GLOSSARY OF USEFUL HEALTH INSURANCE TERMS

Transcription

1 Data Decisions Delivery Directing Comprehensive TA: From Systems to Sustainability GLOSSARY OF USEFUL HEALTH INSURANCE TERMS

2 This glossary is adapted from an array of resources to improve the health insurance literacy of HIV prevention, i, ii, iii testing, care, and wrap around service providers. Affordable Care Act (ACA) Administrative data Allowed amount Automatic Assignment (or auto- assignment) Behavioral health services Benefits (covered benefits/benefit package): Capitation See Patient Protection and Affordable Care Act Data on the cost and utilization of health services collected by a health plan, hospital, or medical group. These data are commonly included in health insurance billing data systems. Information on health care use may be collected from patient medical records as well. The maximum allowable amount a health plan will pay for a service. Mandatory enrollment of eligible Medicaid recipients into a plan chosen by Medicaid or an enrollment broker. It can also refer to the assignment of a new enrollee to a primary care provider chosen by the health plan. Services provided for mental health, substance abuse, or a combination of diagnoses. Substance abuse services include treatment for drug and alcohol abuse, detoxification, and withdrawal. Health care and other services offered by the health plan. Excluded benefits are services the health plan does not cover. Capitation payments are used by Medicaid, Medicare, or an employer to control health care costs. Capitation is a fixed amount of money, per-patient per-unit of time, paid in advance to the physician or health plan for the delivery of health care services. The ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided determine the actual amount of money paid. Capitated rate: The per-member/per-month (PMPM) amount, including any adjustments paid by the Medicaid, Medicare, or other insurance funder to a capitated health plan, for each Medicaid recipient enrolled under a contract for the provision of services during the payment period. Partial capitation: A plan is paid for providing services to beneficiaries through a combination of capitation and fee-for-service (FFS) reimbursements. Capitated health plan: A Health Maintenance Organization (HMO), provider service network, or other health plan that is paid a per-member/per-month fee to cover the cost of providing health care to its enrollees. i. Adapted from: State of California Office of the Patient Advocate. ii. Adapted from the Bureau of Labor Statistics. iii. Adapted from CMS.gov. 2 Care coordination/ case management Carve outs Centers for Medicare and Medicaid Services (CMS) Choice counselor/ enrollment broker Claim Clean claim Co-insurance Community outreach Common Procedure Terminology (CPT) Consolidated Omnibus Budget Reconciliation Act (COBRA) A process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an enrollee's health needs using communication and all available resources to promote quality cost-effective outcomes. Proper case management occurs across a continuum of care, addressing the ongoing individual needs of an enrollee. Arrangements in which some benefits (e.g., mental health) are removed from coverage provided by a health insurance plan, but are provided through a contract with a separate set of providers. The agency within the US Department of Health & Human Services that provides administration and funding for Medicare under Title XVIII, Medicaid under Title XIX, and the State Children s Health Insurance Program under Title XXI of the Social Security Act. The state Medicaid program s contracted or designated entity that performs outreach, education, counseling, enrollment, and disenrollment of potential enrollees into a health plan. A bill for services, a line item of service, or all services for one recipient within a bill submitted to an insurer for payment in a format prescribed by the insurer. A claim that can be processed without the insurer having to obtain more information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Patient share of the costs of a covered health care service, calculated as a percentage (e.g., 20%) of the allowed amount for the service. You pay co-insurance after you ve met your deductible. For example, if the health insurance plan s allowed amount for a hospital in-patient stay is $1,000 and you ve met your deductible, your 20% co-insurance payment would be $200. The health insurance plan pays the rest. The provision of health or nutritional information to benefit, educate, or assist a community in regards to health-related matters, or public awareness that promotes healthy lifestyles. Community outreach includes the provision of information about health care services, preventive techniques, and other health care projects and health, welfare and social services/assistance programs offered by state or local communities. A systematic list of procedures and services published annually by the American Medical Association (AMA). The federal law that helps people retain their group health plan if their job ends or if they retire before 65. COBRA is a federal law. 3

3 Consumer Assessment of Health Plans Survey (CAHPS) The National Committee for Quality Assurance (NCQA) uses CAHPS in its voluntary health plan accreditation process to assess patient satisfaction with their healthcare services. Randomly selected plan members are asked to complete the CAHPS survey. Encounter data A record of diagnostic tests, treatment procedures, or other medical or allied care provided to a health plan s enrollees, excluding services paid on a fee-for-service basis. An encounter is an interaction between a patient and provider who delivers services or is professionally responsible for services delivered to a patient. Contracted provider Co-pay (or co-payment) Cost-sharing Coverage (health coverage) A health care provider who contracts with the health plan. A contracted provider also may be called a preferred provider or a network provider. A fixed charge (i.e., $25), patients pay for a covered health care service, usually the same amount paid at time of service. The amount can vary depending on the type of covered health care services. The share of service costs paid out-of-pocket by the insured individual. Cost-sharing commonly includes deductibles, co-insurance, and co-pays. Usually, cost-sharing does not include premiums, balance bills, or services that the health plan does not cover. The health care services offered by the health plan. Health insurance companies and health plans provide coverage. Government programs like Medicaid and Medicare also provide coverage. Enrollee Essential health benefits Evidence of Coverage (EOC) An insured individual enrolled in a health plan. The ACA ensures qualified health plans (QHPs) offer, in the individual and small group markets, a comprehensive package of items and services known as essential health benefits. Essential health benefits must include items of services within at least ten core categories: emergency services; hospitalization; maternity and newborn services; mental and behavioral health treatment and substance use disorder services; prescription drugs; rehabilitative and habilitative serves; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. A guide of services covered and not covered by the health plan. The EOC also explains what a beneficiary pays for services. Health plans commonly provide beneficiaries with electronic or paper versions of the EOC such as a handbook, contract, policy, or letter of entitlement, instead of a document titled, EOC. Covered benefit/service A service the health plan will pay for if a beneficiary demonstrates need. Explanation of Benefits (EOB) A statement sent by a health insurer to covered individuals that explains the medical or other covered services that were paid for on their behalf. Deductible Disease management Disenrollment Early Intervention Services (EIS) Electronic verification (e-verification) The amount a patient must pay each year for health care before the health plan starts to pay. Deductibles can vary considerably, and some plans have no deductible. Most plans pay for preventive care, like vaccines, even before the beneficiary pays the deductible. Some plans have separate deductibles for prescription drugs and hospital care. A system of coordinated health care interventions and communication for patients with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care; emphasizes prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies; and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. The formal process for leaving a managed care plan or other health coverage program. For example, a Medicaid enrollee may disenroll from a health plan within a specified period of time. A Medicaid program designed for eligible infants and toddlers from birth to 36 months who have significant delays or a condition likely to result in a developmental delay. The process used by a health care provider to determine that an individual is enrolled in a health insurance program (e.g., Medicaid) or health plan, as well as their out-of-pocket payments and coverage for specific services. Federally Qualified Health Center (FQHC) Fee-For-Service (FFS) Formulary Gatekeeper Generic drug Grandfathered health plan An organization that is receiving a grant under Section 330 of the Public Health Service Act. FQHCs provide primary health care and related diagnostic services and may provide dental, optometric, podiatry, chiropractic, and behavioral health services. A payment model where health care providers are paid for each service performed (e.g., an office visit, a test, or a procedure). A list of prescription drugs a health plan usually covers. Formularies are commonly referred to as preferred drug lists by insurers. Some health plans assign the responsibility of a gatekeeper for the administration of a patient s treatment. The gatekeeper coordinates and authorizes all medical services, lab tests, specialty referrals, and hospitalizations. A drug that is no longer owned by one company. Generic drugs usually cost less than brand-name drugs, because no company owns the patent on them or can set the price. Generic drugs have to meet the same quality standards as brand-name drugs. A health plan that started before March 23, There are two kinds of grandfathered plans: (1) An individual plan that beneficiaries joined before March 23, 2010, and (2) a group plan that the employer started before March 23, 2010, even if the patient joined the plan later. Grandfathered plans do not have to follow parts of the ACA. Beneficiaries can contact the plan or employer to find out if the plan is a grandfathered health plan. Over time, if a grandfathered plan makes important changes in its costs or benefits, it is no longer grandfathered and has to follow the new laws. 4 5

4 Group coverage (group health plan) Coverage that an individual gets through a job, union, or other group. Some of the rules for group coverage are different from the rules for individual coverage, which an individual buys. Health plan An entity that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with an organized system of providers, which deliver services and frequently share financial risk. Healthcare Common Procedure Coding System (HCPCS) Healthcare Effectiveness Data and Information Set (HEDIS) Known as hick picks from the pronunciation of the acronym, a set of health care procedure codes based on the American Medical Association's Common Procedure Terminology (CPT) code set. The NCQA uses HEDIS as part of its voluntary health plan accreditation process to assess the performance of a health plan. Clinical measures assess how well health plans do at providing specific care services to their beneficiaries. Information is collected from administrative and medical records. Indemnity plan Individual coverage (individual health plan) A type of medical plan that reimburses the patient and/or provider as expenses are incurred. Conventional indemnity plan: Allows the beneficiaries the choice of any provider without effect on reimbursement, and reimburses the patient and/or provider as expenses are incurred. A health plan an individual buys directly. Some of the rules for individual coverage are different from the rules for group coverage, which an individual usually gets through their employer. Health exchange/ marketplace Health insurance Health Insurance Portability and Accountability Act of 1996 (HIPAA) Health Maintenance Organization (HMO) Competitive insurance marketplaces where individuals and small businesses can purchase affordable and qualified health benefit plans. The Marketplace for small employers, known as the Small Business Health Options Program (SHOP), and the Individual Marketplace for consumers and those who are self-employed. Insurance that helps pay for health care costs. The insurance policy or contract states the fees the individual or family has to pay and the services paid by the insurer. A federal law that protects the right to get an individual plan when the group plan ends. HIPAA also sets national standards for the privacy of personal health information. A type of health plan. HMOs offer health care from one group of doctors, hospitals, labs, and other providers, which is called a network. Patients have a main doctor, called the primary care doctor, who oversees their care. Group Model HMO: Contracts with a single multi-specialty medical group to provide care to the HMO s members. The group may participate exclusively with the HMO, or provide services to non-hmo patients. The HMO pays the medical group a negotiated, per capita rate that the group distributes among its physicians. Staff Model HMO: A closed-panel HMO where patients receive services only through a limited number of HMO employee providers. The physician visits occur at the HMO s own facilities. Network Model HMO: Contracts with multiple physician groups to provide services to HMO members. Networks may involve large, single, and multi-specialty groups. The physician groups may provide services to both HMO and non-hmo plan patients. IPA (Individual Practice Association) HMO: A group of independent practicing physicians who maintain their own offices and work together to contract their services to HMOs. An IPA may contract with and provide services to both HMO and non-hmo plan patients. Individual mandate International Classification of Diseases (ICD), Tenth Edition, Classification Manual Managed Care Organization (MCO) Managed care plans The ACA requires most people have health coverage. There is a tax break for people with lower incomes who buy health insurance. There is a tax penalty for people who do not buy health insurance. An official system of assigning codes to clarify diagnoses and procedures associated with hospital utilization in the US. Managed Care is a unified health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per-member/per-month (capitation) payment for these services. By contracting with various types of MCOs to deliver Medicaid services to their beneficiaries, states can reduce Medicaid program costs and better manage utilization of health care services. Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care. Health plans that provide comprehensive health services to their members, and offer financial incentives for patients to use the providers in their network. Managed care plans use different models including HMOs. EPO (exclusive provider organization) plan: A relatively restrictive type of preferred provider organization (PPO) plan in which employees must use providers from the specified network of physicians and hospitals to receive coverage. There is no coverage for care received from a non-network provider except in an emergency situation. POS (point-of-service or open-ended) plan: POS plans are similar to HMOs for in-network services. Services received outside of the plan s provider network are usually reimbursed using an arrangement similar to conventional indemnity plans, in which provider reimbursement is based on a fee schedule or usual, customary, and reasonable charges. PPO (preferred provider organization): A type of health plan. Patients receiving care from a PPO can go to clinical health care providers inside or outside the network. But if a beneficiary receives services outside of the network, he or she will have to pay more. 6 7

5 Mandatory assignment Medicaid Medical group/ Independent Practice Association (IPA) Medically necessary care or services Medicare The process Medicaid programs use to assign enrollees to a health plan. Medicaid automatically assigns those enrollees required to be in a health plan who did not voluntarily choose one. A government health care program for people with low incomes. Depending on their income and family size, Medicaid is free for some people. Other people pay a share of their Medicaid costs. There are many ways to qualify for Medicaid, but all beneficiaries must have a low income. A group of doctors or other clinicians who have a contract with a health plan. Medical groups include primary care doctors, specialists, and other providers. In some health plans, patients get most of the care from their primary care clinician s medical group. Care that an individual needs to prevent, find, or treat a health problem. In general, health plans only cover medically necessary care. This care must meet accepted standards of medicine. There must be evidence that the patient needs the treatment and that it can help problems presented by the medical condition. A government health insurance program for people who are 65 and older and some people with disabilities. Most Americans age 65 and older have Medicare. Network Non-covered services Open enrollment period Original Medicare/ traditional Medicare (fee-for-service Medicare) Out-of-pocket limit Panel All the doctors, hospitals, labs, and other providers that have contracts with a health plan. The network provides all or most of the health care services required by a patient. Some plans have a network with different levels, called a tiered network. This means that patients must pay extra to see some specialist, even if they are in the network. Specialist in the network may be called preferred or contracted providers. A service that is not a benefit covered under the health insurer. The time when an individual can change the health insurance plan or benefits. This period usually occurs annually. The federal government pays participating providers directly for the services people get with beneficiaries, usually paying part of the cost. This is the amount most people must pay for most health care services in one year. This limit may include the deductible. It is important that beneficiaries be aware of the costs the health plan counts towards the out-of-pocket limit. The number of patients served by a physician or physician group. Medicare advantage plan (Medicare HMO) A private health plan that contracts with the federal government to provide healthcare to Medicare beneficiaries. Participating provider A health care practitioner or entity contracting with the health plan to provide services to the insurer s enrollees. Medicare Part A Medicare Part B Medicare hospital, nursing, hospice, and home care benefits. Medicare benefits for doctor visits, lab tests, and other outpatient care. Patient Centered Health Home (PCMH) A method of organizing primary care that emphasizes care coordination and communication in order to transform primary care to promote consumer satisfaction. Medical homes can lead to higher quality and lower costs, and can improve patients and providers experience of care. Medicare Part C Medicare Part D Medigap/Medicare supplemental insurance National Committee for Quality Assurance (NCQA) Medicare Advantage health plans. Medicare prescription drug benefits. Private insurance for people with original Medicare. Medigap helps cover the services and costs that Medicare does not cover. A private, non-profit organization that accredits health plans and assesses and reports on their quality. NCQA publishes Quality Compass, which reports the HEDIS and CAHPS measure results. Patient Protection Affordable Care Act (PPACA or ACA) Per-member/ per-month (PMPM) Pharmacy Benefits Manager (PBM)/ Administrator (PBA) Colloquially known as Obamacare or ACA. On March 23, 2010, President Obama signed the Affordable Care Act into law, putting in place comprehensive reforms that improve access to affordable health coverage for everyone and protect consumers from abusive insurance company practices. An alternative payment scheme in which a provider is paid a set amount of money each month to provide an agreed upon set of services for the patients enrolled in the plan for the period covered by the contract. An entity contracted to or included in a health plan that accepts pharmacy prescription claims for enrollees in the plan and ensures that claims conform to coverage policy by determining the allowable payment. National Drug Code (NDC) National Provider Identifier (NPI) A standardized code system for drug products. An identification number assigned through the National Plan and Provider Enumerator System of the US Department of Health and Human Services at Physician-Hospital Organization (PHO) Pre-authorization Alliances between physicians and hospitals to help providers gain market share, improve bargaining power, and reduce administrative costs. PHOs sell their services to Managed Care Organizations or directly to employers. A decision by the health plan that a service is medically necessary. The beneficiary may need pre-authorization for certain services before receiving them. Pre-authorization can be called prior authorization, prior approval, pre-approval, or precertification. The provider must get the health plans approval prior to the health plan covering the services this is a method of health plans to control cost. 8 9

6 Pre-existing condition Preferred Drug List (PDL) Preferred provider Premium Prescription drug coverage Preventive care A medical problem the enrollee has before trying to buy or join a new health plan. Some health plans will not accept enrollees with a pre-existing condition, or will limit or deny coverage for these conditions. The ACA prohibited these denials, starting in A list indicating which drugs providers are permitted to prescribe without obtaining prior authorization. For drugs not included on the PDL, providers must obtain approval from the insurer before the drug can be dispensed. A healthcare provider who is in the health plan s network. The provider has contracted with the health plan to provide services to beneficiaries at a lower cost. A preferred provider may be called a contracted or network provider as well. The amount beneficiaries pay each month to participate in a health plan. The employer or the government may pay all or part of the premium. Coverage that helps pay for prescription drugs. Most new health plans will cover prescription drugs. A set of services offered in most health plans, where beneficiaries can get preventive care services, like vaccines, without paying a deductible, co-pay, or co-insurance. Reinsurance Risk adjustment Self-insured plan (self-funded plan) Service area Specialty plan Stop-loss coverage Reinsurers or assuming companies assume a portion of the risk underwritten by another insurer that has contracted with an employer for the entire coverage. A process undertaken by a funder, such as Medicaid or Medicare, or a health insurer to adjust capitation rates to reflect the health conditions among enrolled populations. This process includes, but is not limited to, risk assessment models, demographics, or population groups. A kind of health plan used by large employers. In self-insured plans, the employer sets aside a pool of funds, including employee premiums, and uses it to pay for their employees healthcare. The counties or ZIP codes that a health plan serves. A health plan designed for a specific population and whose enrollees are primarily composed of Medicaid recipients with defined chronic conditions, such as HIV. These recipients are sometimes referred to as special needs populations. Reinsurance for self-insured employers that limits the amount the employers will have to pay for each person s healthcare (individual limit) or for the total expenses of the employer (group limit). Primary Care Physician/Primary Care Provider (PCP) The physician selected either by the beneficiaries or the health plan that serves as the patient s primary physician for care and coordination of care, which includes referrals to specialists. Commonly, people can select a doctor of medicine, doctor of osteopathic medicine, nurse practitioner, clinical nurse specialist, or physician assistant. This person is called the primary care provider. The scope of provider practice is regulated by state law. Summary of benefits Third Party Administrator (TPA) A short list of the costs and benefits in a health plan. People can compare health plans, or learn about their own plan, by looking at the summary of benefits. An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance. The TPA is not the policyholder or the insurer. Prior authorization Provider Quality improvement (QI) The process of a health insurer for authorizing services prior to approving the delivery of service by a health care provider. A trained medical professional or a health care facility, such as a hospital. Providers are licensed, certified, or accredited by state law. The process of monitoring that health care services are available, accessible, timely, high quality, and medically necessary. United States Preventive Services Task Force (USPSTF) An independent panel of non-federal experts in prevention and evidence-based medicine, which reviews scientific evidence of clinical preventive health care services (e.g., screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of Recommendation Statements. Usually, preventative services with a Grade A or B are covered as preventative services without cost sharing. Quality report card Referral A performance report that shows scores about quality of health care services. These scores are based on a set of recommended preventive tests, treatment modalities, and clinical outcomes. Health plans, medical groups, hospitals, long-term care facilities, and other providers participating in a health plan are assessed on whether the right patient receives the right care at the right time in the right quantity, followed by whether the patient is getting the right result. A request from a clinician, asking another provider to see a patient. A referral is commonly needed before a patient can receive care from other providers, such as specialists or labs. The clinician s clerical staff usually faxes, e-fax, or s the referral to the other provider. It explains why the patient needs to see another provider. Some health plans require prior authorization before the plan will pay for the service. Usual, Customary, and Reasonable (UCR) charges Yearly deductible Yearly out-of-pocket maximum Conventional indemnity plans commonly pay providers based on UCR charges. The UCR is the provider s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated, fixed fee schedule for covered services up to a negotiated fixed dollar amount. The amount a beneficiary has to pay each year before the insurance coverage begins. The total that beneficiaries must pay each year for most of the services. 7 11

7 TA: The D Program TM enhances the ability of TA recipients to conduct enhanced data collection and analysis to make better-informed programmatic decisions that impact the delivery of quality HIV prevention services. For more information, visit our website at HealthHIV.org. HealthHIV 2000 S St. NW Washington, DC