Actuarial Value (AV) – the average value of the benefits that a certain health plan covers, calculated as a percentage of total costs. For example, if the actuarial value of a plan is 75, then the consumer will pay 25 percent of the costs of the benefits he or she receives. Actuarial value is an average for a population with a range of patients, so it does not always accurately reflect the cost sharing of each individual. Actuarial value is used to rank insurance plans in the insurance marketplaces so that consumers have a general sense of the coverage offered by plans. The ranking has four tiers—bronze, silver, gold and platinum—with platinum plans having the highest actuarial value.
Affordable Care Act (ACA) – the comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by The Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
Appeal – after insurance issues a denial of coverage for either a claim or a request for prior authorization, you submit written information to justify why a service should be covered; this is called an appeal. The appeals process generally has 2-3 levels.
Benefit Exclusion – when a plan refuses to cover certain health care providers, services or products. The most common exclusion obstacle faced by PH patients is that their drug is not on their plan’s formulary, the limited list of drugs subject to coverage under the plan. Most plans establish steps – called an exception process – which you can take to petition for certain health care benefits.
Benefit Limitation (Benefit Cap) – a limit set by the insurance company on the amount of money (cost limit) or product that they cover (quantity limit). a limit set by the insurance company on the amount of money (cost limit) or product (quantity limit) that they cover. Benefit limitations can be for different time periods: annual or lifetime. However, under the Affordable Care Act, it is now illegal for insurance companies to impose lifetime caps. Starting 2014, it will also be illegal for insurance companies to impose annual caps.
Cost Limit – a limit on the amount of money an insurance company will pay for benefits. For example, you may have prescription coverage up to $2,000 per year. If you have spent more than $2,000 in prescription costs, your insurance company will not cover additional prescription costs for the rest of the year.
Quantity Limit – a limit on the number of services, prescriptions, or products allowed over the course of a particular benefit period. For example, you may have a limit of three prescriptions per month.
Benefit Management – a process, such as prior authorization or step therapy, through which a suggested treatment plan must be reviewed and approved before it is implemented.
Case Management – a planned approach to manage services or treatment for an individual with a serious medical problem. Its dual goal is to contain costs and promote more effective interventions to meet the patient’s needs.
Catastrophic Coverage – coverage provided by the insurance company after the beneficiary has personally paid a certain amount of medical expenses out-of-pocket as predetermined by the payer.
Certificate of Coverage – document that specifies the benefits issued to a member of group health insurance. This can change yearly depending on what an employer group elects to purchase.
CHAMPVA – a health benefit program for the families of veterans with 100 percent service–connected disability and surviving spouse or children of a veteran who dies from a service-connected disability.
Children’s Health Insurance Program (CHIP) – an insurance program jointly funded by state and federal government that provides health insurance to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage.
Claim – information submitted to the insurer by the member or health care provider for the payment of services under a policy.
Coinsurance – the percentage of allowed charges for covered services that you are required to pay. For example, the health insurance may cover 80% of charges for a covered hospitalization, leaving you responsible for the other 20%. This 20% is known as the coinsurance.
Consolidated Omnibus Budget Reconciliation Act (COBRA) – a federal law that allows individuals leaving a company to continue the health insurance policy they had when employed. COBRA applies when individuals lose or leave a job. The individual is allowed to pay group rates plus a set administrative fee, usually for up to 18 months.
Coordination of Benefits (COB) – method of integrating benefits payable under more than one health insurance plan so that the insured’s benefits from all sources do not exceed allowable medical expenses.
Copayment (Copay) – a set amount determined by the insurance company that you pay when you receive covered services. For example, you may have a copayment of $15 every time you visit your Primary Care Physician.
Cost Sharing – the term that insurance plans use to describe costs they “share” with the beneficiary. Because the beneficiary has to pay out of his or her own “pockets,” these costs are also often known as out-of-pocket costs. The most common forms are deductibles, copayments, and coinsurance.
Creditable Coverage – drug coverage that pays, on average, as much as or more than the standard Medicare Part D drug coverage. Insurance companies are required to inform beneficiaries of whether their coverage is creditable. If a patient’s drug coverage is considered creditable coverage, then the patient is not required to purchase Part D coverage once they become eligible for Medicare and can enroll in a Medicare Part D plan without penalty after the initial enrollment period.
Deductible – the amount of money that you have to pay before your insurance plan pays for any medical care or prescriptions. Deductibles can vary between the insured and eligible family members. An individual deductible would need to be paid before the insurance company will pay for medical care. If the whole family is covered under one family member’s insurance, then a family deductible is the amount of money that the entire family would have to pay first before the health insurance company would pay or reimburse for medical care or prescriptions.
Department of Insurance – a state-level regulatory agency that oversees and enforces state insurance laws. Each state has their own Department of Insurance, generally designed to serve consumers in a professional and timely manner by regulating the industry’s practices and encouraging a healthy marketplace.
Durable Medical Equipment (DME) – medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful to an individual in the absence of sickness or injury and is appropriate for use in the home. For Medicare beneficiariesm, DME – such as home oxygen – is covered under Medicare Part B.
Employee Retirement Income Security Act (ERISA) –a federal law that governs pension plans and private health insurance provided by self-funded institutions (employers or organizations who pay for medical bills out of their own funds). ERISA requires insurances providers to disclose plan benefits and funding levels, as well as ways to manage and access your benefits. ERISA also provides certain rights, such as the right to appeal a denial of benefits and a right to judicial remedies.
Essential Health Benefits (EHBs) – a set list of benefits that insurance plans must include if they are sold through a state’s health insurance marketplace. EHBs will be required beginning in 2014 and are intended to eliminate major benefit gaps currently present in many small plans. For example, the Department of Health and Human Services estimates that 62 percent of individual health insurance plans currently lack maternity care coverage, which will become a required benefit in 2014.
Exception Process – steps outlined by your insurance company that you can take to petition for certain health care benefits ordinarily not covered on your insurance plan. If you and/or your doctor are able to show that your prescribed service or product is the best one to treat your condition and that no other satisfactory alternative is available, the plan may agree to make an exception and cover the drug for your care.
Explanation of Benefits (EOB) – a description, sent to patients & health care providers by health plans, of benefits received & services for which the health care provider has requested payment.
Family and Medical Leave Act (FMLA) – a federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.
Federal Povery Level (FPL) – a measure of income level issued annually by the Department of Health and Human Services. The FPL is used to determine your eligibility for certain benefits and programs, such as Medicaid.
Flexible Spending Account/Arrangement (FSA) – an arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.
There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.
Formulary – an approved list of prescription drugs subject to coverage under a specific insurance plan.
Genetic Information Nondiscrimination Act (GINA) – a federal law that prohibits insurance providers and employers from discriminating on the basis of genetic information.
Grandfathered Health Plan – as used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers.
Health Insurance Exchange or Marketplace – online marketplaces where consumers can compare and purchase insurance plans. A provision of the Affordable Care Act, insurance marketplaces will open for enrollment on Oct. 1, 2013. Each state will have its own marketplace, which will either be operate by the state, the federal government or as a joint partnership of the two. The marketplaces will employ insurance marketplace “navigators” to help consumers understand the process and choose insurance plans.
Health Insurance Portability and Accountability Act (HIPAA) – a set of laws that provides rights and protections for participants and beneficiaries in group health plans. HIPAA protects your personal information while also allowing healthcare administrators to conduct necessary business operations. It also outlines standards for portability and pre-existing conditions.
Health Maintenance Organization (HMO) – a payer that provides services for members in a particular geographic area. Services are provided through a network of doctors, hospitals and other medical providers selected by the plan. Members are required to obtain care from this network of providers in order for their care to be covered, except in cases of emergency.
Health Savings Account (HSA) – a medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you do not spend them.
High Risk Insurance Pools – state programs that enable people with health problems to join together to purchase health insurance; even with subsidies, premium rates are high because pool members are high risk.
In-Network – a list of providers who participate in a health plan’s provider network. By using in-network providers, you may have lower copayments, and may not need prior authorization for services.
Itemized Bill – a type of bill for inpatient hospital services that lists every charge, grouped into specific categories.
Lifetime Maximum Benefit (Lifetime Cap) – a lifetime maximum benefit is the highest amount of money that your insurance company will pay to cover you for healthcare expenses. For example, you may have a $1 million lifetime maximum benefit. If your healthcare costs go over $1 million, then your healthcare costs will no longer be covered by that insurance plan.Under the Affordable Care Act, it is now illegal for insurance companies to impose lifetime maximum benefits.
Managed Care Plans – a plan which implements health care measures to control costs associated with heath care services. These measures may include pre-admission review for all hospital admissions, second surgical opinions, discharge planning, case management, prior authorization, physician networks.
Medicaid – a federal program, administered and operated on the state level, that provides medical benefits to eligible low income persons needing health care.
Medical Benefits Exclusion – a limiting provision. Some examples may include: injuries sustained in the act of committing a felony or misdemeanor, workers comp, self inflicted injuries or suicide attempt, cosmetic surgery, and convenience items.
Medical Loss Ratio – the percentage of the premium that an insurance company spends on medical care, as opposed to administrative or overhead costs. As a provision of the Affordable Care Act, beginning in 2011 insurance companies must report their medical loss ratio and provide rebates to their beneficiaries if it is less than 85 percent.
Medically Necessary – term used when the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.
Medicare Part D – Medicare’s prescription drug benefit coverage available through private companies. All Medicare members are eligible to enroll. Enrollment is optional, but to receive prescription coverage you must choose and enroll in a plan.
Medicare Part D Coverage Gap (Donut Hole) – most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again. Learn more
Medicare Private Plan (Medicare Advantage) – a Medicare managed care program that allows Members who receive Original Medicare (Part A and B) the option to purchase a private managed care plan (through Medicare Part C) instead of Original Medicare. These plans must offer the same benefits as Original Medicare and may offer additional benefits as well.
Medigap (Medicare Supplement) – a Medicare supplemental insurance policy sold by private insurance companies to fill in the gaps in Original Medicare coverage. Depending on where you live, you have up to 10 different Medigap plans to choose from, labeled A through N (plans E, H, I and J are no longer offered), each offering a different set of benefits.
Navigators– people employed by their state insurance marketplace to help consumers through the process of choosing an insurance plan.
Open Enrollment Period – the period of time set up to allow you to change coverage and choose from available plans, usually once a year.
Original Medicare – a federal program that provides health insurance coverage to qualified elderly and disabled individuals. Coverage rules and reimbursement methods vary based on the site of service. Original Medicare includes Medicare Part A and B.
Out-of-Pocket (OOP) Costs – costs that beneficiaries “share” with their insurance company and thus pay for out of their own “pocket.” The most common forms of OOP costs are deductibles, copayments, and coinsurance.
Out-of-Pocket (OOP) Maximum – the total dollar amount of the expenses a member would have to pay for covered medical charges during a specified period of time. The out-of-pocket maximum may also be called stop-loss limit cost or catastrophic expense limit.
Out-of-Network – providers who do not participate in the network of a managed care plan.
Pharmacy Benefit Manager (PBM) – a company specializing in the administration of commercial pharmacy benefits.
Per Diem – literally, per day. Term that is applied to the cost of care for a day and is an average that does not reflect the true cost for each patient.
Point of Service (POS) Plan – a type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
Pre-Certification – utilization management program that requires the individual or provider to notify the insurer before hospitalization or surgical procedure. Notification allows the insurer to authorize payment and to recommend an alternate course of action.
Preferred Provider Organization (PPO) – groups of health care providers that contract with employers, insurance companies or other third party payers to provide medical care services at a reduced fee. Typically, enrollees covered by traditional insurance arrangements are offered incentives to use preferred providers, such as reduced deductibles and copayments, or increased benefits such as preventive health care.
Premium – the payment made by an employer or individual to purchase insurance.
Prior Authorization (Pre-Determination or Pre-Authorization) – review of services to determine medical appropriateness before services are rendered. The payer will decide to cover/not cover the charges prior to the services being provided. Many PH therapies require prior authorization.
Primary Care – health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
Primary Care Physician (PCP) – a physician, who oversees the general healthcare needs of a patient and may serve as the first contact in a managed care system.
Provider – institutions and individuals that are licensed to provide health care services; for example, hospitals, physicians, pharmacists, etc.
Rescission – the retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Rider (Exclusionary Rider) – an amendment to an insurance policy. Some riders will add coverage (for example, if you buy a maternity rider to add coverage for pregnancy to your policy.) In most states today, an exclusionary rider is an amendment – permitted in individual health insurance policies – that permanently excludes coverage for a health condition, body part, or body system. Starting in September 2010, under the Affordable Care Act, exclusionary riders cannot be applied to coverage for children. Starting in 2014, no exclusionary riders will be permitted in any health insurance.
Self-Funded (Self-Insured) Plan – a type of job-based health insurance coverage where the employer pays the claims with its own funds. This is different from fully insured plans, where the employer contracts with an insurance company and the insurer covers the employees and dependents. Self-funded plans are governed by the Employment Retirement Income Security Act (ERISA).
State and Community Health Plans – programs that provide coverage and services with minimal private commercial and federal involvement. Funding and administration occurs at the state, county or local level.
Statement of Medical Necessity – official documentation from the medical provider to the payer which contains medical information to justify that the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.
Step Therapy – a requirement that less costly and risky treatment alternatives be explored and deemed unsuitable first.