A or a – Affordable
ACA – Affordable Care Act (Patient Protection and Affordable Care Act)
ACO – Accountable Care Organization (also see IDS) – A grouping of physicians, specialists, and
hospitals responsible for providing efficient and effective care for a patient population.
ADA – Americans with Disabilities Act
ADEA – Age Discrimination in Employment Act
*AFDC – Aid to Families with Dependent Children
AGGREGATION – No Aggregation in determining liability of an Applicable Large-Employer Member
ALE – Applicable Large Employer – An employer that has 50 or more full time equivalent employees (FTE’s).
ASO – Administrative Services Only Agreement
*BBA – Balanced Budget Act of 1997
BENCHMARK PLAN – The benchmark plan definesthe standard set of benefits that must be covered by plans in that state. Kaiser Small Group HMO 30 as was offered during the first quarter of 2012, is the California state benchmark plan as set forth in Senate Bill 951, Chapter 866, of September 30, 2012.
*BHP – Basic Health Program
BUNDLED BILLING – A single, “bundled” payment covers services delivered by two or more
providers during a single episode of care or over a specific period of time.
CADILLAC TAX – Tax on high cost coverage-takes effect in 2018he Cadillac Tax (40 percent excise tax on healthcare premiums (employer + employee) that is placed on employers for premiums that exceed $10,200 for individual coverage and $27,500 for family coverage.
Calendar Year – January 1 through Dec 31
Care Continuum – The care continuum describes the full range of services from prenatal care prior to birth to palliative services at end of life. This term also describes the full spectrum of healthcare delivery including outpatient, inpatient, home care, rehabilitation, nursing, virtual, and pre– and postacute care.
CBO – Congressional Budget Office – Nonpartisan analysis of the federal budget and the economy for Congress.
CDC –Centers for Disease Control and Prevention
CDS –Clinical Decision Support -Healthcare reform encourages the use of clinical decision support to assist physicians and providers at the point of care recognizing that most errors occur due to imperfections in the process. The clinical decision support system is most often a computerized tool that incorporates information gathering (forms and templates) and monitoring and delivery systems (alerts and reminders) to ensure optimal decision-making on the part of the clinician.
CER – Comparative Effectiveness Research – Identifies what treatment options work best for which patients under what circumstances.
CHIP – Children’s Health Insurance Program (formerly State Children’s Health Insurance Program)
CHIPRA – Children’s Health Insurance Program Reauthorization Act
CLASS Act – Community Living Assistance Services and Support Act –This part of the ACA law was repealed.
CMS –Centers for Medicare and Medicaid Services(CMS.gov)
CODE – Means a section of the law
CODE SECTION 105(h) – Rules about nondiscrimination (compliance notrequired until regulations or other guidance is issued.)
COBRA – Consolidated Omnibus Budget Reconciliation Act of 1985
COLA –Cost of Living Adjustment – Increases benefits based on increases in the cost of living.
COMMUNITY RATING – A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.
CONTROLLED GROUP– a group of business entities owned by a single owner
COST SHARING – Deductible and out of pocket maximums, described as Cost Sharing
CPOE –Computerized Physician Order Entry – Electronic entry and transmission of physician orders, such as prescription drugs, lab tests, and radiology studies. It avoids handwriting or transcription errors and avoids delay in care delivery due to slow transmission at the point of care.
CPI – Consumer Price Index – also known as retail price index or cost-of-living index, measures the annual change in cost to workers of purchasing a basket of goods and services
DEFRA – Deficit Reduction Act
*DHS – Department of Homeland Security
DME– Durable Medical Equipment
DOL – Department of Labor
DONUT HOLE– Medicare Drug Coverage Gap/“Donut Hole” – This is a voluntary medication benefit program that started in 2006. Participants with a standard plan have 75 percent of their drug costs covered until they reach a cost of $2,830. Any expense higher than this is paid out of pocket until the
cost reaches $4550.
*DRA – Deficit Reduction Act of 2005
DRG – Diagnosis-Related Group – A payment system in which benefit payments are based on the individual diagnosis of a patient instead of the actual medical service received.
EAP – Employee Assistance Program
EBSA – Employee Benefit Services Administration – Division of DOL responsible for benefit plan compliance
EBM – Evidence Based Medicine –Refers to care that has strong scientific validation.
EC – Employee’s child
EEOC – Equal Opportunities Employment Commission
EHB or EB – Essential Health Benefits -Beginning in 2014, policies in the individual and small group markets will be required to provide coverage for each of the 10 “essential health benefits” regardless of whether the policy is purchased through or outside the exchange. Self-funded plans (regardless of size), large group plans and grandfathered plans (regardless of size) do not have to cover all 10 essential health benefits, but they will not be allowed to put lifetime or annual dollar limits on an essential health benefit.
EHBP – Essential Health Benefits Package
EHR –Electronic Health Record – web based record of a patient’s medical records owned by the patient
*EITC –Earned Income Tax Credit
EMR – Electronic Medical Record – computer based record keeping – as opposed to the traditional paper and pencil method—owned by the doctor, hospital or care facility
EOL – End-of-life
*EPSDT – Early and periodic screening, diagnosis and treatment
ERISA – Employee Retirement Income Security Act—Among requirements is an SPD for any size group
ERRP – Early Retiree Reinsurance Program –Created to provide assistance to employers covering early retirees—funding expired
ESI – Employer -Sponsored Insurance
ESR – Employer Shared Responsibility – Employers with 50+ FTE’s are ALE’s and subject to ESR and potential penalty
ESRD – End-Stage Renal Disease
EXCHANGE– A government operated marketplace to purchase health insurance as an alternative to the private marketplace
EXPATRIATE HEALTH PLANS – Defined asinsured group health plans for employees who reside outside of their home country for at least six months of the plan year (and any covered dependents) and the group policies insuring the plans.
EPO – Exclusive Provider Organization
FDA – Food and Drug Administration
FEHBP – Federal Employees Health Benefits Program
FFE – Federal Facilitated Exchange
*FFP- Federal financial participation
FFS – Fee-for-Service
FISCAL YEAR PLAN – A non calendar year plan
FLSA – Federal Labor Standards Board – Establishes minimum wage, overtime pay, recordkeeping, and youth employment standards affecting employees in the private sector and in Federal, State, and local governments. Requiring employers to notify employees of the availability of the Exchange prior to Oct 1, 2013 and new employees upon hiring.
*FMAP – Federal medical assistance percentage
FMLA – Family Medical Leave Act
FPL – Federal Poverty Level or Line Under 400% of the FPL healthcare subsidies and cost sharing may be available.
FQHC – Federally Qualified Health Center
FSA – Flexible spending account/arrangement, also referred to as a Cafeteria Plan or Flexible Benefits Arrangement (Under Section 125)
FT – Full time
FTE’s – Full Time Equivalent Employees for determining Applicable Large Employers(ALE’s) for Employer Shared Responsibility
GAO – Government Accountability Office – Investigative arm of Congress charged with examining matters relating to the receipt and payment of public funds.
GF – Grandfathered plan
GHP –Employer Sponsored Group Health Plan
GI – Guaranteed Issue
GINA – Genetic Information Non Discrimination Act of 2008
GME – Graduate Medical Education Payment – Medicare subsidizes medical residency training through
GME payments to teaching hospitals. PPACA’s changes to GME payments, along with a new health center grant program and a number of other provisions, are intended to promote primary care training in non-hospital settings.
HABILITATION OR HABILITATIVE SERVICES – Helps a person keep, learn or improve skills and functioning for daily living.
HBE – Health Benefit Exchange – Health Insurance Exchange– In CA, Covered California
HCBS – Home and Community-Based Services
HCERA – Health Care and Education Act of 2010 along with PACA will eventually expand health insurance coverage to 32 million Americans who are currently uninsured for total health coverage of 95% of all Americans.
HCFA – Health Care Financing Administration
HCI – Highly compensated individual
HCR – Healthcare Reform
HCTC –Health Coverage Tax Credits
HDHP –High Deductible Health Plan
HEALTH INSURANCE MARKETPLACE – Health Insurance Exchange
HEDIS – Health Plan Employer Data and Information Set
HHA – Home Health Agency
HHS – Department of Health and Human Services
HI – Medicare Hospital Insurance Trust Fund (also known as Part A)
HIT – Health Information Technology
HIT – Health Insurance Tax
HIFA – Health Insurance Flexibility and Accountability Demonstration Initiative
HIPAA – Health Insurance Portability and Accountability Act
HMO – Health Maintenance Organization
HRA – Health Reimbursement Arrangement/Account
HRP’s – High Risk Pools
HRSA – Health Resources and Services Administration
HRQ – Health Risk Questionnaire
HSA – Health Savings Account
ICF – Intermediate Care Facility – For individuals with Mental Retardation (ICF/MR) (CMS prefers Intellectual Disability-ID) is a Medicaid benefit a state may have.
IDEA – Individuals with Disabilities Education Act | Page Acronyms and Terminology in the Affordable Care Act RBG 2013
INTERIM FINAL RULE –Regulation from an agency (IRS, HHS, or DOL) which has been implemented but is not yet final.
IPA – Independent Practice Association
IDS – Integrated Healthcare Delivery System (also see ACO) – a network of healthcare providers and organizations that provides or arranges to provide a coordinated continuum of services. Services provided by an IDS can include one or more acute care hospitals (community and/or tertiary), home healthcare and hospice services, primary and specialty outpatient care and surgery, social services, rehabilitation, preventive care, and health education.
*IHS – Indian Health Service
*INA – Immigration and Nationality Act
*IRC – Internal Revenue Service Code of 1986
IRO – Independent Review Organization – Perform independent reviews of adverse benefit determinations
LOC – LEVEL OF CARE – Amount of assistance required by consumers which may determine their eligibility for programs and services. Levels include: protective, intermediate, and skilled.
LTC –Long-Term Care
*MAGI – Modified Adjusted Gross Income
MAPD – Medicare Advantage Prescription Drug
MANDATE– Requirement to have coverage
MARKETPLACE – Exchange
MCH – Maternal and Child Health
*MEC – Minimum Essential Coverage
MEWA – Multiple Employer Welfare Arrangement
MMA – Medicare Prescription Drug, Improvement and Modernization Act of 2003
*MMEA – Medicare and Medicaid Extenders Act of 2010
MCO – Managed Care Organization
MHPA – Mental Health Parity Act
MEC – Minimum Essential Coverage A person will have minimum essential coverage if covered under an eligible employer-sponsored plan, an individual policy (through or outside the exchange) or a government plan (Medicare, Medicaid, CHIP, TRICARE, VA, etc.).
MLR – Medical Loss Ratio – ACA sets minimum medical loss ratios of 85 percent for large group health plans and 80 percent for small group health plans. This means that any spending not dedicated to providing health services, such as maintaining business operations, administrative expenses, and earning a profit, is limited to 15 percent and 20 percent of total revenue.
MV, MVC or MEV – Minimum Value or Minimum Value Coverage or Minimum Essential Value – The plan’s share of the total allowed cost of benefits must be at least 60% to be considered minimum value.
MVC – Minimum Value Calculator
NAIC – National Association of Insurance Commissioners
NCQA – National Committee for Quality Assurance
NGF – Non Grandfathered
NIH – National Institutes of Health
NMSM – National Medical Support Notice – Child coverage requirement if not done voluntarily
ObamaCare – Informal nickname for the Affordable Care Act, widely used including by the Obama administration
OE or OEP – Open Enrollment or Open Enrollment Period
*OMB – Office of Management and Budget
OOP – Out of pocket limit
OON – Out of Network
*OPM – Office of Personnel Management
OTC – Over the counter prescription drugs
PACE – Program of All-inclusive Care for the Elderly
PCE – Pre Existing Condition Exclusion
PCIP – Preexisting Condition Insurance Plan – Temporary high risk plan prior to 2014 – new enrollment suspended 2/13
PCMH – Patient Centered Medical Home – New and enhanced model that places a greater accountability on the primary providers. The idea developed in response to the fact that children with special needs received care from independent practitioners who did not coordinate or communicate, leading to duplicative procedures, medical complications, and other issues — a fragmented system. The medical home was to serve as a storehouse for all of a particular child’s information, and the practitioner was to serve as a care coordinator and patient advocate. Modern advocates of the concept seek to expand the scope of the medical home to incorporate all age groups.
PCORI – Patient– Centered Outcomes Research Institute (pronounced puh-core-ree ) – A tax to support this organization’s research is included in PPACA.
PHI – Also referred to as protected health information, generally refers to demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care.
PHR – Personal Health Recordis a consolidated medical record of an individual containing medical history and personal health information owned by the individual
* PHS or PHSA – Public Health Services Act– Sets prohibition on pre-existing conditions, health status discrimination,requires EHB’s and minimum value, limits deductible and out of pocket maximum, limits waiting period,sets clinical coverage requirement
POOLING – Refers to the insurance industry practice of pooling together the insurance risk of individuals or groups in order to determine premiums.Insurers in the individual or small group market are required to consider all individuals in all plans offered by the insurer as members of a single risk pool
POP – Premium Only Plan under Section 125 allows certain benefitsto be paid pre-tax
POS – Point-of-Service Plan
PPACA – Patient Protection and Affordable Care Act (also referred to as ACA)
PPO – Preferred Provider Organization
PPS – Prospective Payment System – Amethod of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services)
*PRA- Paperwork Reduction Act of 1995
*PRWORA – Personal Responsibility and Work Opportunity Reconciliation Act
PT – Part Time
QBE – Qualified Benefit Election
QC – Qualifying child
QHP – Qualified Health Plan – A plan that provides Essential Health Benefits
QMB – Qualified Medicare Beneficiary
QMCSO – Qualified medical child support order
QR –Qualified Relative
RBRVS – Resource-Based Relative Value Scale – The way Medicare determines how much it will pay physicians
RCF – Residential Care Facility – Residential Care Facilities for the Elderly (RCFE) serve person 60 and older. They provide room, board, housekeeping, supervision and personal care assistance with basic activities like personal hygiene, dressing, eating, and walking.
RVS – Relative Value Scale – An index that assigns weights to each medical service; the weights represent the relative amount to be paid for each service.
RX – Prescription
SAMHSA – Substance Abuse and Mental Health Services Administration
SBC – Summary of Benefits and Coverage
SBHP – Small Business Health Plan
SCHIP – State Children’s Health Insurance Program (now CHIP—Children’s Health Insurance Program) SECTION 125 – Provides participants an opportunity to receive certain benefits on a pretax basis.
*SEP – Special Enrollment Period
SHOP – Small Group Health Options Program – Small Group Exchange in CA, Covered California
*SMD – State Medical Director
*SNAP – Supplemental Nutrition Assistance Program
SNF – Skilled Nursing Facility
*SPA – State Plan Amendment
SSA – Social Security Administration
SSDI – Social Security Disability Income
SSI – Supplemental Security Income
*TANF – Temporary Assistance for Needy Families
TELEHEALTH– Involvesthe use of electronic information systems and telecommunications technology to support long-distance delivery of care
TEFRA – Tax Equity and Fiscal Responsibility Act
TMA – Transitional Medical Assistance
TPA – Third Party Administrator
TRANSITION RULES – Allow carriers or employers time to adjust to new rules or requirements.
TX – Treatment
UPL – Upper Payment Limit
UCR– Usual, customary and reasonable
UR – Utilization Review
USERRA – Uniformed Services Employment and Reemployment Rights Act – Protectsthe job rights of individuals who voluntarily or involuntarily leave employment positions for military service or certain types of service in the National Disaster Medical System; also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services
VBP -Value-Based Purchasing – Links provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the bestperforming providers.
VH – Variable Hour employee
WP – Waiting period – Period of time after hiring one must wait to be covered by insurance
*New Additions as of July 12, 2013