arrangements will be designed and the quality of care measured.
ERISA – See the Employee Retirement Income Security Act.
ESI – See Employer sponsored insurance.
Essential health benefits package – See Essential health benefits.
Essential health benefits – The minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide.
Excessive waiting periods – The period of time before coverage begins for a new enrollee. The Patient Protection and Affordable Care Act limits waiting periods to no more than 90 days.
Exchange-eligible employer – An employer that is permitted to obtain coverage for its employees through a state health insurance exchange.
Exchange-eligible individual – An individual who is permitted to obtain coverage through a state health insurance exchange.
Exchange-participating health benefits plan contracts – Contracts signed between the administrator of an exchange and health insurers that govern products sold in an exchange.
Exchange-participating health benefit plans – Health insurance plans offered to individuals and small employers through health insurance exchanges. Companies offering plans in the exchange must meet federal and applicable state requirements.
Exchanges — State health insurance “marketplaces” whose establishment was mandated by the Affordable Care Act. Exchanges are to be established by 2014 for individuals and small employer groups (exchanges for small employers are known as SHOP Exchanges). Exchanges are responsible for calculating premiums subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the exchange, and other matters. By standardizing health insurance products, enrollment, operations, and oversight, exchanges are also meant to make the process of selecting insurance easier and transparent.
Excise tax – A tax on health insurance and health benefit plans whose annual dollar value exceeds a specified limit, as well as on the sale of certain health care items and services such as medical devices and equipment. See also Cadillac health plan.
Exclusion – The denial of coverage on the basis that the requested item or service is not covered under the terms of the plan. An exclusion differs from a medical necessity denial because treatment is not covered regardless of the medical facts of a particular case. An example would be a request for a prescription drug not on a plan’s drug formulary or exclusion of particular types of surgery (e.g., bariatric surgery).
Fair marketing – A term that encompasses a range of reforms aimed at assuring accuracy and completeness in the information provided by an insurer or health benefit plan, fairness in the premium charged, and reasonable and fair practices in coverage.
FDA – See Food and Drug Administration.
Federal Employee Health Benefits Plan – The health benefit plan that covers federal civilian employees and their dependents.
Federal Medical Assistance Percentage — The proportion of total state Medicaid expenditures paid by the federal government, commonly referred to as FMAP. A state FMAP is based on a formula that takes into account state per capita income; by law the federal share is set at a minimum of 50 percent and a maximum of 83 percent. The FMAP for each state is calculated each year by the Secretary of Health and Human Services.
Federal Poverty Level – Income criteria that are adjusted by family size and are published by HHS that are used to determine eligibility for income-related programs, such as Medicaid and the CHIP. Although guidelines are usually updated and published in March of each year, Congress has prohibited HHS from updating the 2009 guidelines until after March 1, 2010. As of date of posting, HHS has not updated the guidelines. Current guidelines are available online at: http://aspe.hhs.gov/POVERTY/09extensionfedreg.shtml.
Federal Trade Commission – An independent federal agency charged with protecting consumers from anticompetitive practices in the health care industry and other types of conduct that violates federal laws related to competition.
Federally Qualified Health Center – A federally funded community health center, as well as a health center that meets all federal requirements applicable to the federal community health centers program (location, scope of services, use of a sliding fee scale, and community board governance) but that does not actually receive a federal grant. Because of their location and high level of treatment of the uninsured, FQHCs receive special payment rates from Medicare, Medicaid. and CHIP and are eligible for special supplemental payments from exchange-participating health insurance plans. See also Community health centers.
Fee-for-service — A health care payment arrangement in which health care professionals are paid for each procedure they furnish.
FEHBP – See Federal Employee Health Benefits Plan.
Flexible Spending Accounts – See Cafeteria plans.
FMAP — See Federal Medical Assistance Percentage.
Food and Drug Administration – The federal agency within the United States Department of Health and Human Services responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), veterinary products, and cosmetics.
FQHC – See Federally Qualified Health Center.
Fraud and abuse – Practices by health insurers or health care providers that violate a range of federal and state civil and criminal laws such as the filing of false claims, payment or receipt of bribes and kickbacks, racketeering, self-referrals and other forms of prohibited self-dealing, and violation of laws requiring good faith and fair dealing.
FTC – See Federal Trade Commission.
Gainsharing– Allowing health care providers that meet standards of quality and efficiency to share in savings realized by insurers for reduced use of unnecessary care.
GAO – See Government Accountability Office.
Government Accountability Office– A special arm of Congress that oversees the integrity and accountability of federal programs and expenditures and that is headed by the Comptroller General of the United States.
Government Performance Results Act– A federal law enacted in 1993 designed to prevent waste and fraud in federal programs, which, as a result of amendments in the Patient Protection and Affordable Care Act, is strengthened in terms of federal enforcement and violations for penalties.
GPRA – See Government Performance Results Act.
Graduate medical education – See Graduate medical education payments.
Graduate medical education payments – Payments made under Medicare or other health care financing authorities to support the cost of medical residency training.
Grandfathered health plan– See Grandfathered plan.
Grandfathered plan – A health benefit plan or health insurance policy in effect as of the date of enactment of the Patient Protection and Affordable Care Act. The term is not defined in the law; the Departments of Health and Human Services, Labor, and Treasury are expected to provide additional clarification regarding the conditions under which grandfathering protections are available as well as what constitutes a “plan” that may be subject to grandfathering limitations.
Grievances – A complaint against an insurer or health plan other than one involving the denial of covered benefits. An example of a grievance would be inappropriate behavior by a network provider or too few pharmacies that are members of a network.
Guaranteed issue and renewal – A rule that bars insurers from denying enrollment or dropping coverage for reasons other than fraud or non-payment of health insurance premiums. Guaranteed issue and renewal are commonly associated with the Patient Protection and Affordable Care Act’s broad prohibition against discrimination on the basis of health status.
Hawaii Prepaid Health Act – Hawaii’s state law, enacted in 1974 (and later exempted from ERISA’s bar against state laws that regulate employee benefit plans) that requires employers to provide health insurance coverage to employees who work more than twenty hours per week.
HealthCare.gov — A website maintained by the Office of Consumer Information and Insurance Oversight of the Department of Health and Human Services that provides information to consumers on available insurance options, data on care quality, and resources for disease prevention.
Health care homes – Primary health care providers that furnish or arrange for comprehensive primary health care, use health information technology, and meet federal and state standards of quality and efficiency. Health care home demonstrations are authorized under the Patient Protection and Affordable Care Act.
Health care related taxes – Taxes imposed on the health care industry under the Patient Protection and Affordable Care Act on health insurance plans, prescription drugs, and medical devices.
Health coverage participation – The requirement under the Patient Protection and Affordable Care Act that most individuals not eligible for public insurance programs purchase private health insurance coverage.
Health disparities – Measurable differences in health and health care that are associated with race, ethnicity, income, language, place of residence, and other factor unrelated to the need for or ability to benefit from health care.
Health information privacy and security – Standards and procedures to ensure that personal health information is not compromised or disclosed in processing health care transactions.
Health information technology – Technology that allows the comprehensive management of health information and enables its exchange among health professionals, consumers, health care providers, health care payers, and public health agencies.
Health Information Technology for Economic and Clinical Health Act – Part of American Recovery and Reinvestment Act, the act imposes more stringent regulatory requirements under the security and privacy rules of HIPAA, increases civil penalties for a violation of HIPAA, provides funding for hospitals and physicians for the adoption of health information technology, and requires notification to patients of a security breach.
Health insurance issuers – Entities that sell health insurance products to employer-sponsored health plans, individuals in exchanges, and the open market.
Health insurance market reforms – Reforms contained in the Patient Protection and Affordable Care Act that are designed to stop certain types of exclusionary or discriminatory activities by insurers. Conduct specifically targeted by market reforms encompasses the use of preexisting condition exclusions, discrimination based on health status, fair health insurance premiums whose rates vary by family size, rating area, age and tobacco use, guaranteed availability and renewability of coverage, non-discrimination against health care provider participation, and the use of excessive waiting periods.
Health insurance ombudsman – A grant program authorized under health reform legislation to assist in health insurance enrollment, eligibility for premium assistance eligibility determinations, consumer education on rights and responsibilities, and assistance in dispute resolution between plan beneficiaries and health insurers.
Health Insurance Portability and Accountability Act – A federal law that regulates health information privacy, health insurance portability and non-discrimination and health insurance simplification and whose provisions have been broadly expanded by the Patient Protection and Affordable Care Act.
Health Resources and Services Administration – A federal agency within the Department of Health and Human Services (HHS) that administers a range of federal health care access, health professions education programs, including community health centers, the National Health Service Corps, health professions training programs, the 340 B prescription drug program, and the Maternal and Child Health Block Grant Program. HRSA also administers the organ transplant program.
HHS — See Department of Health and Human Services.
High-risk pools – A method provided under the Patient Protection and Affordable Care Act for insuring individuals with pre-existing conditions who have been uninsured for six months. High-risk pools will be operated by states during the period prior to the implementation of health insurance exchanges as a means of providing coverage availability to individuals who otherwise cannot secure coverage in the individual market. The subsidies that are available to exchange participants in 2014 will not begin earlier for high-risk pool participants.
HIPAA – See Health Insurance Portability and Accountability Act.
HIT – See Health information technology.
HITECH – See Health Information Technology for Economic and Clinical Health Act.
Home and community-based services – Health care services offered in the home and community to individuals with serious and chronic physical, mental, or developmental conditions that require ongoing care. Home and community based services are designed to promote community residence and to avoid unnecessary institutional care.
HRSA – See Health Resources and Services Administration.
Indian Health Care Improvement Act – A federal law that provides for the establishment and support of health care services to American Indians, Native Hawaiians, and Alaska Natives. The Indian Health Care Improvement Act is overseen by the Indian Health Service.
Indian Health Service – The federal agency within the United States Department of Health and Human Services that oversees health care programs and services for American Indians, Native Hawaiians, and Alaska Natives.
Individual market – The health insurance market for individuals who purchase health insurance directly rather than through an employer-sponsored or other group health plan. This is also known as the “non-group market.”
Individual responsibility – The requirement that all individuals obtain health insurance or pay a penalty. This is also referred to as the “individual mandate.”
Information transparency – Provisions of the Patient Protection and Affordable Care Act that promote clearness and fairness in health insurance information including coverage, rights and responsibilities, and patient and consumer protections. The law mandates that information on health plan terms and conditions and payment policies be spelled out in plain language consumers can understand.
Inspector General – The office within the Department of Health and Human Services (HHS) that is charged with protecting the financial integrity of programs administered by the Department, protecting the health and welfare of program beneficiaries and reporting problems to the secretary of HHS and Congress along with recommendations for correcting identified problems.
Insurance premium rating – The process by which health insurers determine what rates will be charged for health insurance premiums, taking into consideration age, health status, gender, industry, certain personal health care practices (such as use of tobacco), geography, and other factors.
Interagency working group on health care quality – A working group established as part of a national strategy to improve health care quality. The group will identify national priorities for quality improvement as determined by certain criteria and coordinate efforts across federal and state agencies and programs as well as the private sector to achieve quality improvement.
Interstate health insurance compacts – An agreement among multiple states to permit the sale of multiple-state licensed insurance products across state lines.
Large employers – Employer groups that, on average, of a certain number of full-time employees. The definition of large employer varies based on the provision of law. For determining participation in insurance markets, a large employer has 101 or more employees. For determining whether a large employer may be subject to a fine if the employer fails to provide coverage, a large employer has 50 or more employees.
Large group market — The private health insurance market for large businesses purchasing coverage for their employees.
Lifetime limits – An aggregate upper limit on the amount of benefits that an insurer will pay over the lifetime of a policy.
MACPAC – See Medicaid and CHIP Payment and Access Commission.
Meaningful User — Certain health care providers that are able to demonstrate a level of use of certified health information technology (HIT) that meets standards established by the Secretary of Health and Human Services. The concept of “meaningful users” of certified HIT was added to Medicare and Medicaid by the American Recovery and Reinvestment Act (ARRA), which identifies physicians, hospitals, and certain health care entities such as rural health clinics and federally qualified health centers as eligible to be certified as meaningful users. Meaningful users of HIT are entitled to Medicare and Medicaid incentive payments between FY 2011 and 2015 and can avoid Medicare financial penalties thereafter.
Medicaid – A federal program enacted in 1965 that is funded by the federal and state governments and administered by the states that provides health insurance coverage to certain low-income populations. The Patient Protection and Affordable Care Act expands Medicaid to cover all low-income individuals with family incomes below 133 percent of the federal poverty level. Medicaid is a major source of health insurance coverage for “dual enrollees” who are elderly and disabled Medicare beneficiaries who are low-income or medically impoverished and who qualify for both Medicare and Medicaid.
Medicaid and CHIP Payment and Access Commission – A congressional advisory committee established by the Patient Protection and Affordable Care Act responsible for advising Congress on methods to improve the performance of the Medicaid and CHIP programs, including eligibility, enrollment and retention, coverage and quality, interactions between Medicare and Medicaid, and other matters.
Medical home – Health care entities that offer and arrange for comprehensive health care, meet performance, quality, and efficiency standards, use health information technology, and meet other requirements that may be established by public and private health insurers.
Medical Loss Ratio — A medical loss ratio (MLR) is the proportion of premium dollars that an insurer spends on health care services and certain recognized plan administration costs relative to health insurance premium paid by subscribers. The Affordable Care Act requires health insurers offering health insurance coverage in either the group or individual (non-group) market to submit an annual report to the Secretary of Health and Human Services on their MLR and to provide rebates in circumstances in which losses exceed permissible levels (80% in the individual market and 85% in the group market) The MLR and rebate requirements apply to both new and grandfathered insurance plans and go into effect for plan years beginning September 23, 2010.
Medical underwriting – The practice of assessing the medical condition of individuals prior to insurance enrollment in order to identify existing physical or mental health conditions that may affect eligibility for enrollment or the level of coverage following enrollment. The Patient Protection and Affordable Care Act limits medical underwriting both prior to and following enrollment in order to eliminate discrimination based on health status. Medical underwriting may result in the total exclusion from a plan (i.e., the denial of availability) or restrictions on coverage for individuals once they are enrolled.
Medicare Advantage – Private health insurance plans and HMOs that participate in Medicare and into which Medicare beneficiaries may elect to enroll.
Medicare donut hole– The uncovered portion of a Medicare beneficiaries’ Part D prescription drug benefit plan that leaves them financially obligated for the cost of covered prescription drugs once a certain level of expenditures is reached during an enrollment year. The Patient Protection and Affordable Care Act gradually eliminates the donut hole.
Medicare – The federal health insurance program for individuals ages 65 and older, as well as persons with end-stage renal disease and certain persons with disabilities. Medicare covers beneficiaries for hospital, post-hospital extended care, and home health care, as well as a range of medical care services and benefits. Medicare enrollment is compulsory for all individuals covered by the Social Security Act. At their option, Medicare beneficiaries can buy “Part D” outpatient prescription drug coverage. Beneficiaries can elect to enroll either in “traditional” Medicare (which allows patients to receive care from any participating physician, hospital or health care supplier) or through Medicare Advantage plans, most of which restrict patients to specific network providers while typically offering additional benefits and coverage. The Patient Protection and Affordable Care Act expands Medicare coverage for preventive services and additional levels of prescription drug coverage while also introducing reforms to improve health care quality and efficiency.
Medicare Part D — The outpatient prescription drug benefit component of Medicare, established by the Medicare Modernization Act of 2003, Pub. L. 108-173. Part D establishes an optional program for Medicare beneficiaries through which they can pay a premium and enroll in an outpatient prescription drug plan that will pay a portion of their prescription drug costs.
Medicare Payment Advisory Commission – An independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
Medigap policies — Supplemental insurance policies that meet state licensure and federal certification standards and that are sold by private insurance companies to Medicare beneficiaries. Medigap policies cover costs not covered by the Medicare program.
MedPAC – See Medicare Payment Advisory Commission.
Mental health and substance abuse disorder parity – A federal law barring discriminatory limits on mental health and substance abuse disorder coverage by insurers and employer-sponsored benefit plans. The Patient Protection and Affordable Care Act extends parity standards to health insurance products sold through state health insurance exchanges.
MEWAs – See Multiple Employer Welfare Arrangements.
Minimum essential coverage – The minimum insurance package that fulfills the requirement of the mandate that all individuals carry insurance.
MLR — See Medical Loss Ratio.
Modified adjusted gross income–The calculation of income and assets used to determine eligibility for federal programs including Medicaid, and premium and cost sharing assistance for tax credits provided to low and moderate income individuals under the health reform law. In determining income, states must disregard or reduce countable income by 5 percent for the income pathway.
Multiple Employer Welfare Arrangements– An employee health or welfare benefit plan that is marketed to two or more employers and is subject to ERISA regulation as well as applicable state law.
NAIC — See National Association of Insurance Commissioners.
National Association of Insurances Commissioners — An organization representing elected or appointed state officials charged with regulating insurance. The health reform law tasks NAIC with making recommendations on elements of health reform, including the calculation medical loss ratios.
National Health Service Corps – A program authorized under the Public Health Service Act that provides grants and loan repayment assistance to medical and health professionals in exchange for a specified term of service in an urban or rural location identified as having a shortage of health professionals.
National Health Workforce Commission – A special commission to advise Congress, the President, the states, and localities on health workforce needs and measure the unmet need for care.
National Institutes of Health – A federal agency within the Department of Health and Human Services that has lead responsibility for biomedical, clinical, and translational research.
National Strategy to Improve Health Care Quality – A national strategy spanning federal and state health programs, health care providers, and public and private health insurers whose aim is to prioritize areas for national health care quality improvement and coordinate across payers and programs to make more rapid change possible. The National Strategy is required under the Patient Protection and Affordable Care Act.
Navigator Programs — Special programs established by the health reform law that employ experienced and knowledgeable individuals (who may not work for insurers or be paid by insurers for plan enrollments) to assist individuals and small employers evaluate their insurance options within the insurance exchanges that will go online in 2014.
Newly eligible – Effective January 1, 2014, states will be required to provide Medicaid coverage to individuals ages 19-65 with incomes under 133 percent of FPL, who were not eligible for Medicaid based on the state’s eligibility criteria as of December 1, 2009.
NIH – See National Institutes of Health.
Non-group market– Also known as the individual market, the health insurance market for individuals who purchase coverage directly rather than through an employer-sponsored or group health plan.
Nurse-managed health centers – Clinics managed by nurses supported by federal grants authorized under the Patient Protection and Affordable Care Act.
Nursing Home Compare – A website sponsored by the Department of Health and Human Services designed to provide nursing home quality information to consumers.
OCIIO — See Office of Consumer Information and Insurance Oversight.
Office of Consumer Information and Insurance Oversight — A new office within the Department of Health and Human Services created by the health reform law. OCIIO is charged with federal oversight of the state-regulated individual and small group health insurance markets as well as state health insurance exchanges. OCIIO is responsible for developing policies related to the health insurance market reforms contained in the Affordable Care Act such as the ban on rescissions, the bar against pre-existing condition exclusions, and patient protections. OCIIO will also develop policies related to health insurance exchanges and qualified health plans.
Office of Minority Health – OMH was established in 1986 by the U.S. Department of Health and Human Services (HHS). It advises the Secretary and the Office of Public Health and Science (OPHS) on public health program activities affecting American Indians and Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians, and other Pacific Islanders.
Office of the National Coordinator for Health Information Technology –
The principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.
OIG – See Inspector general.
OMH – See Office of Minority Health.
Parity – See Mental health and substance abuse disorder parity.
Part D — See Medicare Part D.
Participating provider – An entity comprised of providers of services and suppliers, including a hospital, a physician group, a skilled nursing facility, and a home health agency, who are otherwise participating in Medicare.
Patient-Centered Outcomes Research Institute — A special federal authority created by the health reform law that operates as a nonprofit corporation with the purpose of advancing the quality and relevance of evidence that can be used by patients, clinicians, purchasers, and policymakers to make informed health care decisions. It replaces the Federal Coordinating Council, which was created by the American Recovery and Reinvestment Act to make recommendations on comparative effectiveness research initiatives. The reform law specifies governance by a Board of Governors consisting of the Director of the Agency for Healthcare Research and Quality, the Director of the National Institutes of Health, and 17 members appointed by the Comptroller General of the United States and representing patients, providers, drug and device manufacturers, health services researchers, experts in quality improvement, and federal and state government officials.
Patient-Centered Outcomes Research Trust Fund — A dedicated trust fund that provides support for comparative clinical effectiveness research between FY 2010 and 2019. Funding is derived from general revenues, fees, and Medicare Parts A and B.
Patent exclusivity– The period of time during which a prescription drug or biological product can be marketed and sold only by the manufacturer holding the patent and cannot be generically copied.
Patient protections – Certain laws establishing protections for patients, such as the right to health information, choice of provider, access to care, the right to file a grievance, or the right to appeal a denied health benefit claim.
Patient Protection and Affordable Care Act — The formal name of the health reform law enacted in 2010.
Performance measurement – A set of recommendations, requirements, or data used to determine whether plans, providers, or programs meet or exceed a specified standard of care.
Plan disclosure – A requirement in the Patient Protection and Affordable Care Act to provide consumers with information on the terms and conditions of health insurance policies and the relationships between insurers, providers, pharmacy benefit managers, and other third-party benefit providers.
Pool – A group of individuals whose premiums are used to pay the covered medical costs of its members. Insurance companies may charge higher premiums to a pool whose members are older or less healthy in order to cover the risk that its members will submit more medical claims.
PPACA — See Patient Protection and Affordable Care Act.
Preemption – A legal concept, grounded in the United States Constitution’s Supremacy Clause, which specifies the displacement of state laws by federal laws with which state laws are found to conflict.
Pre-existing condition – A health condition that exists for a set time prior to enrollment into a health plan, regardless of whether the condition has been formally diagnosed. The Patient Protection and Affordable Care Act prohibits insurers and employer-sponsored health plans from denying or limiting coverage to individuals with pre-existing health conditions.
Premium – The recurring charge paid by individuals or employer-sponsored groups for the purchase of health insurance.
Premium tax credits – Refundable tax credits, paid in advance, that are used for the purchase of health insurance through a state health insurance exchange. Individuals with family incomes greater than 133 percent of the federal poverty level but below 400 percent of the federal poverty level will be eligible for premium credits beginning in 2014.
Presumptive eligibility – A state option under Medicaid which permits certain health care providers to presume that a patient is eligible for Medicaid and allow Medicaid reimbursement for services for a limited time until an official eligibility determination is made by the state.
Prevention and Public Health Investment Fund – A trust fund established under the Patient Protection and Affordable Care Act to provide sustained funding for federal public health and prevention programs.
Preventive services – Procedures and treatments whose purpose is to avoid disease or to identify disease or conditions before they become acute and symptomatic. Immunization, screening programs for breast, cervical, or prostate cancer, and “well-child” or “well-adult” checkups are examples of preventive services.
Price transparency – The ability on the part of consumers and patients to see the actual price of health care charges, as well as accurate information about health insurance charges, in order to promote knowledgeable health care purchasing decisions.
Primary care professionals – Health care professionals who specialize in a primary care practice field such as family medicine, pediatrics, obstetrics and gynecology, adult medicine, nurse practice, and other types of practice designated as primary health care. State Medicaid programs will be required to pay for primary health care at 100 percent of the Medicare payment rate (which typically is significantly higher) beginning in 2014. For two years, the federal government will contribute 100 percent of the cost of primary care payments.
Program Integrity – A special program of the federal government to detect and stop health care fraud and abuse.
Public health investment fund – A trust fund established in health reform legislation designed to ensure a consistent funding stream for federal public health, prevention, and wellness activities.
Public Health Service Act – A law enacted in 1944 that created programs and provides resources for community health centers, the National Health Service Corps, loan repayments for health care providers working in medically underserved areas, providers of home health care services in medically underserved areas, and more.
Public health workforce – A term used to define a range of health professionals in public and private practice who provide public health services such as disease diagnosis, primary care, and public education.
Qualified health plan – Health insurance plans that meet minimum federal insurance-market rules including offering a standard set of services, benefits, and other requirements as determined by health exchanges.
Rating – The practice by insurers of charging different premium amounts to different individuals or groups based on the characteristics of the individual or group as well as other considerations such as location.
Ready Reserve Corps – A special group of health care professionals within the Commissioned Corps of the United States Public Health Service, whose establishment is authorized by the Patient Protection and Affordable Care Act in order to carry out specific duties in the event of a public health emergency.
Reinsurance – Risk protection offered to insurers or self-insured employer-sponsored health benefit plans in order to protect them from unpredictably high cost exposure. Reinsurance begins at an “attachment” point and is designed to cover losses after the losses incurred by an insurer or self-insured plan reach this threshold.
Rescission – The cancellation or refusal to renew a health insurance policy following issuance, typically after the filing of medical claims. A policy may be rescinded in cases in which an individual made material misrepresentations of health status at the time of enrollment. Insurers have been found liable for rescinding policies simply because medical claims were filed and in the absence of any fraud on the part of the enrollee.
Retiree health benefits – Health benefits provided by an employer to its retirees.
Rights of conscience – Federal or state laws that prohibit discrimination against health care professionals, entities, or health insurers that refuse to furnish or cover certain types of treatments because of religious or personal beliefs.
Risk adjustment – A tool for evaluating the relative risk of enrollees within each insurance plan and providing for a financial transfer from plans with low-risk to plans with higher-risk enrollees.
SAMHSA – See Substance Abuse and Mental Health Services Administration.
Self-Funded Plans — Health coverage arrangements under which the plan’s sponsor (e.g. an employer, other type of group such as a union or association) chooses to bear the risk for employee or group member health care costs rather than purchasing private insurance to cover all or part of the group’s losses.
School-based health clinic – A clinic that is located in or in connection with a school and that receives funding under a new grant program authorized in the Patient Protection and Affordable Care Act.
SHOP exchanges – See Small Business Health Option Program
Small business employer health plan – A plan offered by an employer with fewer than 100 full-time employees.
Small Business Health Options Program — The state-based insurance exchanges created by the health reform law through which small employers will be able to purchase health insurance for their employees starting in 2014.
Small business tax credit – A tax credit for small employers to help offset the cost of health insurance coverage provided to their employees. Eligible small businesses consist of those with 25 or fewer employees whose employees’ average annual wages do not exceed specified limits.
Small employers – Employers that on an average business day employ 100 employees or fewer.
Small group market — The private health insurance market for small businesses purchasing health insurance for their employees.
Social Security Act – Legislation enacted in 1935 that provides benefits to retirees and the unemployed, and a lump-sum benefit to survivors upon a spouse’s death. In 1965, the law was amended to create the Medicare and Medicaid programs. The SSA also includes programs for families with dependent children, maternal and child health, public health services.
SSA — See Social Security Act.
SSI– See Supplemental Security Income.
State health insurance exchanges – State-based marketplaces for the sale and purchase of health insurance established in federal law and operated in accordance with federal requirements. Health insurers that sell products in the exchanges to small employers and individuals will be required to meet federal standards of coverage, fair practices, and plan administration.
State innovation waivers – Special waivers given by the Secretary of the United States Department of Health and Human Services that would allow a state to replace the exchange system with an alternative approach to coverage. The Secretary is authorized to waive provisions of the Patient Protection and Affordable Care Act related to qualified health plans, consumer choices cost-sharing protections, and individual and small employer tax credits. Waivers of the law’s provisions related to exchanges can be combined with Medicare and Medicaid waivers so as to permit states to create entirely alternative forms of health insurance coverage, such as a single payer plan.
Subrogation of health insurance benefits – The practice by which an insurer pays an individual health insurance claim then seeks to recoup losses from a responsible third party, such as another health insurer or a recovery in a medical liability or personal injury action. Individuals who sue for medical malpractice and recover may be required to repay their insurers for the cost of covered medical care.
Substance Abuse and Mental Health Services Administration– The federal agency within the United States Department of Health and Human Services charged with improving the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses.
Supplemental Security Income– A Federal income supplement program funded by general tax revenues to help aged, blind, and disabled people, who have little or no income.
Telehealth – Electronic information and telecommunications technologies that support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
Territories – Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Therapeutic foster care – Services provided to special-needs children in foster care by families and group care providers that have received special training as well as ongoing support and supervision including regular contact with case managers or care coordinators.
Urban Indian – Special programs administered by the Indian Health Service (IHS) and by tribal governments that serve American Indians, Native Hawaiians, and Alaska Natives who reside in urban areas.
U.S. Preventive Services Task Force — An independent panel of primary care and prevention experts that makes recommendations on health screening and prevention research. It was initially created by the Public Health Service in 1984 and is currently supported by HHS’s Agency for Health Care Research and Quality.
Value-based purchasing – An approach to health care purchasing employed by consumers and health care payers that considers and rewards health care value as part of paying for care. Health care value is typically associated with quality (as measured by objective benchmarks), provision of useful comparative information about performance, and efficiency as measured by objective standards.
VBP – See Value-based purchasing.
Wellness programs – Special services and benefits offered by employers to employees in addition to coverage under health benefit plans. First authorized in HIPAA, wellness programs offer participation “incentives,” such as premium or cost-sharing discounts, as a means of encouraging employees to lose weight, quit smoking, follow health-maintenance regimens, and generally adopt more healthy lifestyles.
Whistleblower – An individual (typically a current or former employee) who discloses information not readily obtainable and in connection with potential fraud and abuse.
Young adult – Individuals ages 22-26 who, under the Patient Protection and Affordable Care Act, can remain covered under their parents’ employer-sponsored or individually purchased health benefit plans.