Bingham Health Care


Healthcare Terms


Term Description*
3 Rs three ACA programs to help reduce issuer risk; these financial programs are reinsurance, risk corridors, and risk adjustment, and were intended to provide a level of market stabilization, particularly in the years when the ACA was getting off the ground
1094/1095 IRS forms used to report taxpayer coverage by benefit plans that provide minimum essential coverage; Form 1094 is submitted to the IRS, while Form 1095 is sent to subscribers; creation and sending of 1094-A & 1095-A forms are the responsibility of ACA exchanges; creation and sending of 1094-B & 1095-B forms are the responsibility of the benefit plan issuer; creation and sending of 1094-C & 1095-C forms are the responsibility of employers providing coverage to employees; see also 6055/6056
6055/6056 sections of the IRS code put in place by the ACA and requiring those providing minimum essential coverage to report such coverage; section 6055 applies to benefit plan issuers; section 6056 applies to employers providing coverage; required reporting is via IRS forms 1094 and 1095
ability related to access and actual, ability refers to a member with access to coverage or care being able to actually get the coverage or care
ACA see Affordable Care Act
access related to ability and actual, access refers to a member who, with the proper means (i.e., has the ability), can actually obtain coverage or care
accountable care organization a group of otherwise disparate providers who coordinate care for member patients, partnering with issuers and being contractually obligated to provide minimum care quality and efficiency; the ACO is accountable to patients and payers; this is often a managed care financial arrangement
accreditation initial and ongoing review of issuers, providers, medical coders, and others, to ensure standards are met and maintained; accreditation services are provide by such organizations as the NCQA and URAC, among others
ACO see accountable care organization
active purchaser a purchaser or negotiator of coverage options that tailors coverage offerings to better suit member needs; in the case of exchanges, this means that benefit plans offered on the exchange meet certain criteria; this is distinguished from an open exchange, where most any issuer can offer its products via that type of exchange; active purchaser can also apply to large or custom groups that develop benefit plans specifically for their members or employees; it also applies to governments that negotiate key terms of benefit plan offerings, such as which medications to include in a formulary
actual related to access and ability, actual refers to a member that actually received the coverage or care
actuarial value a measure of how much of expected healthcare costs are paid for by the issuer / benefit plan, versus how much is paid for by the member; the ACA captures this by identifying benefit plans by metal level; a higher actuarial value means that the benefit plan tends to pay more for covered benefits, and thus the benefit plan is considered richer than other benefit plans with lower AVs; where premium amount and member cost share tend to move in opposite directions, creating a sort of see-saw (i.e., a benefit plan with a higher premium tends to have lower member cost share, and vice versa), a benefit plan's plan richness can be seen to raise or lower the see-saw's pivot point (e.g., a richer plan with a higher AV would have a correspondingly higher premium than the same plan with a lower AV); see also metal level and plan richness
actuary individuals or firms that identify risk and help build benefit plans and to set rates in relation to those risks; issuers use in-house actuaries or work with actuarial firms to determine pricing of various benefit plan designs depending on expected utilization of those benefit plans
administrative services only plan an ASO plan is the use of an insurance company or other healthcare issuer to handle certain aspects of self-insured coverage provided by typically large employers or groups
advanced premium tax credit a subsidy provided by the federal govenment that offsets monthly premium amounts, effectively lowering the monthly outlay for low-income members; this is an advance receipt of a tax credit that the members could otherwise obtain when filing their taxes the following year, and is available only on benefit plans purchased through an ACA exchange
Affordable Care Act a set of laws and related regulations that signficantly changed healthcare in the United States; the primary bills were signed into law by the U.S. president on March 23, 2010, and March 30, 2010; among the changes were the establishment of public exchanges that provided subsidized coverage beginning 2014 and the option for states to expand Medicaid coverage to include many between 138% (or 133%) of the poverty level, where Medicaid typically ends, and 150% of the poverty level, where subsidized exchange coverage begins; this is referred to as the ACA and less commonly the PPACA (Patient Protection and Affordable Care Act)
agent a person licensed to offer healthcare coverage and benefit plans to prospective members or groups; agents can be internal to an issuer organization, in which case the agent represents the issuer and offers the issuer's offerings, or the agent can be external or independent, in which case the agent represents the prospective member, showing the member applicable benefit plans from multiple issuers, as the case may be
ALE see applicable large employer
allowed amount the amount a provider is allowed to receive from an issuer for providing specific care under a benefit plan's coverage; this can be, but need not be, the same as the billed amount; not infrequently, a provider bills more than is allowed, but is paid only the allowed amount; see billed amount, balance billing, and fee schedule
annual maximum the most an issuer would pay for a member's care under a benefit plan for a particular benefit year, beyond which the member would be responsible for all remaining charges; the ability for issuers to impose this limit was eliminated as part of the ACA; this is related to lifetime maximum
applicable large employer

under the ACA, an employer required to provide minimum essential coverage to its full-time equivalent (FTE) employees or face a penalty

APTC see advanced premium tax credit
ASO see administrative services only plan
AV see actuarial value
balance billing related to billed amount and allowed amount, balance billing is a practice of the provider seeking to be paid the difference between the amount the provider charges for care and what the provider is expected to get from the issuer for that care, with this difference being billed to the member; preferred providers may not balance bill for covered benefits
beneficiary the recipient of benefits provided by healthcare coverage; this is the member (from an issuer's perspective) or patient (from a provider's perspective)
benefit a covered service or product provided by a benefit plan; this is what the consumer purchases when obtaining coverage
benefit categories logical ways to group benefit plan benefits for easier communication with members or providers
benefit limit a cap on the amount that a benefit is provided under the a benefit plan; this is related to visit limit
benefit plan a set of benefits, along with the provider network, restrictions, etc., that a covered member relies on when obtaining covered care; this is often referred to as a policy, an insurance policy, a health plan, a plan, a product, a contract, or an EOC (evidence of coverage)
benefit plan design a set of benefits, cost share, network(s), and parameters used as a base from which benefit plans and plan families are developed
benefit year the term of coverage provided by a benefit plan; this can be, but is not necessarily, the same as a calendar year; for instance, in the individual market, it is usually the same, whereas in the group market it is often not the same; although it is called a benefit year, it can be less than an year if it begins mid-year, for instance, and ends at the end of the year, or it can be more than a year if the term of the coverage is more than one year; to distinguish from coverage period, a benefit year can be the maximum period that a particular benefit plan could be effective, from the earliest possible coverage date (if the binder payment is received) to the final date that benefit plan could provide coverage (after which coverage would end or have to be renewed); see calendar year; this is also called a plan year
billed amount the amount a provider charges an issuer for providing care under a benefit plan's coverage; this may be more than the allowed amount, as is the case when a provider usually charges more than is contracted with the issuer, but the issuer typically would pay only the contracted, allowed amount; see also allowed amount, balance billing, and fee schedule
binder payment the initial premium payment a member makes to initiate coverage; the premium amount is typically paid before coverage begins, and if the binder payment is not received in time, the coverage can be cancelled; see premium and cancellation
broker a licensed person or firm that licensed agents report to and work for in order to offer healthcare coverage to prospective members or groups
bundled payments related to capitation and fee for service, bundled payments are somewhere in between, whereby a provider is paid a certain amount for a set of covered benefits provided as care to members, regardless how many of the included benefits are actually provided to the member
calendar year the period from the beginning of a calendar year to the end of that same year; often benefit plan coverage begins at the beginning of a calendar year (though does not need to), and more often benefit plan coverages end at the end of a calendar year; see benefit year
cancellation if someone signs up for coverage but the benefit plan's coverage period has not yet begun, such as before a binder payment has been received or before the benefit year has begun, the coverage can be cancelled; see also termination
capitated see capitation
capitation a payment structure whereby an issuer would pay providers a set amount per covered member (a capitated amount) that the provider agrees to care for; this amount is paid regardless whether the member actually receives care, or not; this is related to managed care; see also fee for service
care the actual healthcare benefit (service or product) provided to a patient; this is distinguished from coverage in that coverage is the set of benefits a member could obtained under a benefit plan, whereas care is the actual benefit, as received by the member; coverage is provided by issuers, care is provided by providers
carrier a term used almost synonymously with a healthcare issuer or insurer or payer
catastrophic healthcare coverage intended to pay for extreme or very expensive care, with the member responsible for most basic or routine care; this is designed to provide a cap on how much the member would have to pay for care, in the case that the care becomes very expensive; this is implemented by requiring the member to pay for all covered care up to a certain dollar amount, after which the issuer would pay for any extra covered care; this is also referred to as a high-deductible health plan, since the member must first meet the high deductible before the benefit plan pays for most services
CCIIO see Center for Consumer Information and Insurance Oversight
CDHP see consumer-driven health plan
Center for Consumer Information and Insurance Oversight CCIIO is a CMS sub-agency created by the ACA to manage and regulate many aspects of the ACA, including ACA exchanges and Medicaid expansion
Centers for Medicare and Medicaid Services CMS is an agency within the HHS that is responsible for managing and regulating many aspects of the healthcare industry, beyond just Medicare and Medicaid coverage
Children's Health Insurance Program aka, CHIP; a federal program that is part of Medicaid and that covers children in need
CHIP see Children's Health Insurance Program
CMS see Centers for Medicare and Medicaid Services
co-insurance a form of cost-sharing whereby a member pays a percent of the amount a provider charges; for instance, if the benefit plan indicates that an x-ray imposes a 40% co-insurance, and the member gets an x-ray that the provider charges $150 for, the member would be responsible to pay the provider $60 (i.e., 40% of the $150), and the benefit plan / issuer would be responsible for paying the remaining 60% ($90); this is related to copayment and cost share
CO-OP see Consumer Operated and Oriented Plans
COB see coordination of benefits
community services healthcare and other social services provided to members of a community; these augment traditional and formal healthcare care
consumer a beneficiary of a benefit plan; this is the member on the plan, and is the patient receiving care under the plan
consumer-driven health plan CDHP plans allow members to pay into a fund, such as an HSA, HRA, or FSA, from which care is paid, and if funding from these sources runs out, traditional coverage is used to cover catastrophic cases; in general, these plans are seen as giving the member more control over their choices of care, one trade-off being higher per-visit costs since issuers can negotiate more favorable rates with certain providers
Consumer Operated and Oriented Plans a form of issuer created by the ACA that intends for the operation of the CO-OP issuer to be by the members covered by that issuer's benefit plans; these issuers are non-profit, by definition, and were initially started with federal grant money; since the inception of the ACA, most CO-OPs have since ceased operation
contract the healthcare policy or benefit plan; also called the EOC; this is what the member purchases as healthcare coverage
coordination of benefits the sharing of costs among various payers when a patient has multiple, overlapping coverage; for instance, if a person is covered by multiple benefit plans, one may become the primary and pay for care up to the amount under that particular benefit plan, then the secondary benefit plan would pay toward remaining costs, ultimately reducing the amount the person would have to pay, if anything
copayment a form of cost-sharing whereby a member pays a fixed amount for specific care received under a benefit plan; for instance, if the benefit plan indicates that a visit to a specialist imposes a $75 copayment, and the member seeks care with a specialist, the member would be responsible to pay the provider $75, regardless how much the specialist charges for the visit, and the benefit plan / issuer would be responsible for paying any remaining amount the provider is allowed to charge (e.g., if the provider charges $160 for the visit, the issuer would pay the $85 difference); this is related to co-insurance and cost share
cost share cost sharing is the division of the cost of care between the member's responsibility (share of cost) and the issuer's responsiblity (share of cost); for instance, if receiving a particular type of care incurs a $200 charge from the provider, the member's cost share might be 25%, in which case the issuer's cost share would be 75%; or, the member's cost share could be 30%, leaving the remaining 70% as the issuer's cost share; depending on whether looking at the cost share from the member's or the issuer's perspective, the other can be derived; this must be kept in mind when seeing a cost-share of 40%, for instance (is the member's cost share 40% or is the issuer's 40%); often actuaries, working with issuers to develop benefit plans and associated rates, will state cost shares in terms of issuer responsibility, whereas member-facing documents, such as EOCs and SBCs, will state cost share as the member's responsibility; this relates to co-insurance, copayments, deductibles, out-of-pocket maximums, and cost-sharing reductions
cost-sharing reduction also known as CSR, this is the amount that a member's cost share is reduced when on a subsidized plan, or the reduction in cost that a member must pay under a particular benefit plan for specific covered benefits or care as a result of subsidies provided under the ACA through ACA exchange benefit plans; for instance, a benefit plan may require the member to pay $75 as a copayment for a particular service, but if that member qualifies due to low income, the member may have her cost share reduced by $25, in this case requiring the member to pay a $50 copayment and the federal government would pay the $25; the amount of the reduction is the subsidy amount, paid for by the subsidy provider (usually the government); in this case, the issuer's cost-share responsibility remains the same, and the member's cost-share responsibility is paid in part or in whole by the subsidy (government)
coverage benefits—services and products—provided by an issuer at reduced rate for members; this is related to care in that healthcare coverage is provided by issuers and is the set of benefits included in a benefit plan, whereas healthcare care is provided by providers and is the actual reciept of the services and products by patients
coverage period the specific date range that a benefit plan is in force, providing coverage for the member; this is related to benfit year
coverage restrictions certain limits and other restrictions placed on benefits under a benefit plan; these restrictions include which providers can be utilized, benefit or visit limits, pre-authorization requirements, etc.
CSR see cost-sharing reduction
custom group market part of the commercial healthcare segment, typically very large groups that develop specialized coverage options for the groups' members; issuers segment custom groups from other group business
deductible a cost share amount that a member must pay before the issuer pays for that care; a benefit plan specifies what deductibles apply, and can include separate deductibles for individuals and for families, can apply to certain benefits and not others, and can be integrated or discrete, such as a combined medical and pharmacy deductible or separate medical and pharmacy deductibles
department of insurance a state-level regulator of healthcare benefit plans and/or insurance policies, as well as issuers and providers; this is called DOI in many states
distribution channel a way to get benefit plans to purchasers; this can be direct from the issuer to members, or through ACA exchanges to members or groups, or through private exchanges to businesses, or via agents to buyers of coverage, to name but a few distribution channels
DOI see department of insurance
EDGE server an External Data-Gathering Environment server provisioned by CMS to capture an issuer's member experience for risk adjustment and RADV purposes; these can be on-premise servers or Amazon (AWS) virtual servers
effective benefit plan coverage is effective if care can be received under the benefit plan; coverage is effective, typically, once a binder payment is made and it is within the benefit plan's coverage period
effectuated benefit plan coverage that has been paid for; for instance, once a binder payment has been made, the coverage is then effectuated; a benefit plan provides coverage when it has been both effectuated and the care is provided within the coverage period
EHB see essential health benefits
enrollee a person enrolled in a healthcare policy; see also member and subscriber
EOC see evidence of coverage
EPO see exclusive provider organization
essential health benefits a set of benefit categories that, per the ACA, are required to be included in all major medical benefit plans that begin in 2014 or after; the 10 EHB categories cover dozens of distinct benefits; with limited variability, each state determines the actual benefits required to be in each benefit plan; this is done by the state selecting a benchmark benefit plan to use as a guide, and augment the benefits in that benchmark plan to ensure all 10 EHB categories are adequately covered
evidence of coverage see benefit plan
exchange a distribution channel to get benefit plans from issuers to buyers; this is sometimes referred to as a clearinghouse; there are public ACA exchanges that target individual consumers and private exchanges that help businesses choose benefit plans for their employees
exclusive provider organization an EPO is a benefit plan type that is similar to PPO but has a closed network; this is related to PPO, HMO, and POS
expected utilization based on the benefits covered and associated restrictions, along with providers in the network, anticipated member makeup, and pricing, both premium and cost share, how much specific benefits are anticipated to be used, from an actuarial perspective, leading to predicted costs to the issuer; expected utilization and thus issuer cost can be tweaked by changing these variables
federally-facilitated marketplace FFM is the ACA exchange run by the federal government and covering more than half of the states; other states have state-based marketplaces
fee for service a type of payment arrangement whereby issuers pay providers for benefits as they are provided to members; FFS is distinct from managed care
fee schedule a contracted set of prices that an issuer will pay for certain benefits; beyond the fee schedule, usual, customary, and reasonable charges often apply to other covered benefits or for providers outside the network
FFM see federally-facilitated marketplace
FFS see fee for service
flexible spending account an FSA is a healthcare spending account set up by an employer that employees can contribute to; the funds can be used with FSA-associated benefit plans for qualified medical expenses; FSAs are different from but related to HRAs and HSAs
fraud, waste, and abuse FWA is a set of practices and their results that introduce illegal, unethical, or counter-productive behaviors into the healthcare stream; laws and regulations seek to restrict FWA, and investigative and prosecutorial practices seek to root out and prosecute in order to punish and prevent FWA
FSA see flexible spending account
FTE see full-time equivalent; FTE is also used to mean full-time employee
full-time equivalent not to be confused with full-time employees, full-time equivalent (FTE) is a method to determine the count of employees that are effective full-time in order to determine whether the employer is an applicable large employer, or not, for purposes of requiring to provide coverage under the ACA
fully-funded see fully-insured
fully-insured also referred to as fully-funded, fully-insured is a type of benefit plan in which an insurance or similar healthcare company takes on the risk of covering members under the benefit plan; this is the most common type of commercial benefit plan; this is distinct from self-funded or self-insured benefit plans
FWA see fraud, waste, and abuse
GA see general agent
general agent a broker or agent (or brokerage or agency) that interfaces between issuers and external agents
grace period a period of time during which healthcare coverage is effective despite a lapse in premium payments; under the ACA, for subsidized benefit plans, members can have up to 3 months to get current before their coverage is terminated; generally, states have a 30-day or 1 month grace period for non-payment for non-subsidized commercial benefit plans
Health and Human Services HHS is a department in the federal government that is responsible for regulating the U.S. healthcare industry and related areas
Health Insurance Portability and Accountability Act pre-dating the ACA, HIPAA is a set of laws and related regulations that went into effect in 1996 (and following) that affected several aspects of the healthcare industry, including privacy and reporting
health maintenance organization an HMO is a benefit plan type that is often part of an integrated delivery model of care and that requires most covered benefits be received from in-network providers, with notable exceptions of referred and emergency care; this is related to PPO, EPO, and POS
health plan a health plan can be a company providing healthcare coverage or it can be the particular benefit plan providing the coverage; this is often shortened to plan, which also carries both meanings; because it can refer to either the company or the benefit plan, the term should be used only when context or other wording makes the meaning clear
health reimbursement arrangement an HRA is a healthcare spending account set up and funded by an employer to use for expenses not paid for by the benefit plan; HRAs are different from but related to HSAs and FSAs
health savings account an HSA is a healthcare spending account that members can contribute to, pre-tax or post-tax, and that can be used for medical expenses associated with HSA-eligible benefit plans; funds used for non-qualified medical expenses prior to age 65 are taxed; HSAs are different from but related to HRAs and FSAs
healthcare pyramid also a healthcare tetrahedron, a graphical or logical representation of healthcare in which the vertices of a 3-D triangle or pyramid represent the payer, patient, provider, and policymaker, the edges of the pyramid representing the connections between each pair of these participants; at the center of the healthcare pyramid is the policy, plan, or product that the patient purchases from the payer and that describes the covered benefits that the provider provides to patients; see also healthcare triangle
healthcare tetrahedron also a healthcare pyramid; see also healthcare triangle
healthcare triangle a graphical or logical representation of healthcare in which the vertices of a triangle represent the payer, patient, and provider, the sides of the triangle representing the connections between each pair of these participants; at the center of the healthcare triangle is the policy, plan, or product that the patient purchases from the payer and that describes the covered benefits that the provider provides to patients; see also healthcare pyramid or healthcare tetrahedron
HHS see Health and Human Services
high-deductible health plan a benefit plan with a deductible equal to or nearly as high as the MOOP, such that the member must pay a substantial amount out of pocket before the benefit plan's coverage kicks in; see catastrophic
HIPAA see Health Insurance Portability and Accountability Act
HMO see health maintenance organization
HRA see health reimbursement arrangement
HSA see health savings account
hybrid marketplace an ACA exchange that is part state-based and part federally-facilitated; usually this is a state-based marketplace that uses the FFM for backend functionality; hybrid marketplace can also refer to states that use an SBM for one market and the FFM for a different market, such as an SBM for the individual market and the FFM for the small group market
IBNR see incurred but not reported
in-network a provider that is part of the benefit plan's provider network, and often provides care for a lower cost to the member that for the same care from out-of-network providers
incurred but not reported IBNR is an accounting of future financial obligations that the issuer will or may have to satisfy due to utilization of benefit plan coverage; this is often synonymous or nearly synonymous with reserves
individual / family market part of the commercial healthcare segment, offers coverage to individuals and to families
insurance policy see policy
insurer a licensed insurance company that provides insurancy policies; often this term is used to refer more generally to a company that offers similar healthcare products; this term is often used synonymously with issuer, carrier, health plan, or plan
Internal Revenue Service the IRS is an agency within the federal Treasury department; the IRS is responsible for granting credits to low-income taxpayers to offset healthcare premium payments, and for charging penalties to taxpayers for having insufficient healthcare coverage during the tax year
IRS see Internal Revenue Service
issuer the company that offers coverage to people, companies, or other groups; issuer is related to insurer, carrier, payer, plan, and health plan
large group market part of the commercial healthcare segment, offers custom and semi-custom coverge options to large businesses and other organizations
legislation laws, such as the ACA, that instruct and guide healthcare companies; at a particular governmental level (e.g., federal, state, local), a conflicting regulation is trumped by the related legislation
lifetime maximum similar to annual maximums, these are maximum amounts that an issuer would pay for covering an individual, whether paid in a particular benefit year or calendar year, or across multiple years; the ACA mostly did away with lifetime maximums
lobbyist someone from the private sector who works with legislators and government agencies to advocate positions in the hope that legislation and regulation is favorable to the lobbyist's cause(s); see also political action committee
major medical a type of healthcare coverage that includes many common benefits; this is the type of coverage most are familiar with when obtaining a benefit plan; this is also sometimes referred to as primary coverage; major medical benefits can be supplemented by a supplemental plan or wrapper plan coverage
managed care contracted providers that provide care on a PMPM basis; the providers are responsible for managing aspects of care for covered members, and must maintain minimum levels of coverage; see also FFS
market a way to segment the healthcare market to group coverage populations; each is regulated separately; segmentation includes commercial healthcare, which includes individual/family and small/mid/large/custom group markets, and public healthcare, such as Medicare, Medicaid, and CHIP
marketplace an ACA exchange, whether FFM, SBM, or hybrid marketplace
maximum out of pocket MOOP, or OOPM, is the most a member would have to pay in cost share for covered benefits during a benefit year, after which the issuer would cover covered benefits fully; the out-of-pocket maximum can be separate for each member and for all persons on the policy, or can be a single amount
MEC see minimum essential coverage
Medicaid government or public healthcare coverage program for low income and disabled populations; this is a joint federal and state program, whereby federal Medicaid rules, regulations, and laws must be followed, states receive federal funds and supply their own funds, and each state manages its own program and member population
Medicaid expansion a provision of the ACA that allows states to expand Medicaid beyond traditional income and other limits; most states opted to expand Medicaid, ultimately covering many millions more people than were covered pre-expansion
medical group a set of doctors who form a contractual partnership in order to collectively care for patients; by coming together, the larger size give advantages such as better negotiating leverage with issuers, as well as be able to better provide adequate care and improved quality of care
medical loss ratio MLR is a measure of how much of the premiums collected are used for medical care versus for other purposes, such as administrative costs; in addition to state rules, the ACA requires that issuers have an MLR of at least 80% for certain market segments and at least 85% for other, and that issuers must refund to members premiums that fall below those thresholds
Medicare a federal government or public healthcare program that provides coverage mostly for older populations; various parts of Medicare provide hospital coverage, doctor coverage, supplemental coverage, and prescription drug coverage; members can choose to obtain Medicare coverage directly from the federal government or from an applicable private issuer; also, companies and other organizations can design Medicare coverage tailored to their employees or members
member a beneficiary entitled to receive healthcare benefits under a benefit plan or insurance policy; this person is a member from the issuer's perspective, and a patient from the provider's perspective; see also enrollee and subscriber
metal level the ACA distinguishes benefit plans based on how rich they are, by their actuarial value, indicating how much of the cost of care, on average and based on expected utilization, is provided for by the issuer or benefit plan versus by the member; the higher the actuarial value, the higher the plan richness; metal levels for ACA commercial plans include platinum, with an AV of approximately 90%, gold, with an AV of approximately 80%, silver, with an AV of approximately 70%, and bronze, with an AV of approximately 60%; see also catastrophic, which is not a metal level but has an AV typically around the bronze level
mid-sized/medium group market part of the commercial healthcare segment, these benefit plans and products tend to be less customized than those for large groups, and are more tailored to the mid-sized group than products made available to smaller businesses
minimum essential coverage under the ACA, healthcare coverage that provides sufficient benefits to avoid the mandate penalty; MEC can be obtained through commercial plans, including through an exchange, open market, or an employer plan, or from Medicare, Medicaid, or CHIP
minimum value plan an MV plan is a benefit plan that covers at least 60 percent of the total allowed cost of benefits that are expected to be incurred under the plan
MLR see medical loss ratio
MOOP see maximum out of pocket
MV see minimum value plan
network the set of contracted providers that provide care for covered benefits under a benefit plan; see also service area
network adequacy ensuring that providers in a benefit plan's network are adequate to serve the needs of anticipated members on the benefit plan given their expected utilization of the covered benefits; adequacy is often seen as an appropriate minimum level of each type of provider for all covered benefits within a certain time and distance radius from expected members; for instance, for providers of each covered benefit, enough within 15 miles and/or 30 minutes of anticipated member populations in the service area
network breadth roughly how large or small a benefit plan's network is, in total number of providers and/or numbers of providers by benefit type; although somewhat arbitrary, QHP certification regulations ascribed network breadths as broad or narrow based on standard deviation from average; breadth is somewhat tied to cost, in that a broader network with many more providers tends to result in a higher premium for a benefit plan than the same plan with a narrower network, although the makeup of the network—for instance, high-cost versus value providers—plays a factor, as well; networks that are too narrow can have network adequacy issues
network management the active management by an issuer of provider networks for benefit plans; this involves provider contracting, ensuring quality of care standards, and creating appropriate networks for various benefit plans
OEP see open enrollment period
OOPM see out-of-pocket maximum
open enrollment period OEP is a period during which qualified people, businesses, or other purchasers can purchase healthcare coverage freely, whereas outside the open enrollment period healthcare coverage can be purchased only in special circumstances, if at all; see special enrollment period
open exchange contrasted with an active purchaser exchange model, an open exchange allows virtually any issuer to offer almost any benefit plan to qualified purchasers via the exchange as a distribution channel
out-of-network providers that are not part of a benefit plan's contracted providers; obtaining covered benefits from out-of-network providers is either not permitted under the benefit plan or is permitted for a typically higher member cost share than obtaining the benefit from an in-network provider
out-of-pocket maximum OOPM, or MOOP, is the most a member would have to pay in cost share for covered benefits during a benefit year, after which the issuer would cover covered benefits fully; the maximum out of pocket can be separate for each member and for all persons on the policy, or can be a single amount
PAC see political action committee
patient a person seeking care from a provider; from an issuer's perspective, this person is a member; from a provider's perspective, this person is a patient; along with the payer and provider, the patient forms a third vertex of the healthcare triangle, and adding policymaker, forms a healthcare pyramid or healthcare tetrahedron
patient-centered medical home PCMH is a care delivery model in which a member's PCP coordinates care for the patient in a manner tailored to that member, including where it makes sense for the member, even outside traditional provider facilities, ensuring the member is consulted and understands and provides active input into the delivery of care decisions
Patient Protection and Affordable Care Act see PPACA
payer payer is a term used to describe the health insurance company, or issuer or carrier, sometimes called a plan or health plan; along with the patient and provider, the payer forms a third vertex of the healthcare triangle, and adding policymaker, forms a healthcare pyramid or healthcare tetrahedron; note that payer can also refer more generally to any financial contributor of medical cost payments, including individuals, families, businesses, associations, and others that contribute to premium payments, HRAs, etc.
PCMH see patient-centered medical home
PCP see primary care physician
per member, per month PMPM is a metric or calculation tied to the number of members in a particular month, often averaged so as to smooth member fluctuation throughout the month(s)
personally-identifiable information PII is any element within data or information that can relate that data or information to a specific person or narrow group of people, either directly or indirectly in ways that are relatively easy to connect the person(s) to the data or information; often PII must be deidentified or stripped from data or information before that data or information can be shared or stored; in many cases, the inclusion of PII could trigger PHI
PHI see protected health information
physician a common type of provider, the physician is a medical professional licensed to give specific types of care
PII see personally-identifiable information
plan richness a relative indication of how much a benefit plan covers the cost of care, with a richer plan tending to cover more of the cost of care than a less rich plan; the measure for this is actuarial value, which manifests itself in ACA metal level plans
plan year see benefit year
PMPM see per member, per month
point of service a benefit plan type that has lower member costs for receiving care from in-network providers, and requires PCP referrals to see specialists; this is related to PPO, EPO, and HMO
policy an insurance policy is an item purchased to indicate coverage benefits and restrictions, along with an explanation of included providers; this is the contract between the member and the issuer; this is also referred to as a plan, health plan, evidence of coverage, EOC, or coverage document
policyholder this is the person named on the healthcare policy or contract, otherwise known as the subscriber or member and frequently the consumer; this person is entitled to receive healthcare benefits under the policy; when more than one person is a named beneficiary on the policy, the policyholder is the subscriber
policymaker a legislator, legislature, regulator, or other governing or regulating body that establishes and affects the framework and operation of the healthcare industry, including oversight of payers, providers, and healthcare policies; along with the payer, patient, and provider, the policymaker forms a healthcare pyramid or healthcare tetrahedron
political action committee a PAC is an organization that raises private funds to advocate for positions and influence legislation; see also lobbyist
POS see point of service
poverty level also referred to as a poverty line, poverty threshold, or poverty guideline, the poverty level is a measure developed by the federal government that identifies an income level minimally necessary for the basics of life; this income amount is determined for an individual and separately for households with multiple members, and can vary by state, although it is currently consistent among the 49 continental states plus Washington, D.C.; the poverty level is used to determine coverage qualifications and subsidy amounts, often on a sliding or stairstep scale that increases coverage or subsidy the lower the income
PPACA this is an early collective term for the Patient Protection and Affordable Care Act; now this is usually referred to as the ACA; see Affordable Care Act
PPO see preferred provider organization
pre-authorization for certain benefits, the member must first obtain authorization from the issuer to have the care from the provider covered under the benefit plan, and without the pre-authorization the care would not be covered by the policy
preferred provider organization a benefit plan type that has lower member costs for in-network care, and that allows members to obtain care from out-of-network providers without a referral, giving the member more choice, though typically at a higher cost than receiving the same care from in-network providers; this is related to EPO, HMO, and POS
premium the amount a benefit plan costs to purchase, usually monthly; this amount is required regardless how much care is given under the policy, and it results in the member(s) having healthcare coverage; for a particular benefit plan, a higher premium tends to result in a lower member cost share, and vice versa; as cost share applies only when care is obtained, and given the relationship between premium and cost share, people not expecting to use the coverage much are inclined to purchase coverage with lower premiums, but higher member cost share, whereas people expecting to use much coverage are incentivised to purchase coverage with lower member cost share for the benefits expected to be obtained, or possibly with lower MOOP/OOPM or deductible(s), in exchange for a higher premium
preventive care a set of benefits and types of care that are intended to help people avoid more serious health conditions and more expensive health care if preventive care services are received and related health conditions addressed before more serious related health issues arise
primary care physician a PCP, often referred to as a gatekeeper, is a doctor that is responsible for providing basic care to members and to refer members to specialists and others for more complicated health issues; members are either assigned a PCP or can choose a PCP
private exchange a platform or method to connect benefit plans from one or more issuers to purchasers, whether businesses or individuals; this distribution channel is distinct from the public ACA exchanges
producer a term often used by issuers to describe external agents contractually related to the issuer, and that in exchange for the producer selling one of the issuer's benefit plans, the issuer will pay the producer a fee, either one-time or recurring, often higher the first year the sold policy is in effect and lower for each subsequent year that the policy is renewed
product a product can be used synonymously with the terms plan, health plan, benefit plan, insurance policy, or policy; product can be used as a group of related benefit plans, sometimes called a plan family, where each of the product's plans, although sharing key characteristics, vary in different ways making each plan either better or worse for different purchasers, or applicable or not to different consumer groups
product development usually working across departments in a payer organization, the process of designing, pricing, marketing, and making available for sale benefit plans
protected health information types of information, and the actual information of these types, that must not be diseminated publicly, semi-publicly, or to unauthorized recipients, or face legal and even criminal consequences; stripping PII from information does not necessarily make it non-PHI
provider provider is a term used to describe a supplier of health care to patients; along with the payer and patient, the provider forms a third vertex of the healthcare triangle, and adding policymaker, forms a healthcare pyramid or healthcare tetrahedron
provider contracting the function of an issuer to negotiate with a provider or provider group, such that that provider is to provide specific services or products at contracted rates, included in a fee schedule, and that requires the provider to maintain minimum levels of quality of care, giving the issuer the right and ability to monitor and assess provider performance; a provider could be part of an issuer's overall network of providers, and/or it could be included in certain networks attached to certain benefit plans or with different networking structures, such as an ACO, where each inclusion of the provider could carry different reimbursement rates and/or different provider obligations and/or different quality standards and metrics
provider group a collection of contactually connected providers intended to offer broader and better care than the individual providers, separately
public exchange a government-sponsored distribution channel connecting benefit plan sellers to benefit plan buyers; common public exchanges are the ACA marketplaces, some of which are SBMs in addition to the FFM; public exchanges support public programs, even if the actual exchanges are only semi-public or quasi-governmental in their organizational structure and management
purchaser the buyer of coverage or a benefit plan; the purchaser usually is, but is not necessarily, the consumer or member on the policy
QHP see qualified health plan
QHP certification QHP certification is the process by which a QHP is deemed acceptable to be sold via an ACA exchange; each ACA exchange has its own certification requirements, and the QHP also must meet requirements satisfying state and federal laws and regulations
QLE see qualifying life event
qualified health plan under the ACA, a QHP is a benefit plan that meets ACA requirements to be able to be sold via an ACA exchange, including being certified by the exchange on which it is to be offered for sale; each QHP is either a metal level plan or a catastrophic plan
qualifying life event a QLE is an event that allows a person or group to become eligible for a special enrollment period, particularly outside the open enrollment period; QLEs include such changes as marriage, birth, geographic relocation, age change, etc.
RADV see risk adjustment data validation
rate this is the premium amount charged to a member on a particular benefit plan; it takes into account allowed variables, such as age and location; this is usually stated in monthly or sometimes yearly terms, or the amount a member would have to pay for the benefit plan's coverage per month; a rate table includes rates for ranges of factors, including various ages, number of people on the policy, etc.; see also premium
referral an agreement by one provider that a patient can or should seek care from a different provider; often this manifests itself as a PCP referring a patient to a specialist, and without such a referral, the patient would not be able to obtain care from the specialist as a covered benefit under the benefit plan
regulation along with laws, regulations guide participants in an industry or a segment of an industry, and delineate rules to follow and oversight processes, along with penalties and related outcomes; regulations intend to clarify laws, providing a framework within which people and organizations can operate more efficiently, effectively, and fairly; see also legislation
regulator an oversight body, typically governmental, that ensures prescribed rules are followed and that can be consulted for clarifications and direction; regulators include the state departments of insurance, state Medicaid administrations, and certain federal CMS staff
reinsurance (insurance) in short, insurance on insurance; this is a method to reduce risk for insurance policies and other healthcare benefit plans; reinsurance usually kicks in when claims for the insured policy exceed a particular threshold, typically somewhat beyond or in excess of expected utilization
reinsurance (program) along with risk corridors and risk adjustment, reinsurance, is one of the principal market stabilization programs written into the ACA, collectively and colloquially referred to as the 3 Rs; reinsurance was a temporary stabilization program, covering plan years 2014 through 2016, requiring most commercial coverage to contribute to a fund that would pay individual-market issuers for members who experience very high claims costs, above what is called an attachment point
renewal a re-purchasing of the same or essentially the same coverage at the end of the plan year or coverage period in order to provide uninterrupted coverage for members; renewal can occur automatically or may need to be initiated or approved by the purchaser
reserves funding an issuer retains in order to properly and quickly satisfy obligations that arise as a result of coverage utilization; this can be ready-cash, lines of credit, and other quickly-converted ways to pay providers, and is often tracked as IBNR; regulations often require minimum reserve levels, based on expected utilization and expected financial in-flows
risk adjustment along with reinsurance and risk corridors, risk adjustment is one of the principal market stabilization programs written into the ACA, collectively and colloquially referred to as the 3 Rs; risk adjustment is a permanent part of the ACA, intending to redistribute funds from issuers with benefit plans with lower-risk members to issuers with benefit plans with higher-risk members; this ACA program is similar to Medicare risk adjustment; ACA risk adjustment requires issuers to utilize an EDGE server to capture and calculate risk adjustment data for reporting to CMS, for CMS to manage the fund transfers; risk adjustment reporting is validated by a RADV process
risk adjustment data validation RADV is a process to ensure that commercial claims experience and other data reported to CMS via EDGE servers was accurate; there is a risk adjustment data validation process for Medicare, known as MA-RADV, and a risk adjustment data validation process for ACA commercial plans, known as HHS-RADV; HHS-RADV is similar to, but slightly different from, MA-RADV
risk corridors along with reinsurance and risk adjustment, risk corridors is one of the principal market stabilization programs written into the ACA, collectively and colloquially referred to as the 3 Rs; risk corridors was a temporary stabilization program, covering plan years 2014 through 2016, intending to balance unintended claims experience, shifting funds from issuers that had lower-than-expected claims costs to issuers that had higher-than-expected claims costs; Congress cancelled this program shortly after it begun, leaving many issuers with expected payments that likely will never be made, to the tune of $10 to $15 billion dollars over the 3-year period; these shortfalls are cited as a primary reason a number of health plans, including many of the CO-OPs, went under or decided to leave the exchange market or were otherwise abnormally unprofitable
SBC see summary of benefits and coverage
SBM see state-based marketplace
seesaw a visual representation of the relationship between a benefit plan's premium and the benefit plan's member cost share, indicating that raising member cost share amounts tend to lower the benefit plan's premium, and vice versa; this is relevant for members since the premium amount must be paid regardless of how much the coverage is utilized, but heavier utilization results in higher member cost share; in economic terms, the premium is a fixed cost to members, while the member cost share is a variable cost to members; for members expecting to utilize the benefit plan's covered benefits rarely, a lower premium is desired, all else being equal, while members expecting to utilize the benefit plan's covered benefits extensively may be more willing to pay a higher premium in exchange for lower member cost share amounts
self-funded see self-insured
self-insured sometimes referred to as self-funded, self-insured is a type of benefit plan in which the employer or group funds and ultimately is responsible for medical costs and associated risks incurred from utilization of the benefit plan; this is distinct from fully-insured or fully-funded benefit plans
SEP see special enrollment period
service area the geographic region(s) that a benefit plan is intended and approved to service; members in the service area are relatively-assured that covered benefit care can be obtained as a result of regulatory approval of the service area, which includes network adequacy determinations; see also network
small group market part of the commercial healthcare segment, these benefit plans and products tend to be relatively fixed and somewhat off-the-shelf, with little variability afforded to smaller businesses and other organizations seeking to purchase healthcare coverage in this market
special enrollment period a period of time during which a qualified person or group is allowed to enroll in a benefit plan; mostly SEPs are outside open enrollment periods, although a person could qualify for an SEP during open enrollment; see also qualifying life event
specialty provider a type of provider that provides healthcare services beyond basic doctor visit or PCP visit or hospital care; often members can obtain covered care from specialty providers, called specialists, only with a referral from a primary care doctor or approval from the issuer
state-based marketplace unlike the FFM, SBM exchanges are established and run by state organizations or agencies; related to hybrid marketplaces
stop-loss a form of reinsurance that protects against high-dollar claims; stop-loss insurance is purchased by insurance companies as well as large groups that choose to self-insure, to avoid financial devistation due to unexpectedly-high claims experience
subscriber on a family or household policy, this is the person with whom the issuer contracts; subscribers are also members on the policy, but other members on the same policy are not subscribers; on a one-person policy, the member is also the subscriber; see also enrollee
subsidy a way to offset premiums, member cost share, or other costs to members; in the ACA, subsidies take the form of a tax credit, which can be obtained in advance of filing taxes (i.e., APTC), to reduce the amount members must pay monthly for their premium payments, and cost-sharing reductions (CSRs), which reduce the amount members must pay as copyaments or co-insurance as member cost share when obtaining covered care
summary of benefits and coverage a summarization of the benefit plan or EOC; the SBC takes a specific form to facilitate comparing multiple benefit plans side-by-side, for a more apples-to-apples comparison; in addition to a listing of many key benefits and their restrictions, the SBC also has boilerplate example scenarios, along with costs a member might experience, to give potential consumers a sense of what they might experience if purchasing and using the benefit plan
supplemental coverage supplemental coverage is a set of benefits that are beyond most major medical policies, intended to provide healthcare help beyond primary coverage; supplemental coverage can be obtained together with or separate from the major medical benefit plan; see also wrapper plan
telehealth a form of care that is provided remotely; that is, where the provider is not co-located with the patient when care is provided; this is possible for certain types of care, and states are mixed in how this is regulated; Teladoc ® is one such company providing telehealth services; telehealth can be provided using phones, computers, or other devices to connect the patient to the provider
termination coverage can be terminated after it is effectuated and coverage has begun (i.e., on or after the effective date of coverage), as long as the coverage is in effect; coverage can be issuer-initiated, such as termination due to non-payment, or member-initiated, such as because the member has moved or plans to move out of the service area; this is related to cancellation
third party from the perspective of issuers, with regard to premium payments, a third party is a source of revenue from other than the member or policyholder; although subsidized premium payments come from the federal government, which could be considered a third party payer, commonly issuers consider a third party premium payment coming from the member's family member or from an organization with a mission to help in this case; one such organization is the Ryan White Foundation; it should be noted that, absent a separate contractual arrangement, the policyholder is ultimately responsible for the member premium payment, and termination for non-payment can occur if a third party misses payments; however, termination for non-payment cannot be initiated simply for missed federal APTC payments
trade association as with many industries, healthcare trade associations help give a larger voice to issuer-members, and are a conduit for information dissemination and collection; trade associations representing issuers include AHIP and ACAP
Treasury a department of the federal government responsible for, among other functions, collecting payments from issuers and paying money to issuers; in addition; as an agency of the Treasury, the IRS is responsible for managing and monitoring mandated coverage
TRICARE this is a government healthcare program of the U.S. DoD Military Health System, providing coverage to military personnel
UCR see usual, customary, and reasonable charges
UM see utilization management
underwriting the process of assessing risk and determining appropriate coverage options and/or pricing, and/or recommending against providing coverage due to excessive risk or risk that the insurance company is ill-equipped or unable to provide; under the ACA, many traditional healthcare underwriting functions were rendered moot
uninsured a characteristic used to metric the percentage of insured in order to track trends and calculate program efficacy; uninsured typically applies to those who do not have major medical coverage
URC see usual, reasonable, and customary charges
usual, customary, and reasonable charges see usual, reasonable, and customary charges
usual, reasonable, and customary charges a typical amount providers in a specific geographic area charge for a certain type of care, such as a specific medical service or procedure; URC (or UCR) charges are often used to determine an allowed amount, particulary from out-of-network providers
utilization management taking a proactive posture, UM is an issuer performing a utilization review to determine whether a particular course of care is allowed under the benefit plan, is appropriate for the member's case, and is the best option for controlling issuer costs
Veterans Health Administration the VHA is a division of the federal Department of Veterans Affairs (VA) that provides government healthcare coverage and benefits to former military personnel and their families
VHA see Veterans Health Administration
visit limit a maximum number of times a member may receive care for a particular benefit and have it covered under the benefit plan, beyond which cost for the care is not covered by the issuer or benefit plan; this is related to benefit limit
waiver a requested and/or approved exception or modification to a provision or regulation; for instance, section 1332 of the ACA allows for state innovation waviers, to allow states to run their exchange programs in unique ways; similarly, section 1115 of the Social Security Act allows states to deviate from federal Medicaid requirements if the requested waiver is approved by HHS
wrapper plan a wrapper plan is a set of benefits that augment a major medical policy; wrapper plans require the purchase of the primary plan in order to obtain the wrapper benefits; this is related to supplemental coverage

* These terms are defined primarily as they relate to commercial markets, commercial payers, and the ACA, and may have additional or different meanings in other contexts.
Terms can be interpreted in multiple ways. The descriptions above are not intended to be comprehensive.
Italicized words in the right column can be found in the left column.
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