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Health Journalism Glossary

Health Policy Glossary

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  • Accountable Care Organization (ACO) – There is no single definition for an ACO because models are continuing evolving. Medicare has many models, and Medicaid has…
  • Actuarial equivalent – When a health plan has similar coverage to that of a standard benefit plan, the two plans are described as…
  • Actuarial value – The average share of medical costs that a health plan will cover for a beneficiary population. The covered individual pays…
  • Advance Premium Tax Credit (APTC) – The ACA provides subsidies to some consumers who buy health insurance on the federal or state-based Marketplace exchanges through tax…
  • Adverse selection – When more sick people—or those who have a high risk of becoming ill—purchase health insurance than healthier people, this trend…
  • Affordable Care Act – Also known as Patient Protection and Affordable Care Act or “Obamacare,” the ACA became law on March 23, 2010. The…
  • Age band – The Affordable Care Act bans insurers from charging older people more than three times as much as younger people in…
  • Agents and brokers – Agents and brokers are trained, state-licensed professionals who can help consumers enroll in health plans. As a general rule, agents…
  • All-Payer Claims Databases – APCDs collect data from all payers in a given region, including state and federal health players, health insurers, employers and…
  • All-payer system – A health care payment system in all payers, including state and federal health programs, private insurers, employers and individuals, all…
  • Alternative payment models – Under the ACA and The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, APMs for physicians and other providers…
  • Annual limit – Before the ACA, many health plans had a yearly limit on what they would pay, either in total costs or…
  • Any willing provider – Some states require managed care organizations to accept any provider, such as a doctor or hospital, into their networks. This…
  • Auto-renewal – Health care plan enrollees are automatically signed up again for the next year, unless they opt out or choose a…
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  • Balance billing – When a health care provider bills the patient for the difference between what the provider charges and what the insurer…
  • Basic Health Plan (BHP) – Under ACA, consumers whose annual income is less than 133% of the federal poverty level would be absorbed into Medicaid,…
  • Benchmarks – When hospitals, doctors or other provider groups measure quality, they do so against a benchmark, which can be a starting…
  • Bending the curve – This phrase refers to efforts to change the trajectory of health care cost growth by slowing or stopping the growth.
  • Block grant – A lump sum usually given to a state or local government for a specific health care purpose. There can be…
  • Budget reconciliation – A fast-track budget procedure in Congress that requires a simple majority and cannot be filibustered, but the president can veto…
  • Budget-neutral – This term means that a waiver, demonstration or other program cannot cost more than whatever would have been spent without…
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  • Cadillac health plan – An employee health benefit plan in which coverage exceeds a certain dollar amount. Starting in 2018, the portion above a…
  • Capitation/capitated payment – When a health care provider is paid a fixed or per capita amount for each enrolled patient, regardless of how…
  • Care coordination – The ACA encourages care coordination, so that providers work together to avoid complications, recurrences, and rehospitalizations, particularly for patients with…
  • Catastrophic plan – A catastrophic health plan is one with a high deductible that kicks in when medical expenses mount. The catastrophic plans…
  • Center for Consumer Information and Insurance Oversight – The Center for Consumer Information and Insurance Oversight (CCIIO) is an office within CMS that oversees the implementation of various…
  • Centers for Medicare and Medicaid Services (CMS) – Part of the federal Department of Health and Human Services, CMS runs Medicare, Medicaid and the Children’s Health Insurance program.…
  • Certificate of need laws – State certificate of need (CON) laws and regulations seek to limit the building of excess capacity or overbuilding of health…
  • Cherry picking – Before the ACA, health insurers would seek to enroll healthy consumers over less-healthy individuals by “cherry picking: among certain populations.…
  • Co-insurance – Co-insurance is a percentage that a consumer with health insurance would pay for a visit to a physician, hospital, or…
  • COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) – This law allows a consumer who loses a job to keep his or her group coverage under an employer-sponsored health…
  • Community mental health centers – CMS verifies that these clinics must provide outpatient services, including specialized care for children, the elderly, those with chronic mental…
  • Community rating – Under community rating, a health insurer would charge all people in a community who are covered under the same type…
  • Comparative effectiveness research – Research that looks at different approaches or treatments for a condition to determine which are most likely to have the…
  • Coordination of benefits – In the event of coverage from two sources — such as Medicare plus supplemental coverage, or when two people in…
  • Copay (or copayment) – A copay is a fixed fee for each health care service, such as $35 or more for a primary care…
  • Cost sharing subsidies – In addition to the advance premium tax credits (APTC) to help consumers pay premiums, many people can also get cost-sharing…
  • Critical access hospital – Certain small hospitals mostly in rural areas are designated as critical access hospitals. The staffing standards are less rigorous than…
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  • Death spiral – When more sick or high-cost people buy health insurance than healthier members in the risk pool, premiums can rise. This…
  • Defensive medicine – Too often, doctors and other health providers order tests, screening exams or treatments that may not be necessary because they…
  • Defined benefit vs. defined contribution – When a health plan, whether through a private employer or a government program such as Medicare or Medicaid, promises specified…
  • Disproportionate share hospital – A disproportionate share hospital (DSH) is one that has a higher share of low-income patients than other hospitals as defined…
  • Doughnut hole (or Donut hole) – A coverage gap in the Medicare drug benefit, during which beneficiaries pay all the costs until another level of coverage…
  • Dual eligibles – Under the Affordable Care Act, the federal Centers for Medicare and Medicaid Services seeks to improve the quality and efficiency…
  • Durable medical equipment (DME) – Items such as ventilators, wheelchairs, hospital beds or home oxygen systems are examples of durable medical equipment that a health…
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  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services – States must cover these services for all Medicaid-eligible children under age 21. These services include screening for vision, hearing, dental…
  • Effectuate – Insurers use this word to describe the completion of an enrollment. Coverage has been effectuated once a consumer signs up,…
  • Employee choice – Small businesses using the SHOP exchange are supposed to decide how much they will contribute to workers’ health coverage, and…
  • Employer mandate – Under the Affordable Care Act, businesses employing more than 50 workers are required to offer affordable health care coverage that…
  • ERISA – The federal Employee Retirement Income Security Act (ERISA) of 1974 sets requirements for employer-sponsored health plans, both self-insured and fully…
  • Essential health benefits – The essential health benefits under the Affordable Care Act are designed so that every health plan covers a comprehensive list…
  • Exchanges – See Health Insurance Exchanges
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  • Facilities fee – A charge for seeing a doctor at a hospital-owned facility (even if it looks like a regular outpatient doctor’s office…
  • Federal Medical Assistance Percentage (FMAP) – In the federal and state Medicaid program, the federal government pays each state for the medical services those states deliver…
  • Full-time worker – Under the Affordable Care Act, an employee who works an average of at least 30 hours per week is considered…
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  • Grandfathered plans – When Congress passed the Affordable Care Act in 2010, the law allowed all group health plans that were started before…
  • Grandmothered or transitional health plans – Individual and small-group health insurance plans that became effective after the Affordable Care Act (ACA) was signed into law on…
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  • Habilitation services – The essential benefits requirements of the Affordable Care Act include both habilitation and rehabilitation services. Rehabilitation helps a patient regain…
  • Health care sharing ministry – Health care sharing ministries are health plans that do not fully comply with the requirements of the Affordable Care Act…
  • Health insurance exchanges/marketplaces – Under the Affordable Care Act, new health insurance exchanges (called the federal and state marketplaces) were established for people and…
  • Health insurance tax – When Congress passed the Affordable Care Act (ACA), it included excise taxes on health insurance providers, pharmaceutical manufacturers and importers,…
  • Health reimbursement arrangements – A health reimbursement arrangement (HRA) or health reimbursement account is an employer-funded tax-free account that employees can use to pay…
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) – The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a patient-satisfaction survey that the U.S. Centers for Medicare…
  • Hybrid health care – Hybrid health care describes the practices of physicians and other providers who offer both telehealth and in-person treatment. These practices…
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  • Individual coverage health reimbursement arrangements (ICHRAs) – In 2019, the Trump administration established ICHRAs to allow employers of any size to reimburse employees for some or all…
  • Individual mandate – The individual mandate is a provision of the Affordable Care Act (ACA) (and some state laws) that requires individuals to…
  • Invisible risk pool – A program that reimburses insurers for especially high-risk beneficiaries (based on an annual cost threshold or set of diagnoses determined…
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  • Large group health plan – The federal government defines a group health plan as one that covers workers in an employer-sponsored health plan that has…
  • Lifetime limit – Under the Affordable Care Act, health insurers cannot set a dollar limit on what they spend on essential health benefits…
  • Low-income pool (LIP) – This is a revenue stream, currently (mid-2015) in nine states. It’s federal and state dollars that help hospitals that treat…
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  • MACPAC – An advisory committee on Medicaid and the Children’s Health Insurance Program, MACPAC was established in a 2009 law and expanded…
  • Market Basket (MB) – CMS uses “market baskets” – a defined set of health expenditures in a defined time period – to measure price…
  • Market exclusivity – Drug manufacturers use patent protections that the federal Food and Drug Administration grants to market brand-name drugs exclusively in the…
  • Medicaid – Created in 1965, Medicaid is a health care program for those who have low income or are disabled. The states…
  • Medical device tax – A 2.3% sales tax on medical devices went into effect on Jan. 1, 2013, as part of the Affordable Care…
  • Medical loss ratio (MLR) – The MLR is the amount a health plan spends on delivering actual health care services to members, administration and marketing…
  • Medicare – Medicare is a federal health program for all Americans starting at age 65 and for some people with disabilities. Medicare…
  • MEDPAC – The Medicare Payment Advisory Commission is an independent agency established in 1997 to advise Congress on Medicare payment issues, including…
  • Minimum essential coverage – A health plan that meets the individual mandate requirement, including exchange plans, employer-sponsored insurance, or a government plan like Medicaid.…
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  • Navigators – https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance Health insurance navigators provide in-person assistance to consumers, small businesses and their employers when enrolling in insurance plans under…
  • Networks – Health insurance plans contract with hospitals, physicians, clinical laboratories and other health care providers to supply in-network care at rates…
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  • Off-exchange enrollment – Enrollment in the individual market in plans outside the exchange. Most meet ACA requirements. However, starting in late 2018, the…
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  • Partial Medicaid expansion – Several states are seeking permission from CMS to do a partial Medicaid expansion – up to 100 percent of poverty,…
  • Patent protections – Pharmaceutical companies use patents from the federal Food and Drug Administration to gain market exclusivity on their medications and other…
  • Patient Protection and Affordable Care Act – See Affordable Care Act
  • Plan Year – The date that a health plan begins. Some of the new rules under the health law may go into effect…
  • Post-claims underwriting – When a health insurer investigates a consumer’s health history after selling that consumer a health plan and usually after a…
  • Premium shock – Critics of the Affordable Care Act use the term premium shock to describe the rising cost of health insurance premiums…
  • Premium stabilization – When the Affordable Care Act became effective on Jan. 1, 2014, the law included three tools to encourage health plans…
  • Premium support – Proposal to give people a voucher or coupon to help pay for health insurance. At the moment, it’s most often…
  • Private option – Remember the debate over the “public option” in the health law? Some states have pursued what’s been dubbed the “private…
  • Public option – A public option refers to a health insurance program that a state or the federal government would make available to…
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  • Rate review – The process through which state insurance officials review proposed premium increases. Some states can approve or disapprove rates while others…
  • Readmission – This is usually used as shorthand for when a patient returns to the hospital within 30 days. Patients can of…
  • Rehabilitation services – The essential benefits requirements of the health law include both habilitation and rehabilitation services. Rehabilitation helps a patient regain an…
  • Reinsurance – This is what it sounds like – insurance for the insurers. Reinsurance provides a backstop so an insurer doesn’t end…
  • Rescission – Retroactive cancellation of health insurance policy, usually after someone files a claim. This is illegal under the Affordable Care Act…
  • Risk Adjustment – This is a way of spreading the financial risk that insurers bear – in and out of the exchanges –…
  • Risk Corridors – Given the uncertainty for insurers in the exchanges the first few years, risk corridors were established to enable the federal…
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  • Section 1115 Waiver – States can negotiate these waivers with the U.S. Department of Health and Human Services to modify their Medicaid and CHIIP…
  • Self-insured plan – Usually involving larger businesses, in these plans the employer collects the premiums and pays the medical claims for workers and…
  • Sequestration – Automatic budget cuts. It can be across the board, or some programs or agencies can be exempted or partially shielded…
  • Shadow pricing – Shadow pricing describes a practice pharmaceutical companies use to raise prices on prescription drugs by raising prices in lockstep with…
  • Small business health options program (SHOP) exchanges – The Small Business Health Options Program (SHOP) provides health and/or dental insurance coverage for businesses in every state. They are…
  • Superuser (or Super utilizer) – The U.S. Centers for Medicare and Medicaid Services define “super-utilizers” as a patient who often admits themselves to the hospital…
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  • Tax reporting – Beginning with the W-2s for 2012, the year-end income tax forms include the value of the employer’s contribution to the…
  • The Birthday rule – The birthday rule dictates which health insurance company would be the primary source of insurance coverage for a newborn when…
  • Third-party administrator – See “self-insured plan.”
  • Third-party payer – An insurer or government program that pays medical bills for a patient or “first party” given care by a hospital,…
  • Tricare – This federal health care program has almost 9.5 million members worldwide. It covers active duty service members, National Guard and Reserve…
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  • Uncompensated care – When clinics, hospitals or doctors provide care without pay – from an insurer, the patient or a government program such…
  • Underinsured – People who have insurance but either face very high deductibles and out of pocket costs or skimpy benefits (or both)…
  • Underwriting – Health insurers in the small group and individual markets use “underwriting” – weighing an individual’s health status, “pre-existing conditions” and…
  • Usual, Customary and Reasonable (UCR) – This is the amount paid for a certain medical service, and it often varies geographically. It’s based on what providers…
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  • Work requirement/community engagement – Under waivers approved by the Trump administration, some states are requiring certain Medicaid recipients to work (usually about 20 hours…
  • Wrap-around benefits – Low-income people who qualify for various government programs may also qualify for wrap-around benefits – meaning some extra help to…

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