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  • 340-B Pharmacy Program – The 340B Drug Pricing Program requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations or covered entities at significantly reduced prices.

  • A
  • Accountable Care Organization (ACO) – A group of healthcare providers that has entered into a formal arrangement to assume collective responsibility for the care and outcomes of a group of patients.

    Administrative expenses – The expenditures by health insurance companies or public insurance programs unrelated to clinical care. These may include sales and marketing, entertainment, fraud prevention, verification of provider credentials, and other expenses that are not directly related to patient care.

    Advanced care planning – A process in which a patient and physician discuss treatment options and develop a care plan tailored to the patient’s specific needs and preferences. Plans may include preferences known to family members and providers in case a patient is incapacitated or for those with a terminal illness.

    Affordable coverage – A term used in health reform law to designate the types of insurance available to individuals relative to the percentage of family income available to pay health insurance premiums.

    Agency for Healthcare Research and Quality (AHRQ) – The federal agency within the United States Department of Health and Human Services that has the lead responsibility for efforts to improve the quality of healthcare and the promotion of health-services research.

    Ambulatory Payment Classification (APC) – APCs are the United States government’s method of paying for facility outpatient services for the Medicare program.

    American Health Benefit Exchanges – The name given by the health reform law to the state-based insurance exchanges through which individuals began to purchase health insurance in 2014.

    Annual limits – Limits imposed by insurers or employer-sponsored health plans on the amount of covered treatment or services that will be 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)

    Appeals – The process by which health insurance beneficiaries can dispute a denial, reduction, or delay in covered treatments and services.

  • B
  • 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 individuals 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.

    Bundled payment – A single payment for all healthcare services related to a specific course of treatment or condition over a period of time. (See also episodes of care). Under a bundled-payment system, a single payment must be shared among all providers involved in the care of the patient.

    Bundled Payments for Care Improvement Initiative– Under this initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care.

  • C
  • Cadillac health plan– A term used to describe employee health benefit plans where the value of the coverage exceeds a stated annual dollar threshold defined in the Affordable Care Act. (See also excise tax).

    Cafeteria plan – A benefit plan sponsored by an employer under which employees may set aside pre-tax wages in Flexible Spending Accounts (FSAs) to be used for various expenses, such as copayments and deductibles or dental care, not otherwise covered by their health insurance.

    Centers for Disease Control and Prevention (CDC) – The CDC is a federal agency within the Department of Health and Human Services charged with disease prevention, education, and public health activities.

    Centers for Medicare & Medicaid Services (CMS) – The federal agency within the United States Department of Health and Human Services that administers Medicare, Medicaid, CHIP, and innovations in federal insurance programs.

    Certificate of Need (CON) – CON programs originated to regulate the number of beds in hospitals and nursing homes, and to prevent the overbuying of expensive equipment.

    Certificate of Public Advantage – A law that allows a hospital, and any person who is a party to a cooperative agreement with a hospital, to negotiate, enter into, and conduct business without being subject to damages, liability, or scrutiny under any State antitrust law. The agreement caps cost, margin and the number of doctors a hospital can employ.

    Children’s Health Insurance Program (CHIP) – A program administered by the US Department of Health and Human Services that provides matching funds to states for health insurance to families with children.

    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.

    Community health centers – Non-profit clinics established under the Public Health Service Act that provide or arrange for a broad range of primary healthcare 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 percent of whom must be patients of the clinic. See also, Federally Qualified Health Centers.

    Comparative Effectiveness Research (CER) – A specific type of health services research that compares different approaches to treating medical conditions to determine which methods are most likely to produce the best outcomes.

    Coordination of Benefits – The process of reconciling healthcare 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.

    Cost-sharing – A requirement that insured patients pay a portion of their medical costs as a deductible, a copayment, or as coinsurance.

    Critical Access Hospitals (CAH) – A hospital certified under a set of Medicare Conditions of Participation, which are structured differently than an acute-care hospital.

    Culturally and linguistically appropriate and competent services – A federal standard designed to assure better access and quality of care to eliminate ethnic and racial disparities in healthcare.

    Deductible – The amount patients must pay out of pocket before insurance coverage begins.

  • D
  • Department of Health and Human Services (HHS) – The federal cabinet-level agency that administers health, welfare, and human services programs and activities. HHS has lead agency responsibility for significant aspects of the Patient Protection and Affordable Care Act.

    Dependent coverage – Health insurance coverage of a spouse, child, or domestic partner of an insured individual.

    Diagnosis related group (DRG) – A system of patient care classification based on diagnosis, which is used to establish a bundled payment for hospital inpatients.

    Disproportionate Share Hospital (DSH) – The US government provides funding to hospitals that treat indigent patients through this program, under which facilities can receive at least partial compensation.

    Dual Eligibles – Low-income individuals who meet the eligibility requirements for both the Medicaid and Medicare programs.

  • E
  • 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.

    Electronic Health Record (EHR) – A computerized medical record.

    Emergency Medical Treatment and Labor Act (EMTALA) – A federal law that obligates all Medicare-participating hospitals with emergency departments to furnish an “appropriate” screening, medically appropriate transfer or otherwise care for patients until stable regardless of their ability to pay.

    Employee Retirement Income Security Act (ERISA) – 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.

    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.

    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. 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. 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.

    Evaluation and Management (E/M) – E/M coding is the process by which physician-patient encounters are translated into five-digit codes to facilitate billing.

    Exchanges – State health insurance “marketplaces” whose establishment was mandated by the Affordable Care Act. 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.

    Excise tax – A tax on health insurance and health benefit plans where the annual dollar value exceeds a specified limit, as well as on the sale of certain healthcare 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.

  • F
  • Federal Medical Assistance Percentage (FMAP) – 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. 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 used to determine eligibility for income-related programs, such as Medicaid and the CHIP.

    Federally Qualified Health Center (FQHC) – 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 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 fee- for-service delivery system is one whereby healthcare providers are paid for each service, like an office visit, test, or procedure.

    Filibuster – A parliamentary procedure where debate is extended, allowing one or more members to delay or entirely prevent a vote on a given proposal.

    Flexible Spending Accounts – See cafeteria plans.

    Food and Drug Administration (FDA) – The federal agency within the U.S. Department of Health and Human Services that is responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter medications, vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), veterinary products, and cosmetics.

  • G
  • Gainsharing – Allowing healthcare providers that meet standards of quality and efficiency to share in savings realized by insurers for reduced use of unnecessary care.

    Global Capitation – Under global capitation, whole networks of hospitals and physicians band together to receive single fixed monthly payments for enrolled health plan members.

    Graduate Medical Education (GME) – The period of residency and fellowship that is provided to physicians after they receive a medical degree.

    Graduate Medical Education payments – Payments made under Medicare or other healthcare financing authorities to support the cost of medical residency training.

  • H
  • 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.

    Healthcare homes – Primary healthcare providers that furnish or arrange for comprehensive primary healthcare, use health information technology, and meet federal and state standards of quality and efficiency. Healthcare home demonstrations are authorized under the Patient Protection and Affordable Care Act. (See also medical home).

    Health disparities – Measurable differences in health and healthcare that are associated with race, ethnicity, income, language, place of residence, and other factors unrelated to the need for or ability to benefit from healthcare.

    Health information technology (HIT) – Technology that allows the comprehensive management of health information and enables its exchange among health professionals, consumers, healthcare providers, healthcare payers, and public health agencies.

    Health Insurance Portability and Accountability Act (HIPAA) – A federal law that regulates health information privacy and health insurance portability. 

    Health Resources and Services Administration (HRSA) – A federal agency within the U.S. Department of Health and Human Services (HHS) that oversees the improvement of access to healthcare by strengthening the healthcare workforce, building healthy communities and achieving health equity.

    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 at least six months.

    HIPAA – See Health Insurance Portability and Accountability Act.

    Home Health Agency (HHA) – A home health agency is primarily engaged in providing skilled nursing and other therapeutic services.

    Hospital-acquired Infections – An infection that originates in a hospital environment. It may be acquired by a patient during a hospital visit or one developing among hospital staff.

    Hospital Outpatient Department (HOPD) – The hospital outpatient measure set provides accredited hospitals with a broader array of measure sets from which to meet certain requirements, and supports the ability of hospitals to meet multiple measurement requirements from a single data collection effort.

  • I
  • Indian Health Service – The federal agency within the U.S. Department of Health and Human Services that oversees healthcare programs and services for American Indians, native Hawaiians, and Alaska natives.

    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 that consumers can understand.

    Inpatient Rehabilitation Facility (IRF) – IRFs are free-standing rehabilitation hospitals and rehabilitation units in acute care hospitals.

  • L
  • Large employers – Employer groups that, on average, employ a certain number of full-time employees. The definition of large employer varies based on the provision of law.

    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.

    Long-Term Care Hospital (LTCH) – Long-term care hospitals are certified as acute-care hospitals, but focus on patients who, on average, stay more than 25 days.

  • M
  • Meaningful User – Certain healthcare 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.

    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.

    Medicaid and CHIP Payment and Access Commission (MACPAC) – 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 – Healthcare providers, typically primary care physicians, that offer and arrange for comprehensive healthcare, 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 (MLR) – A medical loss ratio is the proportion of premium dollars that an insurer spends directly on healthcare services and certain recognized plan administration costs relative to health insurance premiums paid by subscribers.

    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 “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.

    Medicare Part D – The outpatient prescription drug benefit component of Medicare that 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 (MedPAC) – An independent US federal body to advise the US Congress on payments to private health plans participating in Medicare and health providers serving Medicare beneficiaries.

    Medicare sequestration – Medicare provider payments were cut by 2 percent beginning April 1, 2013 as part of the spending reductions required by the Budget Control Act of 2011.

    Medicare Shared Savings Program – The Shared Savings Program facilitates coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.

    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.

    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.

    Multiple Employer Welfare Arrangements (MEWAs) – 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.

  • N
  • 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 Institutes of Health (NIH) – A federal agency within the U.S. Department of Health and Human Services that has lead responsibility for biomedical, clinical, and translational research.

    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 with evaluating their insurance options.

    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 U.S. Department of Health and Human Services designed to provide nursing home quality information to consumers.

  • O
  • OIG – See Inspector general.

  • P
  • Partial Capitation – Under a partial capitation, a single payment is made for a defined set of services, while other services involved in a patient’s care are paid for on a fee-for-service basis.

    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, that are otherwise participating in Medicare.

    Patient-Centered Medical Home (PCMH) – The patient-centered medical home is a model of care that aims to transform the delivery of comprehensive primary care to patients.

    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.

    Pay for Performance – Pay for performance gives financial incentives to clinicians for better health outcomes.

    Pay for Reporting – Pay for reporting encourages physicians to report on how the care they deliver aligns with evidence-based clinical guidelines for a variety of medical conditions.

    Pay for Value – Pay for value considers the results of the services provided in exchange for the costs incurred.

    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.

    Population Health –The health outcomes of a group of individuals, including the distribution of such outcomes within the group.

    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.

    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.

    Presumptive eligibility – A state option under Medicaid that permits certain healthcare 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.

    Preventive services – Procedures and treatments that are meant to help 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 for a healthcare service, as well as accurate information about health insurance charges, to promote informed healthcare purchasing decisions.

  • Q
  • 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.

  • R
  • 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.

    Readmission – Readmission is an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.

    Recovery Audit Contractor (RAC) – Individuals who perform audits, on behalf of the Centers for Medicare & Medicaid Services, to identify and correct improper payments to healthcare providers on behalf of Medicare beneficiaries.

    Reinsurance – Risk protection offered to insurers or self-insured employer-sponsored health benefit plans to protect them from unpredictable 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.

    Retiree health benefits – Health benefits provided by an employer to its retirees.

    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.

  • S
  • Self-Funded Plans – Health coverage arrangements under which the plan’s sponsor (e.g., an employer, union or association) chooses to bear the risk for employee or group member healthcare costs rather than purchasing private insurance to cover all or part of the group’s losses.

    SGR – See Sustainable Growth Rate.

    Small business employer health plan – A plan offered by an employer with fewer than 100 full-time employees.
    Small business tax credit – A tax credit for small employers to help offset the cost of health insurance coverage provided to their employees.

    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 (SSA) – Legislation enacted in 1935 that provides benefits to retirees and the unemployed, and a lump-sum benefit to survivors upon a spouse’s death.

    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.

    State innovation waivers – Special waivers given by the Secretary of the U.S. Department of Health and Human Services that allow a state to replace the exchange system with an alternative approach to coverage.

    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.

    Supplemental Security Income (SSI) – A federal income supplement program funded by general tax revenues to help aged, blind, and disabled people, who have little or no income.

    Sustainable Growth Rate (SGR) – The SGR formula, which was repealed in 2015, compared the annual change in Medicare spending per beneficiary to the Gross Domestic Product and a conversion factor was implemented to the following year’s Annual Medicare Physician Fee Schedule.

  • T
  • Telehealth – Electronic information and telecommunications technologies that support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration.

    Territories – Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

  • U
  • US Preventive Services Task Force – An independent panel of primary care and prevention experts that makes recommendations on health screening and prevention research

  • V
  • Value-based purchasing (VBP) – Value-based purchasing links the provider payments to improved performance by healthcare providers.

  • W
  • Wellness programs – Special services and benefits offered by employers to employees as a means of encouraging employees to 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.

    Source: Robert Wood Johnson Foundation, 2011