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340B: Federal drug pricing program that requires drug manufacturers to provide outpatient drug prices to “eligible organizations,” such as children’s hospitals and other safety net providers, at significantly reduced prices. The program is administered by the Health Resources and Services Administration (“HRSA”).
A
Accountable Care Organizations (ACOs): groups of doctors, hospitals and other health care providers who collaborate to improve the quality and efficiency of care delivered to their patients. Most often, payers reward ACOs for reducing costs by sharing a portion of the savings generated with them. The Affordable Care Act included a provision to encourage ACOs in the Medicare program.
Actuarial Value: the projected value of benefits delivered by a health plan to an enrollee, usually expressed as a percentage of the total health care costs for that enrollee during a benefit period. An actuarial value of 80 percent indicates that the consumer will be responsible for 20 percent of the costs.
Administrative Simplification: provisions included within the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), that included national standards for electronic health care transactions and code sets, unique health identifiers, and security
Affordable Care Act (ACA): shorthand name for legislation signed into law by President Barack Obama in March 2010. The legislation sought to increase healthcare access and quality, expand workforce and preventive health, and address other shortcomings of the U.S. healthcare system. Known in full as the Patient Protection and Affordable Care Act and, colloquially, as Obamacare, it represented the largest overhaul of the U.S. healthcare system since the passage of the Medicare and Medicaid programs.
Ambulance: transportation, often in emergency circumstances, for healthcare patients, typically by motor vehicle or helicopter
Ambulatory Surgical Centers (ASCs): healthcare facilities designed to provide same-day surgical care, often at lower cost than a typical hospital outpatient department
American Recovery and Reinvestment Act of 2009 (ARRA): economic stimulus package signed into law in 2009 as a response to the recession. Cost estimated at around $800 billion. Commonly referred to as the Stimulus Bill or the Recovery Act
American Taxpayer Relief Act of 2012 (ATRA): signed into law on Jan. 2, 2013 by President Barack Obama, the ATRA addressed the “fiscal cliff.” Provisions extended or modified the “Bush-era tax cuts,” estate tax laws and payroll tax, among other things
Association Health Plans: insurance products offered by trade associations or other groups to mimic the benefits of the large group market for small and mid-sized employers
B
Bad Debt: unpaid financial obligation, usually the amount that a patient is responsible for, but doesn’t pay, for healthcare services rendered
Balanced Budget Act of 1997 (BBA): large deficit reduction package enacted with bipartisan support and signed by President Clinton; cut over $100 billion from Medicare over five years, made significant changes to Medicare and Medicaid, and created Children’s Health Insurance Program (CHIP)
Basic Health Plan: Created by the Affordable Care Act, states have the option of creating a health benefits coverage program for low-income residents who would otherwise be eligible to purchase coverage through the Health Insurance Exchange
Behavioral and Mental Health: fields of medicine addressing psychological illnesses, substance abuse and related conditions
Benchmark Plans: insurance benefit package identified as standard for other products offered in a market; for Exchanges, states may identify benchmark plans for purposes of determining Essential Health Benefits of all plans; benchmark plans are also identified for establishing Medicaid benefits in states
Benefit Design: package of services covered and costs passed through to health plan or program enrollees, including medical benefits, deductibles and coinsurance rates
Biologics: genetically engineered proteins that are usually large and complex, molecules manufactured in a living system; also known as biopharmaceuticals. Examples include vaccines and gene therapy
Biosimilars: a biological product that is approved by the FDA based on a showing that it is highly similar to an FDA-approved biological product and has no clinically meaningful differences in terms of safety and effectiveness
Brokers & Agents: professionals that serve as intermediaries between insurance providers and current and potential enrollees
Budget: in this context, used to refer to the Federal budget and budgetary concerns
Budget Control Act of 2011 (BCA): signed into law by President Barack Obama on August 2, 2011. Increased the debt ceiling and aimed to reduce deficit spending. Also created the Congressional Joint Select Committee on Deficit Reduction and Sequestration
Bundling: reimbursement of health care providers (such as hospitals and physicians) on the basis of expected costs for clinically-defined episodes of care; also referred to as episode-based payment
C
Care Coordination: integration of a patient’s caregivers via improved communication, data sharing and other tools to facilitate safer and more effective care
Care Management: strategies to ensure an enrollee or patient’s successful care, often targeted to the chronically ill or others for whom adherence to treatment regimens are especially important
Children’s Health Insurance Program (CHIP): program designed to cover uninsured children up to age 19 in families who do not qualify for Medicaid, yet have only modest incomes; the program is administered by states according to federal requirements; previously known as State Children’s Health Insurance Program (SCHIP), it was originally enacted as part of the Balanced Budget Act of 1997
Children’s Hospitals: hospitals specializing in pediatric care, most of which carry a national designation for purposes of collecting certain Federal payments
Chronic Diseases: long-lasting conditions that can be managed with adequate care but typically not cured
Clinical Labs: facilities where clinical specimens are tested in order to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease
Coinsurance and Co-Pays: percentage of costs (coinsurance) or fixed dollar amounts (co-pay) that an individual is responsible for paying for medical services, not covered by the individual’s health insurance
Community Health Centers (CHCs): non-profit clinical care centers that receive funding from the federal government, comprised by health care professionals and typically serving the uninsured and underserviced
Community Rating: a rule that prevents health insurers from using age, gender, health status or other factors to determine health insurance premiums within a certain geographic region
Comparative Effectiveness Research: designed to inform health-care decisions by providing evidence on the effectiveness, benefits and harms of different treatment options; the evidence is generated from research studies
Competitive Bidding: program requiring healthcare providers and suppliers to bid on the right to serve patients within certain designated areas; currently in operation in the durable medical equipment benefit of Medicare
Consumer Operated and Oriented Plans (CO-OPs): qualified, member-owned nonprofit health insurance issuers, established under the ACA, offering health plans in individual and small group markets
Consumer Protections: laws and regulations intended to protect consumer freedoms and rights
Continuing Medical Education (CME): ongoing education targeted toward physicians and other healthcare providers to further their education and professional development
Costs: used on this site to refer to health care costs, especially regarding issues of cost growth economy-wide and to consumers
Coverage: as used on this site, refers to benefits covered by health plans or healthcare programs
Critical Access Hospitals (CAHs): rural, community-based hospitals that receive cost-based reimbursement; must be certified under Medicare conditions
D
Debt Ceiling: federal law limiting the amount of money the United States government can borrow, thus also limiting the amount of potential national debt
Deductibles: expenses that must be paid out-of-pocket before an insurer will cover the remaining costs
Deficit Reduction: methods designed to reduce the Federal budget deficit
Deficit Reduction Act of 2005 (DRA): budget-cutting legislation that included limitations on Medicaid and other Federal healthcare programs
Delivery Reform: changing the manner in which providers deliver care to patients to improve the quality and efficiency of health outcomes
Demonstration Programs: time-limited programs that test new payment and delivery models to examine their impacts on cost and quality
Dental: relating to delivery of oral/dental care, including benefits covered by applicable health plans
Dialysis: a process primarily used to control kidney failure by removing excess waste and water from blood
Disease Management: system of healthcare collaboration with patients whose conditions are more reliant on self-care
Disproportionate Share Hospitals (DSH): hospitals that treat indigent patients; qualified hospitals receive additional Medicare and Medicaid payments
Doc Fix: health policy term of art referring to legislation that was needed, sometimes annually, to block cuts in Medicare reimbursement to physicians under a statutory formula known as the sustainable growth rate (SGR); the SGR formula finally was repealed in 2015 by the Medicare Access and CHIP Reauthorization Act (MACRA)
Doctors: MDs and DOs; used synonymously on this site as “physicians”
Dual Eligibles: individuals eligible for both Medicare and Medicaid, typically low-income seniors
Durable Medical Equipment (DME): medical equipment that is long-lasting, used in the home, used for a medical reason and unnecessary for a healthy person; covered by Medicare Part B
E
Electronic Health Records (EHRs): digital records that contain information about a patient’s medical history, treatment plans, test results and other data
Electronic Medical Records (EMRs): digitized versions of paper charts, which include all information of a patient’s medical history from a single practice; often used interchangeably with Electronic Health Records
Eligibility and Enrollment: used here to refer to the standards by which individuals qualify for healthcare plans, programs and assistance and efforts and strategies for enrolling them in such options
Employer Mandate: Affordable Care Act policy requiring all businesses with over 50 full-time equivalent employees to either provide health insurance or pay a monthly fee on their federal tax return
Employer Sponsored Insurance: health insurance options provided for by businesses on behalf of their employees, as part of an employee benefits plan; often, the employer pays part of the employee’s premium; the most common source of coverage in the U.S
End of Life and Palliative Care: patient and family-centered care for a life-limiting illness, often available in the home or in hospice; palliative care need not necessarily be delivered at the end of life
End-Stage Renal Disease (ESRD): final stage of chronic kidney disease, also referred to as kidney failure; dialysis or transplant needed to keep patient alive
Entitlement Reform: legislative efforts to change Federal entitlement programs, i.e., those that guarantee benefits to individuals who meet eligibility criteria, such as Medicare and Medicaid
Essential Health Benefits: services that must be covered by qualified health plans under the ACA
F
Federally Qualified Health Centers (FQHCs): organizations receiving grants under Section 330 of the Public Health Service Act, a subset of community health centers (CHCs); typically serve low income areas or underserved populations
Financing: as used on this website, refers to the methods by which healthcare programs are funded – e.g., by taxes, employer contributions, etc
Flexible Spending Accounts (FSAs): tax-exempt accounts, set up by individuals through their employers, used to pay for eligible medical expenses, such as deductibles, co-pays and covered prescription drugs
Flu: influenza, in its various forms
Food and Drug Administration (FDA): agency within the U.S. Department of Health and Human Services that has regulatory authority over products including prescription and over-the-counter drugs, medical devices, biologics, food safety, tobacco products and cosmetics
Fraud and Abuse: health care fraud relates to intentional misrepresentation with the intent to receive greater reimbursement. Health care abuse relates to practices inconsistent with sound medical and business practices. There are many federal and state laws designed to combat these problems, which cost our health care system billions of dollars each year.
G
Generic Drugs: pharmaceutical products with same active ingredient as a brand name product; usually costs less than brand name product
Geographic Variation: relating to discrepancies across the U.S. in health quality and costs; can also refer to differences in reimbursement among geographic areas due to varying input costs
Graduate Medical Education (GME): any formal medical education following an M.D. or D.O. degree, typically referred to as residencies and fellowships; unique mandatory funding stream in Medicare for these purposes, as well as a discretionary funding stream to pediatric hospitals
Grants: funding opportunities offered, as typically referred to on this site, by the Federal government
Group Purchasing Organizations (GPOs): entities that aggregate purchasing power from several members to manage costs
Guaranteed Issue: insurance market rule requiring all carriers to write policies for all potential enrollees, regardless of their health status
H
Health Disparities: variations in health access, status and outcomes among populations
Health Home: comprehensive care management sites for patients; sometimes used interchangeably with medical homes
Health Information Technology (HIT): broad term describing technological applications to healthcare and coverage, typically relating to management of health-related information
Health Insurance Exchanges: under the ACA, refers to regulated marketplaces for the purchase of commercial insurance by individuals and small businesses; also referred to as Health Insurance Marketplaces
Health Insurance Marketplaces: under the ACA, refers to regulated marketplaces for the purchase of commercial insurance by individuals and small businesses; also referred to as Health Insurance Exchanges
Health Insurance Portability and Accountability Act of 1996 (HIPAA): federal law protecting health insurance coverage for employees who change or lose their jobs and establishing privacy standards
Health Savings Accounts (HSAs): pre-tax deposit accounts that may be used to pay for qualifying healthcare-related expenses if the individual is enrolled in a high-deductible health plan
High Deductible Health Plans (HDHPs): health insurance plan with a higher deductible than traditional insurance plan; usually the monthly premium is lower; often coupled with health savings accounts
High-Risk Pools: historically state-based programs designed to provide health insurance to people considered uninsurable, often due to pre-existing conditions
HIV/AIDS: human immunodeficiency virus and acquired immune deficiency syndrome; individuals diagnosed with these conditions may qualify for special healthcare programs and benefits
Home and Community Based Service (HCBS): opportunities for patients to receive care in their own homes or communities, typically referred to in the context of Medicaid benefits
Home Health: delivery of care in the patient’s home; also a specific covered benefit under Medicare Part A
Home Infusion Therapy: involves treatment through a needle or catheter, administered at the patient’s home
Hospice: services delivered to patients at the end of life, can include palliative care
Hospital-Acquired Conditions (HACs): adverse health conditions occurring as a result of hospital stay
Hospitals: an institution providing medical and surgical treatment and nursing care for sick or injured people; can also include delivery of primary and preventive outpatient care
I
ICD-10: the tenth revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list authored by the World Health Organization used by U.S. providers to code medical services
Imaging: medical process creating visual representations of the body’s interior, including MRI, CT and PET scans
Indian Health: programs and policies focused on medical and public health services for American Indians and Alaska Natives
Individual Mandate: requirement under the Affordable Care Act for individuals above certain income thresholds to obtain health insurance or pay a tax penalty
Individual Market: as opposed to the group (employer-sponsored) market, the commercial insurance sector for individuals and families to independently purchase insurance from carriers
Inpatient Rehabilitation Facilities (IRFs): Medicare classification of facilities that provide therapies to patients following stabilization of acute medical services
Insurance: a guarantee of compensation for some kind of loss, damage or problem in return for a premium payment
Insurance Market Reforms: laws and regulations that reform the United States health insurance system, here especially relating to those under the Affordable Care Act
L
Legal: used here to reference laws enacted by Congress, regulations promulgated by agencies and court decisions issued by judges
Long Term Care Hospitals (LTCHs): a Medicare classification of facilities that focus on patients who stay, on average, more than 25 days for post-acute rehabilitation or care
Long-term Care (LTC): commonly used to refer to clinical services and non-clinical supports delivered to individuals with non-acute, ongoing healthcare needs
M
Managed Care: here used interchangeably with healthcare-related insurance.
Meaningful Use: standard by which the provider adoption of electronic health records is evaluated for purposes of determining their financial reward or penalty under the Medicare EHR Incentive Programs
Medicaid Managed Care: use of private health insurance issuers in the Medicaid program
Medicaid Waivers: options states can use to test approaches to healthcare coverage and delivery via Medicaid and CHIP that deviate from national standards for eligibility and benefit design
Medicaid – General: federal-state healthcare program for families with low income; represents the largest source of funding for low-income individuals’ health and medical service needs
Medical Devices: an instrument, apparatus, implant, in vitro reagent, or similar or related article that is used to diagnose, prevent, or treat disease or other conditions
Medical Home: patient-centered and comprehensive model of primary care
Medical Liability/Tort Reform: reforming the legal system to instate a maximum amount a person can sue a physician for after a medical error or adverse event
Medical Loss Ratio (MLR): the proportion of premium revenues spent on improving healthcare quality
Medicare Administrative Contractors (MACs): private organizations that facilitate the responsibilities of Medicare Part A and Part B, especially paying and auditing claims for medical services
Medicare Advantage: also referred to as Medicare “Part C,” the commercial insurance option under Medicare for obtaining the medical benefits otherwise provided under Parts A and B
Medicare Advantage Special Needs Plans (SNPs): type of Medicare Advantage plan tailored toward people with specific conditions, income levels or institutional status
Medicare Improvements for Patients and Provider Act of 2008 (MIPPA): legislation that suspended payment cuts to healthcare providers, implemented accountability measures and payment reductions for Medicare Advantage plans, reformed dialysis payments, caused Medigap changes, and made other changes to the Medicare program
Medicare Modernization Act of 2003 (MMA): legislation that established the prescription drug benefit in Medicare and made numerous other changes to the program
Medicare Part D: element of Medicare program that provides prescription drug coverage via private plans for which most enrollees must pay a premium
Medicare Prescription Drug Benefit: also known as Medicare Part D, element of Medicare program that provides prescription drug coverage via private plans for which most enrollees must pay a premium
Medicare Savings Programs: federal and state-funded programs that help beneficiaries pay for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments
Medicare Secondary Payer: refers to cases in which the Medicare program does not have primary payment responsibility for medical claims, such as when a senior has employer-provided coverage
Medicare Supplemental Plans: optional private plans that provide additional Medicare benefits – especially reducing coinsurance and deductibles – in exchange for a premium payment
Medicare – General: national, federally-administered insurance program that guarantees access to health insurance for Americans aged 65 and older who have paid into the tax system
Medigap: also referred to as Medicare Supplemental Plans, optional private plans that provide additional Medicare benefits – especially reducing coinsurance and deductibles – in exchange for a premium payment
Mid-Level Practitioners: healthcare providers who have a formal certificate, but have received less training than a physician or similar health professional; typically references clinicians such as advanced practice nurses and physician assistants
Minority Health: issues relating to the unique medical needs of minority populations
Modified Adjusted Gross Income (MAGI): an individual’s total gross income minus specific reductions, often calculated with tax-exempt interest
Multi-State Plan Program: established under the Affordable Care Act, requirement that the federal Office of Personnel Management contract with private health insurers to offer plans in multiple Exchanges
N
National Institutes of Health (NIH): NIH is the primary agency of the United States government responsible for biomedical and health-related research. The NIH both conducts its own scientific research and provides major biomedical research funding to non-NIH research facilities
Nursing: issues related to scope of practice and health care provided by nurses
Nursing Homes: places of residence for people who require continual nursing care and have significant difficulty coping with the required activities of daily living
O
Obamacare: common name for the Patient Protection and Affordable Care Act
Oncology: a branch of medicine that deals with the prevention, diagnosis and treatment of cancer
Other Healthcare Laws: here used to refer to healthcare-related laws enacted by Congress that are not otherwise listed as unique topics
P
Patient Centered Outcomes Research Institute (PCORI): federally chartered, non-government body that investigates and compares the relative effectiveness of different medical treatments
Patient Experience: initiatives focused on the patient perspective of the medical system across the continuum of care
Patient Safety: initiatives designed to improve patient health outcomes and to reduce adverse events
Pay for Performance: payment model in which the medical specialist receives compensation for meeting pre-established healthcare delivery targets
Payment Reform: new models for paying for medical care that typically expand on or replace the historical fee-for-service approach
Pediatrics: branch of medicine dealing with infants, children and adolescents
Pharmaceuticals: relating to the production and sale of drugs and medicine
Pharmacy: issues related to pharmacies that fill patient pharmaceutical and related clinical prescriptions
Pharmacy Benefit Managers (PBMs): entities responsible for developing and maintaining a plan’s formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims
Physicians: medical doctors
Post-Acute Care (PAC): specialized follow up care with focus on restoring medical and functional capacity to enable the patient to return to the community and prevention of further medical deterioration
Preexisting Condition Insurance Plan (PCIP): federal program offering temporary coverage to individuals with preexisting conditions, before the Affordable Care Act’s (ACA) ban on preexisting condition exclusions took full effect
Preexisting Conditions: medical conditions already in effect before health insurance is acquired
Premium Subsidies: tax credits created by the Affordable Care Act to help low-to-moderate income families pay for healthcare coverage on the exchanges
Premiums: usually monthly fees paid in exchange for health insurance coverage
Prescription Drugs: pharmaceutical products that require a prescription
Prevention: public health efforts and related clinical interventions intending to limit the probability of acquiring a healthcare condition
Primary Care: the day-to-day healthcare given by a health care provider, who usually serves as the first contact and principal point of continuing care for patients within a healthcare system
Privacy: issues relating to the security of medical data and other personal information
Program Integrity: efforts to minimize fraud, waste and abuse, here typically under the Medicare, Medicaid, and other federal programs
Program of All-Inclusive Care for the Elderly (PACE): provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits
Psychiatric Hospitals: a hospital specializing in the treatment of serious psychiatric diseases, such as clinical depression, schizophrenia, and bipolar disorder
Public Health: all organized measures to prevent disease, optimize health and prolong life among the population as a whole
Public Option: proposal to create a government-run health insurance program floated by democrats but never adopted during the negotiations for the Patient Protection and Affordable Care Act
Q
Qualified Health Plans (QHPs): an insurance plan that is certified by the Marketplace and follows pre-established rules promulgated under Affordable Care Act (ACA) requirements
Quality: issues related to health outcomes and health outcome measures. Sometimes Quality is defined as “doing the right thing, at the right time, in the right way, to achieve the best possible results”
R
Rate Review: the Affordable Care Act (ACA) requires that insurers planning to significantly increase plan premiums submit their rates to either the state or federal government for review. The threshold for this requirement is 10%
Readmissions: instances when patients need to come back to the hospital after discharge
Recovery Audit Contractors (RACs): program using private entities to identify fraudulent or otherwise improper Medicare payments paid to healthcare providers
Reinsurance: insurance purchased by one insurance issuer from another to reduce risk
Risk Adjustment: corrective tool used to modify payments to insurers or providers based on the acuity of patients’ needs and other factors
Risk Corridors: a temporary feature that applies to individual and small group qualified health plans (QHPs) from 2014 through 2016 to protect health insurance issuers against the pricing uncertainty of their plans by sharing risk with the federal government
Rural Health Clinics (RHCs): community health centers located in medically underserved areas and certified to receive special Medicare and Medicaid reimbursements
Rural Healthcare: issues unique to care delivered in rural settings
S
Safety Net: programs designed to prevent the poor and others in need from falling below a critical level of resources to support their medical needs
Self-Insured Plans: insurance policies whereby an employer takes on the financial risk of providing healthcare to its employees
Self-Referral: referral of a patient to a specialized medical facility, when the referring entity has a vested financial interest in that entity
Sequestration: automatic, Federal budget-wide spending cuts first instituted in 2013
Single Payer System: model in which one insurance provider (usually the government) is the sole provider of coverage, rather than the existing system in the U.S. whereby multiple issuers to do, including private plans
Skilled Nursing Facilities (SNFs): institutional setting for patients who require continual nursing care
Small Business Health Options Program (SHOP): plan for small businesses to offer health insurance to their employees by selecting options in a more closely-regulated marketplace
Small Group Market: refers to the insurance pool for businesses with up to 100 employees
Supreme Court: issues related to Supreme Court and its cases
Sustainable Growth Rate (SGR) Formula: method used by Medicare to set physician payment rates that has produced significant cuts over the past several years that Congress has acted to block
T
Tax: Here refers to policies relating to the Internal Revenue Code, etc
Tax Subsidies – Small Business: employer health care tax credits offered to some small businesses under parameters set by the Affordable Care Act
Telehealth: delivery of health-related services via telecommunications
Therapy: rehabilitative services delivered to individuals with ongoing medical need or after acute care services
Transparency: here refers to disclosure and/or publication of healthcare-related data, including that relating to the cost and quality of medical services
U
Uninsured: those lacking health insurance coverage, may also be used to relate to the underinsured
V
Value-Based Benefit Design: predominantly an insurance model that seeks to incent use of lower-cost and/or higher-quality services
Value-Based Purchasing (VBP): strategy to measure, evaluate and reward higher quality and/or lower cost in health care delivery
Vision: here refers to ophthalmic and other services relating to eye health
W
Wellness: clinical and non-clinical services intending to promote overall physical and mental health
Wholesalers: entities that that sell products to other businesses for resale to end-users
Women’s Health: issues specific to women’s health, including obstetrics, gynecology, and family planning
Workforce: here referring to policies and issues relating to the supply and training of clinicians and other healthcare workers