If you have ever been confused by the jargon used in managed care or insurance policies, here are a few definitions to help.
Note: These definitions are not tax advice. We recommend contacting licensed CPAs specializing in tax.


1095 Forms (1095A, 1095B, 1095C, 109)
Section 6055 and Section 6056 forms & filing requirements mandated under ACA. These forms detail information provided by one of the following: Federal Exchange/State Exchange/IRS/Employer for self funded plans, or Employers of fully insured plans offered to employees. 1095-A is sent to INDIVIDUALS from the Federal Marketplace. 1095-B is sent from self insuring employers or insurance providers and detail compliance with minimum essential health coverage. 1095-C is provided by (ALEs) employers to employees. The tax filer must use the information on Form 1095-A to complete Form 8962 (Premium Tax Credit) and file it with his or her federal tax return.


ACA Final Rules (CMS issued ACA Final Rules)

See: Rrepublican Agenda HR1 law passed formally repealing Individual mandate. ACA law passed in 2010 is still effective.  Multiple Executive Orders issues eliminating individual protections (Essential Health Benefits, unlimited EHB, Preexisting medical condition exclusion prohibition, Max out of pocket patient protection limits, elimination of CSR, etc.)

Federal Info at HHS:

Accountable Care Act of 2010 (ACA)

See: Patient Protection and Affordability Act

See: Republican Agenda

Accountable Care Organization (ACO)
An organization allowed by CMS to enter into risk /non-risk bearing contracts to care for assigned Medicare and/or Medicaid lives. Commercial demonstration projects may also be submitted for review by CMS. ACO’s generally provide full range of medical services. Central to ACO purpose is the elimination of traditional FFS provider compensation within optional "Shared Services" at-risk 3 year term contracts. FFS contracts are also offered. ACO's actively focus upon outcomes of care and bundling of care surrounding chronic disease and high cost procedures case management. FYI: in 2015 the OIG estimated that 29% of the federal budget was spent on major medical programs by the Federal Government. see Next Generation ACO

ACO Risk Contract/CMS Fact Sheet

Accountable Health Communities (AHC)
Centers for Medicare & Medicaid Services (CMS) has announced the participants for the Assistance and Alignment Tracks of the Accountable Health Communities (AHC) Model. By addressing critical drivers of poor health and high health care costs, the model aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries. The organizations in the Accountable Health Communities Model Assistance Track will provide person-centered community service navigation services to assist high-risk beneficiaries with accessing needed services. The organizations in the Accountable Health Communities Model Alignment Track will also provide community service navigation services, as well as encourage community-level partner alignment to ensure that needed services and supports are available and responsive to the needs of beneficiaries. The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, 2017 with a five-year performance period. To view a list of the Assistance and Alignment Tracks bridge organizations, please visit the Accountable Health Communities Model web page. (Source CMS)
ACO Performance

Actuarial Value (AV)
An MLR legislated ACA value requirement of "metallic" level plan pricing. "Issuers in the Individual Marketplace can choose to offer one or more “standardized options” with a specific cost-sharing structure at the Bronze, Silver, and Gold levels. Each standardized option consists of a fixed deductible, fixed annual limit on cost-sharing, and a fixed copayment or coinsurance with specified applicability of the deductible for a key set of essential health benefits that comprise a large percentage of the total allowable costs for an average enrollee. Issuers that offer a Silver standardized option must also offer the three associated standardized Silver plan variations for cost-sharing reductions (i.e., 73% actuarial value, 87% actuarial value, and 94%" actuarial value). (source: Source: MLM training by CMS The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care. The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care. •Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40%. •Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30%. •Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%. •Platinum.The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%.
Adjusted Clinical Groups (ACGs)
Johns Hopkins Adjusted Clinical Groups System
Adjusted Gross Income (AGI)
The amount used by a single person to calculate tax credits on ACA compliant plans for people earning between 100%- 400% of FPL. AGI is reduced by child support and student loan interest.
Admitted Carrier
An insurer that is both authorized and Eligible to place insurance within a given state. Admitted carriers enjoy protected status against competing Surplus Lines carriers who are not subject to the same premium taxation. Admitted carriers enjoy State Insurance Guarantee Association protection, whereas. Surplus Lines carriers do not.
Advance Payments of the Premium Tax Credit (APTC)
Advance Premium Tax Credit: The premium discount amount a person earning between 100% - 400% of FPL is eligible. The credit is paid by the federal government directly to the health insurance company each month. see Periodic Data Matching (PDM)
Advanced Aggregate
Advanced Aggregate is reinsurance provided to ERISA exempt entities. Reinsurance over multiple self funded employers is provided by advancing aggregated coverage recoveries for risk between specific retention and a percentage of the fully funded and underwritten major medical insurance premium.
Advanced Alternative Payment Models (APMs)
Advanced Premium Tax Credit (APTC)
Tax credit people earning between 100% -400% FPL are eligible related to commercial insurance premiums. It also refers to Medicare eligible beneficiaries that may also be purchasing a tax credit eligible plan. Total advance premium tax credit payments increased to $20 billion, from $12 billion in 2014. (Source: Think Advisor May 2017)
Advancing Care Information (ACI)
Replaces the Meaningful Use program Medicare used to pay physicians - is one of four components CMS will use to make payment adjustments under MIPS. ACI looks at EHR use as it relates to patient engagement and healthcare quality and is 25% of the MIPS score for 2017, and determines if Medicare Part B, physician reimbursement will increase, decrease or stay the same in 2018.
Advancing Care Information (ACI)
Advancing Care Information (ACI), which replaces the Meaningful Use program is one of four components CMS will use to make payment adjustments under MIPS. ACI looks at EHR use as it relates to patient engagement and healthcare quality and is 25% of your MIPS score for 2017. See QPP, MACRA, MIPS
An ACA legislated term defining eligibility for tax credits for individuals purchasing "On- Exchange" or "On Marketplace" plans who earn between 100% - 400% of the Federal Poverty Level. Citizens and non US citizens who file tax returns. See: Applied Premium Tax Credits, and 2010 ACA law.
Affordability Contribution Percentage
Term used to calculate if a Group (QHP employer offered plan) is affordable for purposes of avoiding a employer tax penalty, or Individual employee eligibility for a ACA available tax credit. (for 2017) Mainland FPL for 2016 affordability determination is $11,770 (9.66%) = $94.75. Means if employee earing $11,770 is required to pay more than $94.75 per month for QHP, that employee is eligible for INDIVIDUAL marketplace tax credit, and the (ALE) employer gets fined $3,240 for EACH employee getting a marketplace plan with tax credit.
Affordable Care Act (ACA, PPACA, Obama Care)
The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA. The ACA (Affordable Care Act) is a 2310 page law encompassing all medical care in the US, but with very limited application to Veterans affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 minimum essential benefits (MEB) without annual benefit limits, tax credits for individuals earning below 400% of Federal Poverty Level (FPL), and Cost Sharing for people earning between 100%-250% of FPL. Cost sharing lowers deductibles and max-out-of- pocket costs, and limits personal total annual health expense (spend) from (about) 2% to a maximum of 9.66% (2017) AGI/MAGI. Small employers (under 25 FTEs) are now offered tax credited plans through SHOP. Shop tax credits can be 50% for year one and 35% for year 2. Insurance is provided be commercial carriers, not the government. See Eligibility for Advance Payment. Similar to Medicare Advantage plans, Individual and Small Group Insurance is offered and managed by commercial carriers, not the government. Means: Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), which are referred to collectively as the Affordable Care Act. Info is not tax advice.
Age Compression Rule
A regulation by HHS mandating premiums vary no more the 3:1 for all ages, including Medicare Advantage plans.
Aggregate Pharmacy Reinsurance
Aggregate Pharmacy Reinsurance is a program of coverage which shifts the financial risk of pharmacy benefits from the employer, PBM or risk bearing entity to the reinsurer. Coverage typically triggers at 110%-125% of the expected annual budgeted amount.
Aggregate Stop Loss/Reinsurance
Aggregate Stop Loss provides coverage against an entire population's budget overrun in a calendar year. Coverage typically reimburses the policy owner when claims exceed 110 percent - 125 percent of the expected annual claim volume.
Aggregating Specific Deductible (ASD aka "Inner Ag" ,"Split Funded Arra)
A "second" deductible on top of the "specific" deductible that must be paid by the insured to "itself". I.e. If the Specific (per person per year deductible) is $50K and the ASD is $100K, then the insured will pay up to $100K (to itself) of all eligible claims excess of $50K until it reaches $100K. At that point, the reinsurer then reimburses "all" eligible claims excess of $50K. Properly done, the insured "self-funds" (deposits in a separate personal account each month), an amount equal to 1/12th of the $100K to be available for "expected" claims payment. This process effectively avoids: Premium tax, agent commission, and carrier profit margin, carrier overhead load, reinsurance costs, and actuarial fudge factor thereby lowering "expected" costs" on an additional $100K of premium.
Alternative Payment Models (contracts) (APM)
A term used by LAN (CMS or Medicare administrators under HHS) to describe the identification, reporting and/or creation of new provider payment methodologies, and whose goals include increasing (private payers, providers, employers, state partners, consumer groups, individual consumers, etc) engagement, to drive lower (Medicare, Medicaid, Commercial, Workers Comp, Auto, etc) medical costs and better medical outcomes. Many are watching as republicans move to scrap many methods being tested to align better outcomes with hospital and physician reimbursement incenting maximum procedure production versus "some" attempt at avoiding or curing the problem from happening in the first place. contracting tpes include: Fee for service, Management Fee, Bundled Payment, Shared Savings or Shared Savings & Risk, Performance Incentives (See MIPS) See MACRA
Ambulatory Surgical Center (ASC) Payment System (ASC)
CMS 2018 advisory of how they are changing ASC payment that includes unburdening rural hospital reductions.

Annual Benefit Limits
ACA law eliminates annual limits on 10 essential health benefits. Grandfathered INDIVIDUAL may still have plan limits. Individuals are allowed to keep their grandfathered plan until Sept 2017 or after if their carrier is ACA compliant. All Group plans must be ACA compliant.
Applicable Federal Rate (AFR)
The applicable federal rate (AFR) is set monthly by the IRS and used for various purposes under the Internal Revenue Code, including for imputed interest and original issue discount rules. The AFR is normally available during the third or fourth week of the month. It is used for purposes of establishing a loan interest rate applied to Collateral Assignment Split dollar Life Insurance ( see SERP)
Applicable Large Employer (ALE)
An employer of sufficient size (typically involving groups over 50 FTEs, but can also include smaller groups) to fall under section 6055 or 6066 of the ACA law, and who is required to file forms 1095B and 1095C (health plan and employee information) with the government.
Applied Premium Tax Credit (APTC)

An ACA authorized tax credit paid by the federal government directly to a commercial carrier that reduces premiums for people earning between 100% and 400% of FPL.

The Treasury Department is reported to estimate 2017 payments totalling $40 BILLION. 

APTC is not CSR.

Form 1095-A must be submitted annually with each tax return to qualify for the credit. The Form is provided by the commercial carrier, and attached to the individual tax return to maintain eligibility for the tax credit.

Assignment of Benefits
A contractual provision of an insurance policy contract allowing payment for services directly to the medical provider, and not directly to the insured.
Automatic Reinsurance
See Treaty Reinsurance


Balance Billing
Balance billing is the difference between an out of network (non contracted) provider billed charge, and "contracted rate" (insured by the policy), charged to the patient. Balance billing amounts do not attribute to deductibles or out of pocket expenses, and can create substantial uninsured liability for members receiving Out Of Network (OON) care. Balance billing issues are highly contentious, and subject to dispute.
Beneficiary Engagement and Incentives (BEI)
Beneficiary Engagement and Incentives

Benefit Package
The amount and limit of medical insurance provided within an insurance plan document, or Summary of Benefits. Benefits are typically summarized by: Deductible , Co Insurance, Copay, and out of pocket maximum. Additional benefits may also be part of the Package such as Dental, Life, LTC, STD, etc at customer option.
Best Interest Contract Exemption (BICE)
On April 6, 2016 the DOL published the Conflicts of interest - retirement Investment Advice regulation, and on April 7. 2017 the DOL made some revisions to that rule for the time period of June 9. 2017 through December 31, 2017. Under the rule, the DOL significantly expands the types of retirement advice subject to fiduciary protections under ERISA, including investment advice provided to Individual Retirement Accounts (IRAs), IRA owners, and other retail retirement plans and participants, Fiduciary status applies when investment advice is provided to existing or prospective clients regarding assets held in a "qualified" (Tax deferred) plan or an IRA account, including ERISA retirement plans, traditional, ROTH, and other IRAs. and certain other tax advantaged saving plans and accounts, such as Health Savings Accounts and Coverdell education Savings Accounts. Those who are fiduciaries under ERISA must satisfy the terms of prohibited transaction exemption in order to receive compensation that varies based on the recommendation (e.g. a commission). The Best Interest Contract Exemption (BICE) and FORM PTE 84-24 are both exemptions available for annuity transactions and applicable life insurance transactions, (Source: Directions: DOL Fiduciary Rule Producer Certification) Note: A fiduciary standard potentially sets the stage for massive Class-Action litigation 20 years from today of just about any insured (or indexed crediting product) alleging higher returns regardless of if that person forgot what they once understood, was taught, or otherwise confused many years later. Customers have a duty to understand what they are purchasing. Provider Risk Recommends speaking with licensed tax specialists to confirm tax benefit, and investment safety of very safe IUL, Fixed annuity, Indexed annuity and whole life insurance policy features protected by contractual guarantees.

Better Care Reconcilliation Act
Proposed Republican lead Senate replacement to ACA.

BIC (Best Interest Contract)
See BICE Check with DOL for certainty of where the rule applies. DOL delayed Fiduciary Rule until 7/1/19

Book Rate
See Manual Rate
Book to Manual (BTW)
Jargon typically used by underwriters to express the percentage discounted from the manual rating filed with the state.
Brokers are licensed agents who represent multiple carriers, and who are legally obligated to serve their client’s best interest.
Bundled Payments
A single medical reimbursement amount defined however a medical provider wants to offer there services, or a payer (CMS, commercial insurers, etc) want to contract its providers. (i.e. OB deliveries, dialysis, factor therapy, transplants, or accepted reimbursement amount with and without bonus incentives, etc.) Services are typically stated in terms of a fixed reimbursement amount by specific diagnosis, or episode (period of time) of care. Some refer to them as "full value-based reimbursement". An implied goals to the "value-based" amounts are tied to EBM directing healthier outcomes of care at lowest cost. The Trump Administration has unilaterally decided by CMS regulatory rule to bundle payments for ALL Medicare beneficiaries for 32 types or “episodes” of care. These include hip and knee replacement operations, heart bypass surgery and procedures to open clogged coronary arteries, as well as treatments for heart attacks, stroke, pneumonia and chronic obstructive pulmonary disease. See MACRA, MIPS, PQRS, etc

Business Owners Policy (BOP)
Slang term for commercial General Liability policy inclusive of "packaged" coverages that can include sundry and ancillary requested coverages. Most standard BOP policies include $1M/$2M minimum coverage requests.


Cafeteria Plan
See Section 125 plans
Capital Aggregate Program
An aggregate reinsurance program offering two major features:
  • Aggregate reinsurance attaching at 100% (not 125%, as is typical).
  • Capital placed on the client's Balance Sheet of $1-$2 million. Capital is typically priced 5% of placement.
The product offers very competitive alternative to venture capital that typically requires equity assignment, 15%-20%+ return, repayment in less than three years, and 10% interest.
A Capitation is a fixed dollar amount per member per month (PMPM) paid to providers regardless of medical utilization. This contract shifts the catastrophic financial risk from the insurance company to the physician and/or hospital. Provider Excess Loss is purchased to pay potential catastrophic claims and prevent insolvency.
Career Limiting Move (CLM)
A Career Limiting Move is defined as bankruptcy or insolvency. Policy holders have an obligation to understand and establish adequate funding to manage solvency.
Carry Forward
A Carry Forward is a negotiated endorsement to a policy allowing a member's medical charges incurred in the last 31 days of the expiring policy year to accrue toward the new policy year deductible.
Carve Out
In the context of medical second dollar risk contracts, it refers to deleted risk exposures like Transplant, Neonatal, Cancer, ESRD, out-of-network risk, pharmacy, or any medical benefit exclusion within a managed care agreement.
Case Management
A process directed by a licensed nurse or physician, or an unlicensed specialist trained to manage, coordinate, steer and direct efficacious and efficient care in conjunction with an insured member’s physician. Goal is to increase patient well being and reduce cost.
Case Rates
A fixed hospital reimbursement by episode or diagnosis, and inclusive of all care. Outlier codes are also available to accommodate comorbidity issues and challenges. Typical case rates are promulgated by HHS on Medicare patients as defined Diagnostic Related Group (DRG codes).
Catastrophic Coverage / Cancer/Cardiac/Stroke/Transplant plan
An insurance triggered by a disease specific diagnosis, and that typically pays out directly to the insured in a fixed lump sum in addition to primary medical coverage.
Center for Clinical Standards and Quality
A CMS section assigned as a kind of umpire to establish, estimate, report and publically publish EBM "outcomes" measurements. See QPP
Center for Consumer Information and Insurance Oversight (CCIIO)
Center for Consumer Information and Insurance Oversight within the (CCIIO)
Centers of Excellence (COE)
Medical centers offering disease or procedure specific care that are known for favorable medical outcomes and or pricing. i.e. Transplants, Cardiac, Cancer, ESRD, Neonatal. These centers are typically defined by "condition specific nurse case management teams' that can also include hands on reinsurer personal "support" and steerage.
Certification and Survey Provider Enhanced Reporting application. (CASPER)
See IRF and QRP: Providers can access these reports by selecting CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage. These reports: • Contain quality measure information at the facility level • Allow providers to obtain aggregate performance for the past four full quarters (when data is available) • Include data submitted prior to the applicable quarterly data submission deadlines • Display whether the data correction period for a given CY quarter is “open” or “closed” Source: CMS
Charge Master
Relative to hospital billing, it is a schedule of maximum charges billed to a customer. Charge Master amounts are limited to contractual limits agreed to by hospitals. Those without insurance get hit with the maximum amount which can exceed 300% - 1000%more than a typical contracted rate. A charge master can also refer to the schedule a provider is obligated to accept as full payment.
Charlson Comorbidity Index (CCI)
a scoring method of 1-20 detailing presence or absence of 17 diagnosis related medical conditions designed to predict one-year mortality rates.
Child Health Insurance Program (CHIP)
Medicaid insurance managed under HHS for minors of parents who typically earn below 100% of FPL. Premium costs charged to parents are subsidized according to income.
Chronic Care Management
A program of medical care usually directed at members with: asthma, diabetes, high blood pressure, back pain, and/or high cost or chronic disease conditions. The goal of these programs is to lower typical costs of treatment and improve medical outcome for the member.
Chronic Comorbidity Count (CCC)
The sum of "selected" medical conditions (diagnosis) grouped into six categories.
Chronic Illness Conversion Agreement (CICA)
An optional TERM life insurance policy feature that acts almost identically to a Long Term Care benefit allowing 2% - 4%/yr of death benefit payout in the event of satisfying pay out trigger. The insured qualifies when 2 out of 6 ADL's produce "significant cognitive impairment" thereby allowing BOTH coverage for unexpected death, AND a long-term-care-like benefit within the same policy.
Clinical Document Improvement (CDI)
Term used by "physician advisors" who work with physicians in recommending better care for better EMB outcomes and reimbursement.
Clinical Practice Improvement Activities (CPIA)
Clinical Quality Language (CQL)

See: eCQM

Centers for Medicare and Medicare Innovation See Beneficiary Engagement and Incentives & Shared Decision Making (SDM) Model
CMS Alliance to Modernize Healthcare FFRDC (CAMH)
Achieving large-scale connected integration—of transforming the health sector into a health system—is a systems engineering challenge of enormous scale. Sponsors and clients engaged in health functions within the federal government have an unprecedented need for the kinds of systems engineering and integration expertise, organizational and cross-boundary change management, and objective, trustworthy advice provided by (Federally Funded Research and Development Centers) FFRDCs. CAMH objectively analyzes long-term health system problems, addresses complex technical questions, and generates creative and cost-effective solutions in strategic areas such as quality of care, new payment models, and business transformation. Source : MITRE

Co Insurance
In Stop Loss, Co Insurance is the percentage of eligible charges reimbursed to the stop loss policyholder after the deductible has been satisfied. In major medical insurance, Co Insurance is percentage of eligible charges the individual policy holder is required to pay the medical provider for services rendered after the deductible has been satisfied. In primary medical insurance, co insurance can be the percentage of medical claims paid by the insured up to the maximum allowed by ACA
Co Payment
Co-payment is a fixed (flat) dollar fee an individual insured pays each time he accesses care from physicians, hospitals and medical services providers.
The Affordable Care Act established the Consumer Operated and Oriented Plan (CO-OP) program, which created a new type of private nonprofit, member-run health insurer. CO-OP health plans are governed by their members, must operate with a strong consumer focus, and reinvest any profits into lowering premiums, improving benefits, or otherwise improving the quality of health care delivered to their members. CO-OPs offer health plans through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace.
Federal Law requiring employers with more than 20 employees to extend Medical Benefits to severed employees leaving employment for up to 18 to 29 months. Costs for insurance are born by the employee. Employers under 20 employees generally direct their employees to Mini-Cobra in Florida allowing them access to various benefits.

See Link

Community Living Assistance Services and Supports (CLASS)
Affordable Care Act (ACA) included an optional program called Community Living Assistance Services and Supports, or CLASS, that would have paid caregivers, including family members with no professional training in caregiving, to help older Americans stay in their own home and not access long-term care in institutional settings. The CLASS program was fashioned, however, as a voluntary endeavor with enrollees choosing whether or not to enroll, unlike traditional social insurance programs such as Medicare that mandate enrollment. But this voluntary enrollment feature, when combined with the ACA’s explicit mandate that the CLASS program be self-financing, made that program unsustainable and it was repealed in early 2013. Nevertheless, a publicly administered and funded social insurance program that would pay family caregivers remains an option beyond its present Medicaid context.
Community Rating
An employer premium rating method based on claims history by region (zip code). ACA promulgates rules employers (over 50 FTE) MUST apply (higher priced) community rating, thereby eliminating potential premium discounts associated with favorable claims experience.
A general term used to loosely or accurately convey meeting or addressing regulatory standards/reporting.
Composit Performance Score (CPS)
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Comprehensive Primary Care Plus (CPC+)
CPC+ is a five-year model that will begin in January 2017. CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations, and Medicare Advantage plans in 14 regions across the nation. Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S.). The care delivery redesign ensures practices in each track have the infrastructure to deliver better care to result in a healthier patient population. The multi-payer payment redesign will give practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback, to guide their decision making.

Comprehensve Joint Replacement (CJR)
a Value based or bundled payment initiative by CMS. A mandatory risk based provider reimbursement model inclusive of complete treatment with outcome reporting.
Congenital Heart Disease (CHD)
Consumer Assessment of Healthcare Providers & Systems (CAHPS)
• Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey – Sample PDF: The CAHPS for MIPS Survey measures patient experience and care within a group. The data collected on these surveys will be submitted on behalf of the group by the CMS-approved survey vendor. (The CAHPS for MIPS Survey is optional for groups with two or more MIPS clinicians and is not provided as an option for individual clinicians.) See QPP

Consumer Operated and Oriented Plan (CO-OP)
An ACA designated health plan authorized to sell insurance, and predicated on a community of care givers designed to lower cost and improve evidence based medical outcomes or quality. Many CO-OP's have failed leaving their insureds scrambling for coverage mid year, and leaving area medical providers with large unpaid bills.

Contingency Fees
A Contingency Fee is compensation to the agent above the commission. This fee is not usually discussed with the client. It can be similar or identical to an underwriting profit or override on profitable business sales. In larger brokerages, these "fees" are usually negotiated by senior management, where the local agent is unaware the fees exist. RIMS recently mandated a policy statement that these fees be clearly divulged by all agents to avoid the appearance of impropriety.
Continuety of Care Application
An application filed with the insurer to allow continued medical treatment for patients receiving advanced care/therapy at a facility that becomes an out of network (OON) provider DURING treatment. Certain patient protections may apply that require carriers to pay for ongoing episode(s) of care, at the higher rates This is a grey area of ACA mandates, and practice standards.
Cost of ACA to Taxpayers
According to the Congressional Budget OFfice

Cost Share Reduction (CSRs)
A term sometimes used to describe the lower deductible and out of pocket maximum payment limits an individually insured person earning between 100% - 250% of FPL is eligible. See: Cost Sharing Reductions. October 2017: President Trump issued an Executive Order (EO) removing many ACA requirements, and consumer protections(without passing a law). i.e. Undoing preexisting medical condition exclusion, maximum annual out of pocket limits, and carrier CSR reimbursements. etc. Current Trump interpretation of the ACA law declares the federal government is prohibited from paying funds to carriers for CSR retroactively. By rule, the Trump administration ended CSR federal reimbursements to carriers who funded the lower out of pocket costs for eligible insured members they insured. Many large carriers are currently suing the Federal government at this time to recover funds estimated in the hundreds of millions for 2017, and already sold 2018 plans.

Cost Sharing Reduction (CSR)
Federal payments directly to carriers applying only to INDIVIAULLY insured Silver level plan members earning Between 100% - 250% of FPL. President Trump eliminated federal funding of it by executive order Oct 12th, 2017, thereby "practically" removing ACA law requirement. No question it will cause more insurers to abandon offering Marketplace (tax credited) plans. Cost sharing reductions can also refer to federal reinsurance (limited) safety net to Marketplace participating carriers offering tax credited major medical plans. See Shared Services, which applies to MEDICARE (not Group or INDIVIDUAL commercial Marketplace offered plans). Per the NY Times: "Discontinuing cost-sharing reduction payments to insurers would increase premiums for silver-tier plans, the most popular plan tier sold on Affordable Care Act exchanges, by 20% next year and by 25% by 2020, and would raise the federal deficit by $194 billion through 2026, according to an analysis by the Congressional Budget Office. The move would prompt insurers in some states to exit the market, leaving about 5% of Americans with no insurance options next year, although insurers are expected to rejoin the market in 2020." Source: NY Times August 2017 Many carriers have filed suite to recover CSR for hundreds of millions already paid out to medical providers, and that lowered individual out of pocket accounts, and that carriers they relied upon before rating and binding 2017 and 2018 plans. CSR is sometimes erroneously referred to in the context of Marketplace reinsurance. ================================== Per United Agent Advisory October 2017:Final Reinsurance Fee Payment Due Nov. 15 for Self-Funded Employers =================================== October 5, 2017 The final installment of the Transitional Reinsurance fee is due by Nov. 15, 2017 for those employers who selected to pay the 2016 fee in two installments. For the final year payment, self-funded employers who selected to pay in one installment paid the $27.00 per covered life Jan. 17. Those self-funded employers have no further payment obligations. For those employers who selected two installments, the payment schedule is: •$21.60 per covered life – payment made Jan. 17 •$5.40 per covered life – due Nov. 15 Background Under the Affordable Care Act (ACA), the Transitional Reinsurance fee has been paid by health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance Program in place from 2014 to 2016. •For fully insured clients, UnitedHealthcare pays the fee. •For self-funded employers, the employer is required to pay the fee. For the final year, the fee was determined to be $27 per covered life and was based on enrollment in major medical coverage for the first nine months of 2016, regardless of the plan’s renewal date. Employers were responsible for submitting their enrollment count and selecting their payment date(s) on the government portal ( last fall. ======================== See Shared Services at risk provider contracts, which applies to MEDICARE (not Group or INDIVIDUAL commercial Marketplace offered plans). See: Republican Healthcare Agenda.
http://See: Rebublican Agenda

Credit Life Reinsurance
Credit Life Reinsurance is coverage provided to insurance companies writing mortgage payment insurance. It can take the form of Specific, Aggregate, Quota Share and/or Surplus Relief depending on the needs of the insurance company being served.
Current Procedure Terminology
A 5 digit code for Hospital procedures. See: ICD-10
Cyber Security: Medical: HHS Tast Force Recommendations


A Declaration is an addendum to all stop loss and reinsurance policies which warrants all members expected to exceed 50% of retention have been reported prior to binding coverage.
Sometimes referred to as Retention, or threshold, a Deductible is the dollar amount exceeded before a policy pays all, or part of an eligible claim. In most Stop Loss and Reinsurance, deductibles accrue independently of any co insurance or copays. In most individual and Group major medical insurance, a deductible includes most Copays and OOP spent on eligible care.
Department of Insurance (DOI)
State agency or regulatory authority that, among other things, licenses, oversees, and regulates Issuers, Agents, and Brokers, as applicable.
Designated State Health Programs (DSHP)
Federal Medicaid money to states used to fund various healthcare programs for the poor. Trump administration is ending the program currently used by Arizona, California, New York, New Hampshire, Rhode Island and Washington now have waivers that include DSHP funds. Source: Modern Healthcare
Diagnostic Related Group (DRG - see Bundled Payment)
A Medicare assigned reimbursement by diagnosis code. Many rules apply. Some DRGs allow for "outlier" modifier codes causing certain events to qualify for greatly increased eligible reimbursement to reflect comorbidity events.
In context to medical stop loss or reinsurance, disclosure means the presentation of claims data and Large Claimants. Typical reporting includes reporting anyone in the hospital, not actively at work and/or whose claims exceed 50% of the solicited stop loss/reinsurance deductible. Most all carriers also demand reporting by "catastrophic" diagnosis as well. Successful disclosure is required prior to binding or firming stop loss offers.
Dual Eligible’s
A term generally used to identify an individual eligible for both Medicare and Medicaid.


Early Lock Down
A renewal feature offered by some carriers to renew stop loss coverage early, and avoid last minute potential lasers on sick employers who present illness within 60 days of renewal.
Early Retiree Reimbursement Program (ERRP)
Early Retiree Reimbursement Program. $63 (2014) PMPM charge to employers for the program.
Electronic Clinical Quality Measure (eCQM)

The Centers for Medicare & Medicaid Services (CMS) and the National Library of Medicine (NLM) will publish updates to the electronic clinical quality measure (eCQM) value sets to align with the most recent releases to terminologies, including, but not limited to, International Classification of Diseases (ICD)-10 Clinical Modification (CM) and Procedure Coding System (PCS), SNOMEDCT, LOINC, RxNorm, and Current Procedural Terminology (CPT). CMS will publish two addenda containing updates to these terminologies for the 4th Quarter (Q4) 2017 reporting period, and 2018 reporting and performance periods. 2017 Q4 Reporting Period eCQM Value Set Addendum: In September, CMS will publish an addendum to the eCQM specifications (published in April 2016) to update relevant eCQM value sets for Q4 2017 reporting. This addendum will affect the electronic reporting of eCQMs for the following hospital programs: • Hospital Inpatient Quality Reporting (IQR) Program; and • Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for eligible hospitals and critical access hospitals (CAHs). The 2017 Q4 Reporting Period eCQM Value Set Addendum does not impact eCQM reporting for eligible professionals (EPs) in the Medicaid EHR Incentive Program or eligible clinicians in the Quality Payment Program. 2018 Reporting/Performance Period eCQM Value Set Addendum: By October, CMS will publish an addendum to the eCQM specifications (published in May 2017) to update relevant eCQM value sets for the 2018 reporting year. This addendum will affect the electronic reporting of eCQMs for the following programs: • Hospital IQR Program; • Medicare and Medicaid EHR Incentive Program for eligible hospitals, CAHs, and EPs; and • Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). (Source: CMS)

Electronic Health Record (EHR)
A computer stored file consisting of a member’s personal medical information.
Electronic Personal Health Information (e-PHI)

Eligibility Determination Notices (EDN)
Health Insurance Marketplace explanation of what may qualify for SEP, OEP, etc.
Eligibility for catastrophic plans under ACA
In addition to the level of coverage plans, issuers in the individual market can offer catastrophic plans. Eligibility for catastrophic plans is limited to:
  • Individuals under age 30 before the plan year begins
  • Individuals who have a certification from the Marketplace that they are exempt from the responsibility requirement because they do not have an affordable coverage option, or because they qualify for a hardship exemption (Source
Eligibility: Method of Determining Eligibility for Insurance Affordability Programs
As part of the application process, the Marketplace determines an individual’s eligibility for advance payments of the premium tax credit and cost-sharing reductions based on projected household income relative to the FPL. Household income is the sum of a tax filer’s MAGI, and the MAGI of the tax filer’s dependents who are included in the tax filer’s family and required to file a federal income tax return. Additionally, the Affordable Care Act requires all states to determine eligibility for Medicaid and CHIP for the majority of individuals (essentially, all non-disabled, non-elderly individuals) based on their MAGI. MAGI is adjusted gross income within the meaning of the Internal Revenue Code, plus any excluded foreign earned income, tax-exempt interest received or accrued during the taxable year, and non-taxable Social Security benefits. Assets are not considered in determining eligibility. This income methodology is the same for determining eligibility for advance payments of the premium tax credit and cost-sharing reductions, and determining eligibility for Medicaid and CHIP, with the following exceptions:

Eligible Clinician ((Replaces Eligible Professional))
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Employee Retirement Income Security Act (ERISA)
The ERISA Act provides federal laws and regulations pertaining to the operation of self funded health plans for single employers, unions, trusts, and associations. ERISA plans are effectively immune to state insurance laws and regulations regarding assumption of risk and solvency standards. However, Plans sponsored by municipalities may be regulated by the domiciled state. These plans may include Life, Health, Dental, etc as part of the Group plan(s) offerings. The purchase of Specific and Aggregate reinsurance is optional, but usually done to transfer the risk of unpredictable catastrophic claims.
Employee-Pay-REB Split Dollar Plan (REB)
Employee-Pay-REB Split Dollar Plan When the employer owns the life insurance policy and pays the entire premium for it in a split dollar plan—the insured employee must pay the income tax on the reportable economic benefit (REB) which is the amount of premium paid by the employer each year.
Employer Group Waiver Plans (ESWP)
Employer Group Waiver Plans ("Egg Whips") Pharmacy plans available to fully insured or self-funded plans offering cost savings for the pharmacy fees associated with capitation based PBP
Employer Mandate
Employer Mandate Under the Affordable Care Act, the employer mandate affects employers with 50 or more full-time employees to offer their workers health care coverage or pay a tax penalty.
Employer Mandate – aka Play or Pay
ACA mandate requiring employers with more than 50 full time equivalent full-time-employees (FTEs) to buy medical insurance for their employees, or Pay $2,000 per head (after 30 FTE’s “deductible”). FTE is defined as an employee working more than 30 hours. ACA requires employers with sister corporations to count all their allied companies employees toward the 50 FTE mandate.
Enterprise Identity Management System (EIDM)
CMS offered identity registry created to access multiple entity reporting of QPP related reporting. See PRQS:
Enterrise Identity Management (EIDM)
See PQRS An Enterprise Identify Management (EIDM) account with the appropriate role is required for participants to obtain their 2016 PQRS Feedback Reports and 2016 Annual QRURs. Both reports can be accessed on the CMS Enterprise Portal using the same EIDM account. Visit the How to Obtain a QRUR webpage for instructions on accessing both reports.
Episode of Care
A term used to denote care delivered from beginning to end of treatment. Episode of care is the vernacular being used by Payors attempting to fashion reimbursements schedules or contracts with providers inclusive of all services delivered over a specified period, or by medical outcome desired.
Episode Payment Models (EPM)
Episode Payment Models (EPMs); Cardiac Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model On August 2, 2016, the Centers for Medicare & Medicaid Services (CMS) published four new payment models and refinements to a current model through a notice of proposed rulemaking to further advance care coordination for Medicare fee-for-service (FFS) beneficiaries, which will begin on July 1, 2017. Three new episode payment models (EPMs) would test making participants financially accountable for the quality and cost of episodes of care helping achieve the goal of higher quality at a lower cost for the following episodes: • An acute myocardial infarction (AMI), including both medical therapy and percutaneous coronary intervention (PCI), • A coronary artery bypass graft (CABG), and • A surgical hip/femur fracture treatment, excluding lower extremity joint replacements (SHFFT). The Cardiac Rehabilitation (CR) incentive payment model for EPMs and Medicare FFS participants would test financial incentives for Inpatient Prospective Payment System (IPPS) hospitals that encourage the management of beneficiaries following an AMI or CABG toward greater utilization of CR services. The proposed rule can be found on the Federal Register. See CMS fact sheet and press release.

Essential Community Providers (ECPs)
Essential community providers (ECPs) include providers that serve predominantly low income and medically underserved individuals, and specifically include providers described in section 340B of the PHS Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act. "The first of these proposals relates to network adequacy review for QHPs. The modified approach would not only lessen the regulatory burden on issuers, but also would recognize the primary role of States in regulating this area. The second change would allow issuers to use a write-in process to identify essential community providers (ECPs) who are not on the HHS list of available ECPs for the 2018 plan year; and lower the ECP standard to 20 percent (rather than 30 percent), which we believe would make it easier for a QHP issuer to build networks that comply with the ECP standard." Also relates to Network Adequacy standards Source HHS

Essential Health Benefits
10 categories of unlimited insurance coverage defined under ACA that create a Qualified Health Plan. Categories include: Maternity & Newborn care, Hospitalization, Emergency Services, Pharmacy, Laboratory, Pediatric Vision & Dental, Rehabilitative Services and devices, Emergency Services and Preventive/Chronic disease medical treatment.
Excess and Surplus Clause
This is a standard Clause that means coverage is afforded after all other available insurances have been exhausted. It can also be associated with language stating coverage being applied to all medical charges the client is at risk for unless specifically excluded by design.
Excess of Loss
Excess of Loss is a type of Stop Loss or Reinsurance coverage that triggers after a specific and or aggregate deductible is satisfied. These policies take many forms, and insure many types of risk. This coverage may employ a Specific deductible or variations within an aggregating specific deductible. It is “second dollar” coverage.
Exchange aka Marketplace
Meaning set forth in 45 CFR 155.20An online site accessing ACA compliant medical and dental plans that is managed/funded by the federal government (HHS). 14 states did not expand Medicaid or create their own commercial insurance exchange or Marketplace, and have relegated administration to the federal government. The word MarketPlace or Exchange means the same. Technically, the exchange was detailed in the original ACA law, and can be referred to as the Federally Facilitated Market place or Exchange. Most refer to it as the MarketPlace, for either the 14 states the federal government sponsors or the individual state paid for service. Note, that a CO-OP or Cooperative may have different distribution and plan access parameters.
Exclusive Provider Network (EPO)
A network of physicians and hospitals offered to members for In Network care. EPOs typically do not insure care received out of network, and look similar or identical to HMO Gatekeeper model plans.
Exemption (of Individual ACA Mandate)
People with low incomes and individuals who meet certain conditions can receive an exemption from the Individual Mandate. Exemptions include: •Income below 100% of the federal poverty level •Coverage costs more than 8% of family income •Being without coverage for less than three months during the year •Religious reasons •Not living in the United States •In prison •Having a hardship waiver

Expected Claim Value
The underwritten expected annual claim value used to rate specific and aggregate insurance premium.
Experience Credit
Experience Credit aka Premium Refund aka Minimum Premium aka Profit Commission aka Terminal liability aka Alternate Funding aka Experience Refund policy. A premium rebating feature that returns excess premium when claims are lower than a negotiated loss ratio typically under 70%.
Experience Modifier
An underwriting term. In context of workers compensation, it is a (multiple or factor) measures loss experience relative to that of other employers in the same industry.
Expert Medical Advisor (EMA)
An highly qualified medical professional accepted by a workers compensation court for purposes of determining the percentage of medical claims injury caused by a work related activity v the percentage caused by a preexisting medical condition. Expert Medical Advisors report on Major Contributing Cause (MCC) of medical claims loss. Findings of cause being 51%+ caused by a work related activity means the claim is eligible for workers compensation insurance response provided the court accepts the findings. Orthopedic Surgeons are considered EMA's. See MCC, IME, DWC25 form, MSA, MMI
Explanation of Benefits (EOB)
A carrier generated medical bill itemization detailing the billed charge, contracted rate, and insured payment responsibility. EOB detail maximum "accepted" contract rate(s), carrier reimbursements, and patient payment responsibility. Errors in medical billings are common.
External Review
A process that meets minimum standards set forth under ACA/HHS regulation related mostly to coverage exclusions or insurance denials. ACA details greater consumer appeal rights for denied or under-reimbursed medical claims. Self Funded (ERISA) plans are held to a different standard than Individual plans, mostly limited to review of insurance eligibility.


Facultative Reinsurance
Facultative reinsurance is coverage where a Reinsurer evaluates a specific risk on a case- by-case basis. Typically, the primary insurer has no obligation to submit NEW risks to the reinsurer, and the reinsurer is free to accept or reject any risks submitted by the primary insurer or ceding company. Facultative reinsurance can also be referred to as Pro Rata or Excess of Loss coverage. Typically, the reinsurer accepts the same percentage of claim liability as billed premium. Each policy is different.
Federal Budget 2017 - 2018

Federal Information Security Management Act (FISMA)
Federal Information Security Management Act
Federal platform for eligibility and enrollment functions (SBM-FPs)
A federal term used to denote various sites the public can access for price and medical quality metrics.
Federal Poverty Level (FPL)
2017 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA PERSONS IN FAMILY/HOUSEHOLD POVERTY GUIDELINE For families/households with more than 8 persons, add $4,180 for each additional person. # in Family Income 1 $12,060 2 $16,240 3 $20,420 4 $24,600 5 $28,780 6 $32,960 7 $37,140 8 $41,320

Federal Poverty Level Guidelines

Federal Provider Penalties
HHS Increases Civil Monetary Penalties September 6, 2016 by Heather Landi The U.S. Department of Health and Human Services (HHS) issued an interim final rule Sept. 2nd that raises various civil monetary penalty amounts to adjust for years of inflation. “The Department of Health and Human Services (HHS) is promulgating this interim final rule to ensure that the amount of civil monetary penalties authorized to be assessed or enforced by HHS reflect the statutorily mandated amounts and ranges as adjusted for inflation. Pursuant to Section 4(b) of the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (the 2015 Act), HHS is required to promulgate a “catch-up adjustment” through an interim final rule. The 2015 Act specifies that the adjustments shall take effect not later than August 1, 2016,” HHS stated in the interim final rule. The rule noted the new maximum penalties apply to any fines assessed after Aug. 1, 2016, as well as all penalties stemming from violations that took place after Nov. 2, 2015. Under the interim final rule, some civil monetary penalties will nearly double due to inflation adjustments. HHS increased the penalty for a HMO or competitive medical plan that implements practices to discourage enrollment of individuals needing services in the future by 106 percent from $100,000 to $206,000. Hospitals with 100 beds or more now face penalties of more than $103,000 if they dump patients needing emergency medical care. That’s up from the $50,000 penalty established in 1987. Circumventing Stark Law’s restrictions on physician self-referrals will now cost $159,000, a 59 percent increase from the original $100,000 penalty established in 1994. Some penalties are relatively small, such as the penalty for payments by a hospital or critical access hospital to induce a physician to reduce or limit services to individuals under the direct care of the physician or who are entitled to certain medical assistance, which increased 115 percent from $2,000 to $4,300. Many updated penalties affect both Medicare and Medicaid managed-care companies. HHS raised the penalty for a Medicare Advantage organization that improperly expels or refuses to reenroll a beneficiary by 47 percent, from $25,000 to $36,794. Medicare Advantage organization that substantially fail to provide medically necessary, required items and services will now face penalties of more than $37,000, an increase from $25,000. The penalty for a Medicare Advantage organization that charges excessive premiums went up from $25,000 to $36,794. And, a Medicaid MCO that improperly expels or refuses to reenroll a beneficiary now faces a $197,000 monetary penalty, up from $100,000.
Federally Facilitated Exchange (FFE)
The federally created and managed platform designed for accessing ACA eligible INDIVIDUAL and SHOP plans in states that opted out of creating their own state based exchange / Marketplace for medical insurance.
Federally-Qualified Health Centers (FQHC)
Federally-Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs). Centers providing heavily subsidized or free medical care for the poor or vulnerable population in the US.
Fee For Service
Fee For Service is the full billed charge a provider invoices an insurer for services rendered.
Fee Schedule
A Fee Schedule is an explicitly detailed schedule used by the carrier to determine the eligible amount charged. In many stop loss coverages, the RBRVS schedule is used for re-pricing physician fees The Medicare maximum allowable amount, and or DRG's are commonly used as well in pricing the hospital reimbursement. The fee schedule used dramatically effects eligible and reimbursable charges. Commonplace are variations of charges for the same service rendered by medical providers, contract and insurance type. Variations in what is considered the eligible and reasonable charge can be contentious.
Finite Reinsurance
Finite Reinsurance is defined by the Reinsurance Association of America as "a highly structured reinsurance contract where structured elements reduce the amount of risk assumed by reinsurers to the point that it may not meet the accounting requirements of risk transfer." Finite reinsurance is typically coverage transferring little or no risk, and is designed to pay known losses, or improve issues related to cash flow from irregular market conditions involving interest rates, and asset values. It typically improves financial ratios related to compliance, and capital surplus reserves. There are many types of finite loss development coverages. The essence of coverage may amount to a line of credit to pay known losses today and reimburse the reinsurer by amortized future premium payments. NAIC has recently agreed on a uniform policy form.
Firm Rate
Sometimes called firm quote, or "a bindable" quote. It is the underwritten rate offered by an carrier who has priced a given policy premium (and quote deadline). This rate typically does not change if the policy proposal is accepted by the customer by deadline. Rules governing last minute claims disclosure & underwriting acceptance are specific to each carrier, and are subject to offering terms, conditions, deadlines, and coverage, etc.
First Dollar Risk
A dollar amount most underwriters consider a likely cost per calendar year for each insured member. Second Dollar risk is typically medical claims risk above $50,000.
Flexible Spending Accounts (FSAs)
Flexible spending accounts (FSAs) enable workers to contribute before-tax amounts to an account that they can then access tax-free to pay eligible out-of-pocket health-related expenses. Amounts left in the plan at the end of the year in excess of $500 are forfeited—up to $500 only may be rolled over for use in future years. 2018 limits: For FSAs, up to $2,650 a year; for HSAs, up to $3,450 annually for individuals and $6,900 for families. See HSA.
Fronting Assignment
Fronting can refer to multiple types of reinsurance and insurance. Fronting can be the leasing of an authorized insurance policy form in an individual state. Sponsoring carriers may elect to assume all, part, or none of the risk being assumed by the entity attempting to establish an insurance program. Fronting carriers may, or may not act as reinsurers. A fronted and reinsured assignment can be a program of transferring an existing book ($1+M) of insurance into an existing authorized policy form that creates a less expensive "compliant" insurance alternative to a fully insured premium, and that allows agents to both commission on the sale, and share in profits. Assumption of “some” risk by the sponsoring agency/entity/ company/broker is usually required to assure a true risk partnership and comfort reinsurers. Fronting and "reinsured" assignments take MANY forms. Where a larger company establishes a (n offshore captive, or on shore "compliant") program to assume and manage their own risk (General Liability, Major Medical, ERISA, Workers Compensation, etc.), the primary purpose is to fund "1st dollar" risk and cede "second dollar" (unpredictable) risk at a cost that can be much less than buying a fully insured coverage to satisfy compliance and/or manage risk. Program managers strive to balance premium savings and liquid-surplus-reserves- funding for known and unknown claims risk. There are many types reinsurance coverages designed to manage unpredictable risk, and/or help improve compliance ratios, and/or solvency risk management. See Finite Reinsurance.
Full Time employee
A term defined under ACA meaning an employee working more than 30 hours per week. It is calculated by summing all part time employee hours and dividing by 30hrs to determine a FTE for purposes of ACA employer-employee count being above or below 50 FTE. Under ACA, the number is used to assess ACA tax penalties for employers employing over 50 FTEs. Employers over 50 FTE not providing ACA compliant medical insurance to their employees get fined $2,000 per employee (after the first 30 FTE exemptions).
Full Time Equivalent (FTE)
An employee working more then 30 hours a week. It should be noted that ACA law calculates part time employees working under 30 hours a week – summed and in total to determine if an employer has over 50 full time employee “equivalents” and is subject to either a $2,000 or $3,000 penalty tax for non compliance.
Fully Disabled Limitation
A Fully Disabled Limitation is a condition of a self funded stop loss policy that excludes members not actively at work, and/or who might be in the hospital at time of “disclosure”. This provision is typically waived by the carrier by proper claims declaration.
Fully Insured
A term to describe an "eligible" and "Authorized" ( or "admitted") insurance policy approved in a state characterized by a significantly LOWER deductible than a Self Funded Plan. The term fully-insured-rate can be associated with an "admitted" insurance policy form and cover offering premium rebates for favorable claims experience. See Minimum Premium Plans, which are a type of fully insured plan that charges the "fully-underwritten-rate", and rebates premium for favorable claims experience while adding no unfunded risk to the policy holder.
Functional Capacity Evaluation (FCE)


Gatekeeper Plan
A term used to identify medical plans requiring a primary care physician referral requirement before accessing specialty physician care.
General Agent (GA)
A GA is a General Agent for a single carrier. A GA is bound legally to represent the best interest of their appointing carrier, and sometimes earn commissions, overrides and/or profit sharing.
Geriatric Resources for Assessment and Care of Elders (GRACE)
An ACO program designed to study low income elderly people to determine reductions in ER visits, hospitalization and readmissions by using in home assessments & better-monitored plans.
Grace Period
A Grace Period is the number of days past the premium due date the premium will be accepted before canceling the policy for non-payment of premium. A typical grace period is 30 days. Marketplace plans have an ACA mandated 90 day grace period.
Grandfathered or Grandmothered Plan
An ACA compliant plan allowed that is not ACA compliant (with 10 EHB, etc.) Under the new CCIIO notice, in states that let grandmothered coverage stay in force, an insurer can renew grandmothered coverage up until Oct. 1, 2018. The grandmothered coverage can stay in effect until Dec. 31, 2018 Failure to comply with ACA means individuals and employers are subject to tax penalties for NOT having ACA compliant coverage.
Grandfathered Plan
INDIVIDUAL Plans started before 3/23/10 are allowed to remain in effect until September 2017. Grandfathered plan members do not get fined 2.5% for ACA non compliance. Many Grandfathered plans have materially less coverage than ACA compliant plans. Group plans issued after 1/1/16 are ACA compliant. Grandfathered plans are exempted from ACA mandated changes like unlimited benefits for 10 essential health benefits. Grandfathered plans are typically prohibited from making any changes that increase MOOP. (Source
Group Health Plan
A plan sponsored by an employer and requiring a minimum of 50% employer premium contribution, and 70-75% of employee participation, and that is guarantee issue without underwriting and outside of OEP.
Guarantee Issue / Guarantee Renewability
A policy feature offering insurance issuance without additional underwriting or exclusion of preexisting medical condition. ACA offers guarantee issue policies during OEP and SEP only each year.
Guaranteed Purchase Option (GPO)
A life insurance rider guaranteeing option to purchase additional permanent protection in the future without providing evidence of insurability.
Guarentee Purchase Option (GPO)
A life insurance rider allowing up to $350,000 of additional life insurance without evidence of insurability.


Act to provide for Reconciliation pursuant to Title II and V of the Concurrent Resolution on the Budget for the Fiscal Year 2018. See PPACA, ACA

Health and Human Resources (HHS)
Federal Department of Health and Human Resources - the agency charged with managing ACA and CMS, etc.
Health Care Payment Learning and Action Network (LAN)
A HHS-CMS department assigned with tracking & communicating alternative (non FFS) medical provider reimbursement contract successes in lowering cost and maximizing evidence based medicine outcomes. “CMS is proud to achieve the 30% target almost a year ahead of schedule. Moreover, true transformation of our health system cannot be done through Medicare alone, and so CMS looks forward to continuing to work with partners across the country to achieve the goals of tying 30% of spending to APMs by the end of 2016 and 50% by the end of 2018 for the entire U.S. health care system.” “The Health Care Payment Learning and Action Network will bring together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models.” “HHS has set a goal (PDF) of tying 30 percent of Medicare fee-for-service payments to quality (PDF) or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018.” (source: Health Care Payment Learning and Action Network (LAN))
Health Information Exchange (HIE)
Health Information Technology (HIT)
Section 1561 of the Affordable Care Act requires the Department of Health and Human Services (HHS), in consultation with the Health Information Technology (HIT) Policy Committee and the HIT Standards Committee (the Committees),
Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)
The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI.
Health Insurance Claim Number (HICN)
See MBI Health Insurance Claim Number (HICN) in context to a Medicare patient claim patient identifier number.
Health Insurance Exchanges Program (HIX)
Health Insurance Issuer
Health insurance issuer means an authorized insurance company licensed to sell insurance in a state, and is subject to state law that regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act (ERISA)). This term does not include a group health plan. (Source
Health Insurance Marketplace
The name HHS gives to Exchange plans aka Marketplace plans aka Tax Credited Plans aka Obama Care plans.
Health Insurance Portability and Accountability Act of 1996 (HIPPA)

Federal Law created to help people keep their insurance between different employers, and ended up adding massive electronic personal information security requirements and (civil and criminal) penalties. Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, as amended, and its implementing regulations. (source MLN Learning) A law that sets standards for securing privacy of personal health information, and affording people changing jobs guaranteed insurance without preexisting medical condition exclusion or waiting period. Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers, and sets forth privacy and security standards for handling health information Public Law 111–148, Patient Protection and Affordable Care Act, March 23, 2010, 124 Stat. 119, Minimum Acceptable Risk Standards for Exchanges – Exchange Reference Architecture Supplement i Version 1.0 August 1, 2012 1 Centers for Medicare & Medicaid Services Executive Overview • Department of Health and Human Services Final Rule on Exchange Establishment Standards and Other Related Standards under the Affordable Care Act, 45 CFR Parts 155, 156, and 157, March 12, 2012, which establishes privacy and security controls required for processing Exchange applicant information • Internal Revenue Code (IRC), 26 U.S.C. §6103, which establishes criteria for handling Federal Tax Information (FTI) In addition, numerous other federal and state regulations impact the processes for securing information. For example, the Privacy Act of 1974 places limitations on the collection, disclosure, and use of certain personal information, including PHI. The e-Government Act of 2002 requires federal agencies to conduct privacy impact assessments (PIA) associated with collecting, maintaining, and disseminating PII. The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI. There is no integrated, comprehensive approach to security. (Source HHS)

Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) is a state-designated insurance entity authorized to sell commercial, Medicare or Medicaid health insurance in certain counties. HMO's are known for emphasizing preventative medicine, and paying their doctors and hospitals a fixed dollar “capitation” for each member assigned to a provider group. An HMO is typically separated from a PPO or Indemnity Health Insurance by two major things: a capitated primary care physician (PCP), and required referral from a PCP for specialty physician access.
Health Reimbursement Account (HRA)
A tax exempt account used to pay eligible health expenses, typically paired with high deductible plans, and that gets funded by the employer. (This is the use or lose it account but for about $500 per year that can roll over to the new year.) See HRA and MSA See IRS requirements
Health Resources Account (HRA)
HRA accounts are used to assist employees in paying typical deductible, co insurance and other eligible out-of-pocket medical expenses during a calendar plan year. These funds are deposited by employers and/or employees each year Pretax, and can be spent on eligible medical costs by typically using an assigned Debit card. Total annual deposits are regulated and limited per calendar year. Unlike Section 125 plans, unused HRA account balances do not roll over to a new policy year, and therefore are referred to as “use it or lose it”. See Section 125 plans. . Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys.
Health Savings Account (HSA)
A health savings account (HSA) is a special tax-exempt account an individual owns and establishes with untaxed funds to pay for qualified medical expenses. HSAs are used in conjunction with high-deductible health plans (HDHPs) offered by many insurance companies that IRS accepts as eligible. The maximum amount that may be contributed to an HSA is set by law and subject to change each year. Under Sec. 223, individuals who participate in a high-deductible health plan (HDHP) are permitted a deduction for contributions to HSAs set up to help pay their medical expenses. The contribution deduction limit is subject to an annual inflation adjustment. For 2018, the annual limit on deductible contributions is $3,450 for individuals with self-only coverage (a $50 increase from 2017) and $6,900 for family coverage (a $150 increase from 2017 after not increasing last year). See more at:

Health Sharing Ministry Organization (HSMO)
A new type "faith-based" association health plan that cost less than ACA compliant INSURANCE available to Individuals, and perhaps some employers. Requires signed statement of faith. May not be QHP and avoid tax penalties. Plans are not insurance, but offer reimbursement to a PPO contracted rate for eligible medical care.

http://See Aliera

Healthcare Effectiveness and Information Set (HEDIS)
A good set of clinical measures and rules that can help (along with others like NQF measures) used to identify gaps in care or potentially unnecessary care occurring, and/or who is experiencing it, and/or optimal clinical intervention timing.
Healthcare Research and Quality (AHRQ)
An agency under CMS that uses Clinical Classification Software (CCC) to detail co-morbid conditions grouped into six categories.
New & increasing tax ($11.3 B) on Fully-Insured medical carriers, but not ERISA plans.
Hospice Quality Reporting (HQRP)
See: MACRA, QPP, MIPS The Hospice Quality Reporting Program (HQRP) Requirements and Best Practices web page provides updates regarding reporting requirements, and announcements focusing on best practice methods to help hospices be successful specific to the HQRP. In section 3004(c) of the Affordable Care Act, the Secretary is directed to establish quality reporting requirements for Hospice Programs. Currently, there are two requirements for the HQRP: •The Hospice Item Set (HIS) is a component of the HQRP for the FY 2016 annual payment update (APU) and subsequent years. For more information on the HIS, please visit the “Hospice Item Set (HIS)” portion of this webpage.

Hospital Inpatient Quality Reporting (IQR)

Hospital Inpatient Quality Reporting Program (IQR)
See eCQM
Hospital Outpatient Prospective Payment System (OPPS)
CMS issued a proposed rule that updates payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed rule is one of several for 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility and innovation in the delivery of care.

Hospitals Star Ratings Program
A contentious one to five star quality rating published on 3662 hospitals by Centers for Medicare and Medicaid Services (CMS) being released later in 2016. Teaching hospitals and hospitals dealing with the poor typically rank lower because of higher (previously untreated) comorbidity care.
Human Resources


I-9 Employment Eligibility Verification Form
From Required by Department of Homeland Security

ICD- 10 codes (ICD 10)
A 5 digit hospital procedure coding system for billing purposes.

Independent Medical Exam (IME)
A medical report from a qualified medical professional detailing percentage of work related injury and claim caused by a work related injury, and potentially insured by workers compensation insurance. See EMA & MCC & DWC25 form
Independent Medical Examination (IME)
Independent Practice Association (IPA)
An Independent Practice Association (IPA) is typically a group of physicians who organize themselves into a contracting entity to care for an HMO's and PPO's members. It can also be a licensed HMO owned by its member physicians.
Individual Mandate
Under the Affordable Care Act, the individual mandate requires individuals to have health care coverage or pay a tax penalty. Information for 2016 and 2017 Open enrollment in the health insurance marketplace for 2017 begins on November 1, 2016, and runs through January 31, 2017. The penalty for not having coverage in 2016 is the greater of 2.5 percent of income in excess of the filing threshold, or $695 per adult ($347.50 for a child under 18) up to a maximum of $2,085. For 2017 and beyond, the percentage penalty will remain at 2.5 percent of income, but the flat fee will be adjusted for inflation. Source: Florida Agent Licensing Exam course.
Individual Mandate and Tax Credit
Tax Credit applied against monthly medical insurance premiums available to people earning between 133% - 400% of FPL. In states where Medicaid Expansion was adopted, tax credits are available from 138% - 400%. Practically speaking, the tax credit is meaningful (big enough to matter) under 300% FPL.
Injured Worker (IW)
A potential workers compensation eligible claimant in process of determining maximum medical improvement and major contribution cause of the injury.
Inner Agg
See Aggregating Specific Deductible
Inpatient (Hospital) Quality Reporting (IQR)

Inpatient Prospective Payment System (IPPS)
See IQR CMS term used for updating hospital and LTC inpatient rates that by final rule must be updated each year. CMS states, "We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program."

2018 Medicare Medicare Hospital Inpatient Prospective Payment System

Inpatient Rehabilitation Facility Quality Public Reporting (IRF QPB)
see Preview Report Access link first. :

Insurance Services Office (ISO)
ISO (Insurance Services Office) and AAIS (American Association of Insurance Services) policy forms" Insurers deviate from industry standards and react to changing loss scenarios, underwriting challenges, legislative changes and court decisions before ISO or AAIS my change or accept such deviations in promulgated examples of policy forms. Compliance gets complicated.

Integrated Delivery Systems (IDS)
Integrated Delivery Systems (IDS) are physician, hospital and insurance company joint ventures which are authorized to sell health insurance in a state. Sometimes simple unorganized Physician and Hospital groups refer to themselves as integrated despite their inability to coordinate care, manage their physicians or reduce cost.
Internal Revenue Code (IRC)
Internal Revenue Code § 162 bonus plans ( IRC § 162 bonus plans )
An IRC § 162 bonus plan is a nonqualified retirement type of plan where an employer pays a bonus to a participating executive and directs the bonus toward payment of premiums on a life insurance policy owned by and covering the executive. Monies used to pay the premium are taxed prior to paying the premiums, and the death benefits are generally recovered tax free. Cash value is instantly available - generally without tax as well (through loans on the policy). See SERP
International Classification of Diseases (ICD-10 )
Irrevocable Letter of Credit (ILC)
An Irrevocable Letter of Credit is a bank document guaranteeing funds on accounts payable to the obligee in the event a contractor is unable to meet their obligations.
Internal Revenue Services


Level Funding (Minimum Premium)

A higher deductible group medical plan that allows for a premium refund when TOTAL GROUP claims (aggregated) cost under a terget value - typically 120% of the previous years underwritten claims cost.  Level Funded plans price about 15%-20% less than lower deductible tratidional medical plans.  These plans typically do not enjoy material premium reductions because they off

  Essentially, these plans offer employers with good claims experience the opportunity to pay up front, and get some back if claims remain under an expected value.


These plans are not construed as traditional ERISA self funded plans which typically require deductibles in excess of $50,000 per person per year.  Typical ERISA self funded plans insure both specific (per person per year), AND aggregate (per population per year) risk.

Life Expectancy (LE)
The length of time a person is expected to live. In Life Settlements, it is the length of time in months an insured person is expected to live. LE's are commonly estimated by physicians and entities involved with buying and selling life insurance policies. These estimations help entities purchasing life settlements budget expected premium cost through policy execution. See life settlements.
Life Insurance
There are three to four basic types of life insurance: Term, Universal Life, Whole Life, and Variable life. Only Variable life policies can put cash values at risk to market crashes. Policies goals are typically designed to maximize or balance death benefits, debt relief and/or retirement distributions. Universal Life, Indexed Universal Life and Whole life can guarantee Principal safety & accumulated interest being locked-in MONTHLY. UL, IUL and WL also allow for tax deferred loans up to about 95% of their surrender value. Loans are available without penalty prior to age 59.5, and are pre-planned to remain IRS compliant and generally enjoy tax preferred spending (taken as loans againstt the Surrender Value). All loans are repaid after death with tax free death benefits while the policy remains IRS compliant. Because policy loans do NOT reduce Cash Value, the insured enjoys spending up to his policy Surrender Value in retirement, while still earning interest on the same values spent (taken as loans) for life. IUL, UL and Whole life never place an insured's cash value in the market, and have historically outperformed indexed investments exposed to market-crash risk. Our opinion is these policies generally offer exceptional "tax preferred" retirement benefits without market crash risk, WITH interest guarantees.
Life Settlements
A term referring to the business of buying and selling life insurance policies. It can also be used interchangeably with the process of determining a market value for a given life insurance policy, or portfolio of policies being purchased by investors.
List Bill
An invoice for INDIVIDUAL medical insurance sent and paid by an employer, but that is funded by an employee. It is not Group insurance.
Local Coverage Determination (LCD)
An ICD-10 term used to classify and charge for care.
Locum Tenens
A physician who is typically employed under contract for a period of under one year, and while a permanent physician employee is being sought to fill a position. locum tenens physicians are routinely used for several types of hospital based physician (ER, Pathology, Radiology, Anesthesiology) functions.

Long Term Care (LTC)
A policy that insures Activities of Daily Life that are considered “custodial, and excluded under typical medical insurance policies. see:
Long Term Care Insurance
An insurance policy triggered by a member’s inability to perform 2 or more activities of daily life (ADL). ADL’s can include: bathing, shopping, transporting, toileting, check writing, cleaning, cooking, housework, banking, etc. These are explicitly defined in long term care policies. Long term care is considered custodial and not acute care, and is not insured by most major medical or Medicare plans beyond the period defined in the policy for rehabilitation. Coverage is generally of two types: lump sum to spend as needed, or lump budget doled out by a daily limit schedule (i.e. $250 per day up to $150,000 limit).
Long Term Care Quality Public Reporting (LTCH QPR)
See Instructions here first:

Long-term and Post-acute Care (LTPAC)
Loss Conversion Factor (LCF)
A multiple or factor used to assign good or bad experience when rating premiums typically used in rating workers compensation, premium. NCCI manages major responsibility for overseeing application of retrospective rating. Application of LCF and retrospective ratings can become central to charged premium disputes.


Major Contributing Cause (MCC)
A term used to determine potential compensability (eligibility) of a medical claim insured under workers compensation. The term addresses a determination of a medical claim being 51% or more caused by the job related injury event, and not from an uninsured preexisting medical condition. IME's and EMA's can be used to determine if treatment is appropriate. See IME, EMA, SA, MMI. These determinations are subject to contentious debate.
Major Extended Diagnostic Groups (MEDC)
A five tier method of categorizing patients from basic to complex medical conditions.
Managing General Underwriter (MGU)
A Managing General Underwriter (MGU), sometimes called an MGA -- Managing General Agent, is an independent facility authorized by a carrier to rate, bind and issue policies. MGU's are legally bound to represent the best interests of their sponsoring carrier. They typically share in contingency fees and overrides on profitable business. MiniMed or Limited Medical Insurance Plans
Mandated Quality Reporting
ACA promulgated Federal Government position as umpire regarding Evidence Based Medicine (EBM) to certify efficacy of care standards for given alleged treatments. Carriers and self funded employers are charged a tax each year to fund NQOI management.
Mandatory Benefits
Minimum insurance benefits allowed in an insurance policy that are required by statute for compliance. EHB are an example of ACA mandated benefits.
Manual Rate aka Book Rate
A schedule of rates typically created by actuaries that are filed and approved by state as required by each state. Underwriters use these "maximized" rating schedule(s) to rate individual opportunities for insurance. Sometimes underwriters refer to the "discounted" and underwritten rate at Book Rate". Sometimes underwriters refer to underwritten rate (s) as "Book to Manual" (BTM).
Marketplace Learning Management System (MLMS)
Federally managed continuing education courses and certification for (licensed agents, and unlicensed Navigators)agents selling ACA compliant tax credited plans.
Marketplace Open Enrollment Period Noticies (MOENs)
Maximum Medical Improvement (MMI)
Term used in workers compensation to represent an injured worker's maximum recovery/medical state and expence for purposes of settling the medical claim payout. Generally, the file is closed after final medical bills are paid.
Maximum Out Of Pocket (MOOP)
The maximum limit an insured pays before their medical plan insured 100% for eligible medical care. Deductibles, Co insurance and copay amounts typically attribute to MOOP. ACA regulations set MOOP each year. See Balance Billing.
Maximum Per Diem
This term is used to convey the maximum reimbursement of hospital charges a policy holder will recover each day. It is a figure compared to the average cost per day derived by dividing the total charges by the length of stay. Almost all HMO reinsurance and PEL policies have this provision that can tend to reduce coverage.
Meaningful Access
ACA "Meaningful Access" Time Line September 13, 2016 Return to page Print This Section 1557 of the Affordable Care Act (ACA) applies to protected classes of individuals whose health coverage may not be denied, cancelled, limited or refused on the basis of race, color, national origin, sex, age, or disability and it builds on other federal civil rights laws to do so. The rule was effective July 18, 2016, with a couple of exceptions. •First, provisions that require changes in health insurance or group health benefits design are applicable on the first day of the plan or policy year beginning on or after January 1, 2017. •Second, portions of the law that address meaningful access for persons with limited English proficiency are effective beginning on Oct. 16, 2016. Overview The law is broad and will affect health insurance issuers and employers that receive federal financial assistance from Health and Human Services (HHS). One part of the law provides expanded protection for transgender individuals, which we covered in the July Broker Connection. The other parts cover meaningful access regulations that address the following requirements. Access to Language Assistance Covered entities must provide language assistance services free of charge, and the services must be accurate, timely, and protect the privacy of an individual with limited English Proficiency. Language assistance includes interpretation (oral) and translation (written). Covered entities must offer a qualified interpreter to an individual with limited English proficiency free of charge and use a qualified translator when translating written content in paper or electronic forms. Access to Auxiliary Aids and Services The Final Rule also requires covered entities to make communications with individuals with disabilities as effective as communications with others, including the use of appropriate auxiliary aids and services to persons with impaired sensory, manual, or speaking skills. Assess to Electronic and Information Technology Covered entities must ensure their health programs or activities provided through electronic and information technology are accessible to individuals with disabilities. This includes technology used by individuals on portals and mobile phone applications. The disabilities contemplated in the final rule include vision, hearing or sensory impairments, such as a person who in unable to use a mouse or keyboard. Distribution of Nondiscrimination Notice and Taglines Covered entities must take appropriate initial and continuing steps to notify beneficiaries, enrollees, applicants, and members of the public: 1.That the covered entity does not discriminate on the basis of race, color, national origin, sex, age, or disability in its health programs or activities; 2.How to request assistance in another language or format and that these services are free of charge; 3.How to file a discrimination complaint and get assistance; 4.How to file a discrimination complaint with OCR. This “non-discrimination notice” is required to be included for all significant communications sent by the covered entity whether written, electronic or both. Covered entities must also post the non-discrimination notice and taglines to alert individuals that language assistance services are available. •The regulations uses a state threshold, requiring covered entities, generally, to post taglines in at least the top 15 non-English languages spoken in the state in which the entity is located or does business. •Covered entities that serve individuals in more than one state can aggregate the top languages to determine the top 15, or for small sized communications such as postcards or tri-fold brochures, to the top two languages. Languages are determined by census data. Assurances A covered entity must submit an assurance on a form specified by the Director of the Office of Civil Rights of HHS that its health programs and activities will be operated in compliance with Section 1557. Access to Buildings and Facilities Each facility or part of a facility in which health programs or activities are conducted that is constructed or altered by or on behalf of, or for the use of, a recipient, must comply with the 2010 Americans with Disabilities Act (ADA) standards for accessible design if the construction or alteration was commenced on or after July 18, 2016. There are exceptions related to facilities that depend on the date of building construction and compliance with ADA standards. Requirements are limited to the public facing areas of entities. Oversight and Grievance Procedures Each covered entity that employs 15 or more persons has to: •Designate at least one employee to coordinate its efforts to comply with and carry out its responsibilities, including the investigation of any grievance alleging noncompliance with Section 1557. •Adopt grievance procedures that incorporate appro
Meaningful Use
A term used by CMS to reduce Hospital Medicare reimbursement in 2018, based upon CMS conclusion if Hospitals have used Electronic Health Record (EHR) data to improve outcomes, lower cost or both. The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). MIPS has replaced three Medicare reporting programs: • EHR Incentive Program (Meaningful Use) • Physician Quality Reporting System • Value-Based Payment Modifier The Quality Payment Program listserv will provide news and updates on: • New resources and website updates • Upcoming milestones and deadlines • CMS trainings and webinars The Quality Payment Program’s first performance period began on January 1, 2017 and ends on December 31, 2017. Participation in MIPS can start as early as January 1, 2017 or as late as October 2, 2017. The first payment adjustments based on performance go into effect on January 1, 2019.
Meaningful Use ( re: MACRA) (MU)
See MACRA One of two payment options Physicians accepting Medicare Part B patients will choose to be reimbursed. MIPS uses MU, PQRS and VM to score performance across four areas and modifies Part B reimbursement. APMs use two-sided risk-based payment inclusive of Next Generation ACO, and Comprehensive Primary Care Plus (CPC+) value to adjust reimbursement and potential bonus for meeting guidelines.

http://See MACRA

A state health insurance program for people earning under 100% of FPL, and eligible for Medicaid. Medicaid is different in each state. Medicaid can have about 15 categories of eligible people, and coverage. Typically, the federal government gives 50% of a state’s Medicaid budget. Under ACA, Medicaid eligibility was expanded from 100% to 133% of FPL for eligibility in states electing to expand Medicaid eligibility. 13 states elected not to expand Medicaid under ACA
Medicaid Expansion
A voluntary state expansion of Medicaid eligibility offered under ACA by the Federal Government for three years. The provision allows poor people access to free or less expensive Medicaid insurance by increasing income cut-off eligibility from 100% to 138% of FPL.
A program that the Supreme Court allowed individual (13) states to opt out, despite the federal government funding the first three years of added cost. Under the Affordable Care Act, states have the option to expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household MAGI at or below 138% of the FPL. This is known as "Medicaid expansion."
However, some states have chosen not to expand Medicaid eligibility. Regardless of whether a state chooses to expand its Medicaid eligibility, all state Medicaid programs:
  • Use MAGI as the income methodology for the majority of applicants (generally, all non-elderly, non- disabled populations)
  • Do not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI
  • Streamline income-based rules, systems, and verification procedures (Source
Medical Loss Ratio (MLR)
Medical Loss Ratio is typically defined as Total Premiums/Total claims. ACA mandates premium rebates to Individuals where claims are less than 80%/85% for Individual/GROUP (employer) of paid premium.

Medical Savings Account (MSA)
A federally authorized medical savings account funded by INDIVIDUALS with pre-tax income to pay eligible medical expenses. Funds are typically used to pay eligible deductibles, co insurance and max out of pocket costs. See: HSA and HRA MSA can also refer to the Medicare Set-Aside program offered by CMS and related to workers compensation insurance. " Guide-Version-2_6.pdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
A bipartisan bill signed in 2015 that stopped the automatic 21% discount of Medicare reimbursements, and replaced it with value based reimbursements. See: MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment QPP does not change hospital or Medicaid MU. Medicaid MU participants who also bill Medicare will need to participate in both Medicaid MU (through 2021) and MIPS. (Source: Athenahealth) MACRA bonuses (Medicare Part B)physicians up to 4% in 2017 and up to 9% by 2022 for "performance" based on meeting or exceeding quality metrics IF same physicians submitted the annual quality metrics. Unresponsive physicians get penalized up to same percentages of the "at risk portion of their Medicare reimbursement" for procedures. MIPS offers essentially four avenues to entice physician engagement. Submitting nothing in the MIPS program means reimbursements go down (-4% in 2018), or do not get annual increases, or "bonus" assigned to Medicare Part B by meeting or exceeding "quality measures" being defined now. ********************* CIGNA Agent Advisory 1. What is the Medicare Access and CHIP Reauthorization Act of 2015? (MACRA) MACRA has many components, one of which is a limit on first dollar coverage in certain Medicare supplement insurance plans for individuals considered “newly eligible” and a transition away from using Social Security numbers as identifiers. It also includes a change to the way Medicare pays healthcare professionals. Currently, healthcare professionals are paid based on the number of services they perform. MACRA allows for healthcare professionals to be compensated on quality of care as opposed to the number of services they perform. 2. Who is considered newly eligible? “Newly eligible” is defined as anyone who is turning 65 on or after January 1, 2020 or anyone who is eligible for Medicare benefits due to age or disability as defined by the Centers for Medicare and Medicaid Services (CMS) on or after January 1, 2020. 3. What does MACRA require? As of January 1, 2020 MACRA does the following:  Prohibits first dollar Part B deductible coverage on Medicare Supplement so Plans C and F cannot be sold to those “newly eligible” for Medicare.  Makes Plans D and G the new guaranteed issue plans for those who are “newly eligible” within the guaranteed acceptance rules for Medicare Supplement plans.  Mandates that a Social Security Number can no longer be used as an identifier. 4. How are enrollees in current Plans C and F affected? No change. Plans C and F can still be sold after January 1, 2020 BUT only to Medicare beneficiaries who were age 65 PRIOR to 1/1/2020 or first became eligible for Medicare PRIOR to 1/1/2020 regardless of what plan they had previously.  Plans C and F are NOT going away. Current policyholders can continue with their Plan C or Plan F and may continue to buy Plans C and F beyond January 1, 2020. Example: A customer who bought Plan F (or any other plan) in 2018 can purchase any plan, including C and F, prior to January 1, 2020 or thereafter. 5. What will the new Medicare card design be? MACRA mandates the removal of Social Security Number (SSN) based Health Insurance Claim Number (HICN) from Medicare Cards to address the risk of beneficiary medical identity theft and fraud.  New numbers are unique and randomly assigned  The new number will be referred to as the Medicare Beneficiary Identifier Number (MBI)  Beginning April 2018 new cards will be issued and will continue through April 2019.  Review the new Medicare card design and press release to learn more.

Medicare Advantage (MA)
HMO and PPO plans offered by commercial carriers, but paid for by the HHS to people over 65 years of age. Unlike Medicare Supplemental plans, MA plans mandate in-network provider access to reduce or eliminate out of pocket costs. See MAPB
Medicare Advantage Pharmacy Benefit (MAPB)
Pharmacy Plans attached to MA plans.
Medicare Beneficiary Identifier (MBI)
CMS announced a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. The new cards will use a unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI), to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card. CMS will begin mailing new cards in April 2018 and will meet the congressional deadline for replacing all Medicare cards by April 2019. Work on this important initiative began many years ago, and was accelerated following passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). (Source: CMS)
Medicare Diabetes Prevention Program (MDPP)
On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) proposed rule that would make additional proposals to implement the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The MDPP expanded model was announced in early 2016, when it was determined that the Diabetes Prevention Program (DPP) model test through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards met the statutory criteria for expansion. Through expansion of this model test, more Medicare beneficiaries will be able to access evidence-based diabetes prevention services, potentially resulting in a lowered rate of progression to type 2 diabetes, improved health, and reduced costs.

Medicare Disproportionate Share (MDS)
CMS programs to help guarantee rural hospital access to Medicare and Medicaid lives. Medicare Disproportionate Share Hospital (DSH) Payment Adjustment, Medicare-Dependent Small Rural Hospital (MDH) Program, and Low-Volume Hospital Payment Adjustment Issues.
Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)
Health Outcomes After Bariatric Surgical Therapies in the Medicare Population Posted materials for meeting.

Medicare Evidence Development & Coverage Advisory Committee MEDCAC (MEDCAC)
HHS supervised EBM umpire of sorts
Medicare Fee for Service Regulations (PFFS)

Medicare Outpatient Observation Notice (MOON)
See CDI, and QIO Physician Advisor used term to help improve medical outcomes and reimbursements for Medicare eligible patients. The goal here is to improve medical outcomes, efficacy of care, and reimbursements. The key is efficiently giving treating physicians well supported information that benefits the patient, and timely reduces administrative burdens.
Medicare Part A
A federal entitlement to eligible Medicare beneficiaries that insures up to 150 days of acute-inpatient-hospital care (plus 20 days), and also outpatient hospital care. Up to 100 days of Skilled nursing facility are covered for qualifying care. Medicare Part A does not insure Long term (custodial ) Care.
Medicare Part B (Part B)
A Federal medical insurance premium deducted monthly from social security, and that insures physician charges. A federal entitlement insurance available to people over 65 years of age who are eligible (paid FICA tax for 40 quarters over their lifetime) for Medicare Part A (Hospital insurance insuring 150+ days per lifetime). Part B premiums: Medicare Part B pays for doctor visits and other outpatient services. • If you are on Medicare but not yet collecting Social Security benefits, your Part B monthly premium is expected to hold steady at $134. • If you are collecting Social Security, which automatically pays your Part B premium, you’re paying about $109 a month in 2017 because of a law that prevents Medicare premiums from lowering Social Security payments. That amount could change for 2018 depending on how the 2 percent Social Security cost-of-living adjustment (COLA) affects your individual monthly payment. Eligible persons wishing to elect a low cost Medicare Advantage (HMO/PPO plans insuring Hospital, Physician, and typically Rx coverage (from "participating" physicians and hospitals) must first enroll in part B, and pay the additional premium each month. Pharmacy plans may also need to be purchased at additional charge as well, depending on if the carrier includes the MA-PD in the plan or not.

Medicare Part C
Legislation enacted to offer HMO & PPO options to Medicare eligible people. The law also details PSO's or Provider Services Organizations designed to engage physicians into deliver care within several types of reimbursement scenarios.
Medicare Part D (MA-PD)
Medicare Part D Medicare Part D offers optional prescription drug benefits for those entitled to Medicare Part A and Part B. Eligible individuals can obtain Medicare Part D coverage from either a stand-alone prescription drug plan or through Medicare Advantage (Part C) plans that include prescription drug coverage. Prescription drug (Part D) premiums dip: These monthly charges are expected to decline slightly to an average of $33.50, compared with $34.70 a month in 2017. This premium decline will be the first for Part D since 2012. Premiums vary by where you live and what plan you select. Make sure your current plan still covers all your medications — and explore the cost. Part D coverage gap narrows: Once the total cost of your prescriptions reaches a certain threshold — set each year by the federal government — you pay more for your prescriptions. That’s because of a quirky aspect of Part D called the coverage gap, also known as the doughnut hole. For 2018, once you have incurred $3,750 worth of drug costs, you’ll be in the coverage gap. At that point, you’ll pay 35 percent of the cost of brand-name drugs and 44 percent of generics. You’ll continue to pay those prices until the total cost of your drugs reaches $5,000. Once you’ve hit that limit, you’ll no longer be in the doughnut hole and you’ll pay no more than 5 percent of your drug costs for the rest of the year. The doughnut hole has been narrowing each year since the Affordable Care Act was passed in 2010. The gap will close in 2020, and beneficiaries will pay 25 percent of the cost of all their prescriptions. High-income surcharges: Medicare beneficiaries with incomes at a certain level pay higher Part B and D premiums. What’s different for 2018 is that more people will be subject to these surcharges because the income thresholds have changed. For 2018, if you are an individual earning $133,500 a year or a couple earning $267,000 a year, your premiums will increase. You can find the complete chart of the surcharges at (Source AARP)
Medicare Set Aside (MSA)
In contexts to workers compensation claim and the total estimated medical expense to establish maxium medical improvement (MMI), of a Medicare eligible injured worker (IW), it is the amount NOT paid directly to the worker available to pay medical bills. This is done to avoid workers pocketing the cash, and not paying the medical providers, exposing Medicare to the liability.
Medicare Shared Savings Program (MSSP)
A contract offered by the federal government that shares savings from the successful management of Medicare or Medicaid members with physicians and or hospitals who are able to manage care under the expected budget for that population. These contracts are typically over a three year term. See ACO contract. See:

Medicare-Medicaid Coordination Office ((MMCO) )
Member Shared Responsibility Amount (MSRA)
A nonstandard term to describe out of pocket costs of a medical plan that may, or may not be ACA compliant.
Merrit Based Incentive Payment System (MIPS)

The successor to meaningful use, known as Advancing Care Information. See MU, PQRD, & VM The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). MIPS has replaced three Medicare reporting programs: • EHR Incentive Program (Meaningful Use) • Physician Quality Reporting System • Value-Based Payment Modifier The Quality Payment Program listserv will provide news and updates on: • New resources and website updates • Upcoming milestones and deadlines • CMS trainings and webinars The Quality Payment Program’s first performance period began on January 1, 2017 and ends on December 31, 2017. Participation in MIPS can start as early as January 1, 2017 or as late as October 2, 2017. The first payment adjustments based on performance go into effect on January 1, 2019. Under MIPS, providers have to report a range of performance metrics and then have their payment amount adjusted based on their performance. Under Advanced APMs, providers take on financial risk to earn the Advanced APM incentive payment. See: MU, PQRS, VM, CPC+, QPP, & Bundled Payment QPP does not change hospital or Medicaid MU. Medicaid MU participants who also bill Medicare will need to participate in both Medicaid MU (through 2021) and MIPS. (Source: Athenahealth)


see eCQM

MiniMed or Limited Medical Insurance Plans
MiniMed is non ACA compliant insurance offering a limited medical benefit typically under $50,000 a year. It typically limits hospital, pharmacy, surgical and physician charges to a maximum amount or per diem. Vision, Mental, Dental and Pharmacy benefits may be included within the insured benefit schedule, or as a discounted network access benefit or feature. The program is generally purchased by groups unable to afford traditional major medical insurance.
Minimum Premium plans

See Level Funding

Minimum Savings Rate (MSR)
MSR is the percentage of claims saved under an ACO Shared Savings contract period (typically three years), and is used to convey how efficient and effective medical care was delivered under budget, MSR denotes a Shared Savings provider bonus. See MSSP.
Modified Endowement Contract (MEC)
A modified endowment contract is a life insurance contract entered into on or after June 21, 1988, that fails to meet the seven-pay test. Meaning the cumulative premiums paid into the policy during the first seven years exceed the amount needed to produce a paid-up policy based on seven net level annual premiums. If the policy is considered a modified endowment contract, FIFO tax treatment is forfeited, and last in, first out (LIFO) tax treatment takes its place—causing withdrawals to be taxed on an income-first basis. Meaning that if you plan to borrow funds from life insurance surrender values in retirement, any loans must remain in compliance with what IRS considers legitimate life insurance contracts. IRS uses two primary tests to determine if a policy is, or is not life insurance.
Most Favored Nations
A Most Favored Nations clause in a managed care contract guarantees that the lowest charge master will be used when filing claims.
Multiple Employer Welfare Association (MEWA)
A MEWA is a Multiple Employer Welfare Association. It is a protected class of health insurance regulated by the Department of Labor under ERISA that provides various exemption from state insurance regulation. Practically speaking, most states despise MEWA’s and will legally challenge them regardless of ERISA standing. Of the protected classes ERISA legislation governs: (Associations, Trusts, Self funded Employers and Unions), MEWAs are rare. The over-reaching purpose of self funding any of these organizations is to reduce the cost of providing insurance benefits to employees. Self funded MEWAs offer many small employers a group structure to command greater buying power. But, because each member employer is small, they may not be capitalized to sustain unexpected or unpredictable deductible losses which is one reason states dislike MEWA’s. A Fully Insured Health Plan MEWA may not be federally required to possess a state issued Certificate of Authority. However there is long history of many states aggressively moving to eliminate them unless the MEWA’s reinsurance meets “their” specific coverage standard. Material legal assistance is required to set these up and maintain them successfully within state guidelines despite ERISA exemption.
The purchase of Specific and Aggregate reinsurance is usually required to transfer the majority of risk to an approved insurance carrier. Historically, placement of MEWA stop loss is the hardest part of the program
Multiple Loss Medical Reinsurance
Multiple Loss Medical Reinsurance is a feature found in high deductible employer stop loss policies. It provides additional coverage for medical charges incurred from the same trauma, or within a 50-mile radius, or within a period of 7 days. I.e. On a traditional $500,000 specific policy, the deductible drops from $500,000 to $10,000, and pays a benefit up to $490,000. Coverage is defined in terms of a maximum, minimum and 3 life warrants.


N0-Fault (PIP)
A term typically related to auto insurance that pays the owner of the policy for damages to their vehicle or for medical expenses caused in an accident without assignment of fault. Limits are statutorily assigned at $10,000 per person and $20,000 per accident. These limits pay Primary, and additional limits (if purchased) pay secondarily.
National Association of ACOs (NAACOS)
One of the main federal committees charged with establishing and certifying medical care standards.
National Council on Compensation Insurance (NCCI)
An agency funded by carriers responsible for setting employee Class Codes, and applicable insurance rates charged on payroll. "• NCCI, which serves as the filing agency and rating organization for workers compensation insurance in the majority of states, promulgates a standard workers compensation and employers liability insurance policy (WC 00 00 00 C). The 2015 edition of that policy is in used in all 46 states (and the District of Columbia) that allow private insurers to write workers compensation insurance. (The other four states require all workers compensation insurance to be purchased from a monopolistic state fund.) Most states allow insurers to file their own forms, although few insurers choose to do so. Consequently, almost all workers compensation policies issued in the United States are written on the 2015 NCCI form." (Source Web CE for Florida Agent licensing exam)
National Council on Compensation Insurance (NCCI)
The NCCI is an association funded primarily by insurance companies, that compiles and distributes workers compensation rating, underwriting guidelines and job-typed "Classification" codes used to calculate workers compensation premiums in non-monopolistic states. NCCI collects loss information and calculates "advisory" rates that many Workers Compensation carriers use to bill employers. Because carriers also calculate their own underwritten rates, differences between NCCI calculated losses and carrier calculated losses cause disputes. Reference materials, such as the Basic Manual, Experience Rating Manual, and Scopes for Basic Manual Classifications published by NCCI, and IRMI’s Classification Cross-Reference (i.e. conversions) guide accuracy in determining the basis of premium, the proper classification(s), and other relevant pricing factors.
National Coverage Determiniation (NCD)
In ICD-10 coding term promulgated by a CMS lead group that is used to set medical coding and reimbursement.
National Insurance Producer Registry (NIPR)
Federal Listing of agents tied to NPN administration
National Producer Number (NPN)
Federal ID number assigned to each state licensed agent who sells medical insurance.
National Quality Forum (NQF)
A medical expert forum that publishes maximized clinical practice standards. See HEDIS
NCCI Workers Compensation Statistical Plan Manual (NCCI Stat Manual)
NCCI Workers Compensation Statistical Plan manual governs how the losses are reported to the NCCI and what effect the deductible plan has on the insured’s experience modifier.
Network Adequacy
Federal and or State defined minimum standard for QHP eligibility. "To show that the QHP’s network meets the requirement in §156.230(a)(2), the access plan would need to demonstrate that an issuer has standards and procedures in place to maintain an adequate network consistent with the National Association of Insurance Commissioners’ Health Benefit Plan Network Access and Adequacy Model Act (the Model Act is available at This approach would supersede the time and distance criteria described in the 2018 Letter to Issuers in the Federally-facilitated Marketplaces." (Source HHS) For QHP certification, a plan that uses a provider network must have an adequate provider network available to its enrollees. A QHP must: Offer a network with a sufficient number and types of providers, including mental health and substance abuse disorder providers, to ensure access to all services without unreasonable delay Make a good faith effort to provide written notice of discontinuation of a provider 30 days prior to the effective date of the change or otherwise as soon as practicable to enrollees who are patients seen on a regular basis by or who receive primary care from a discontinued provider and, if the provider is terminated without cause, allow an enrollee in an active course of treatment with that provider to continue treatment until it is complete or for 90 days, whichever is shorter, at in-network cost-sharing rates Include a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income and medically underserved populations in the QHP’s service area. Source MLN Training/Certification Exam.

Next Generation ACO
The Next Generation ACO Model is a healthcare delivery and payment model created by the CMS Innovation Center. The goal of the Next Generation ACO Model is to test whether strong financial incentives for ACOs can improve health outcomes and lower expenditures for Original Medicare fee-for-service beneficiaries. Additionally, it allows participating providers to assume higher levels of financial risk and reward than are available under the Shared Savings Program or were offered in the Pioneer ACO Model. The Next Generation ACO Model previously accepted organizations into the initiative for January 2016 and 2017 start dates. As of January 2017, there are a total of 45 Next Generation ACOs all over the nation—from Los Angeles, California to Boston, Massachusetts. (source CMS)
Non Public Personal Information (NPPI)
Nursing Home Quality Measures (NHQM)
See related measures 16 Quality Measures


Office of the National Coordinator for Health Information Technology (ONC)
A federal office whosepurpose is to refine data collection and disbursement into more effective information public delivery.
Open Access
A type of medical insurance plan offering access to specialty physician care without the requirement of a primary care physician referral. Plans requiring referral from a primary care provider to access specialty care are called Gatekeeper plans.
Out of Pocket Maximum (OOP)
An Out of Pocket Maximum (OOP) is the annual total liability an individual, or family must pay before the plan pays 100% of all medical charges, including the deductible. Premium is not part of OOP.


An informal term used to describe a licensed or Certificate holding “admitted” carrier in a particular state or country. These carriers are both eligible and authorized in states. Surplus lines carriers are eligible, but not authorized to conduct insurance business in a state.
Patient Activation Measure (PAM)
A term used to describe a method of gathering more individual medical history to augment better care.
Patient Centered Medical Home (PCMH)
A term used to describe a team approach to primary care medical management, and centering on primary care coordination with specialty and hospital care.
Patient Centered Outcomes Research (PCQOR)
Patient Centered Outcomes Research

Patient Protection Affordable Care Act (ACA / PPACA / Obama Care)

The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA or Obama Care. The ACA (Affordable Care Act) is a 900+ page law encompassing all medical care in the US, but with very limited application to Veterans affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 Essential Healthcare Benefits (EHB) without annual benefit limits, tax credits for individuals earning below 400% of Federal Poverty Level (FPL), and Cost Sharing for people earning between 100%-250% FPL. Federal Cost Sharing Reductions (CSR) have been retroactively denied to carriers already committed, and are in litigation today to resolve. Cost sharing reductionns lower deductibles and max-out-of-pocket member costs, thereby limiting total annual member health spend from (about) 2% to 9.66% AGI/MAGI.  January 2017, the Trump administration denied "risk corridor" (reinsurance recovery safety-net payments to carriers) retroactively as well, thereby causing immediate (alledged $8 BILLION damages) suite by the carriers involved against the federal government. HR1 (Tax Reform law) was passed December 2017, and eliminates the Individual ACA law mandate (2.5% tax penalty), effective plan year 2019.  ACA law is not repealed. 

Small employers are now offered tax credited plans through SHOP with employer available tax credits for years 1 and 2 of the plan offering. Similar to Medicare Advantage plans, Individual and Small Group Insurance is provided by commercial carriers, not the government.  As a rule the SHOP program has failed, and few plans are even offered by carriers in 2018. 


See: H.R. 1




PDM (Periodic Data Matching )
See Advance Payment Tax Credit
PEO Guidelines (NAID PEO Guidelines)
NAIC adopted Guidelines, Regulations and Legislation on Workers’ Compensation Coverage for Professional Employer Organization Arrangements.
Per Admission Deductible (PAD)
An out of pocket cost to an insured member admitted to a hospital for an inpatient stay. These costs are typically in addition to annual plan deductibles, and are subject to maximum out of pocket maximum stated in the policy.
Per Diem Contracts
Per Diem Contracts are contracts reimbursing hospitals a flat amount per day for specified hospital services. Per Diems are common stop loss and reinsurance coverage limitations consisting of average daily maximum allowable amount per day. Per diem contracts can also be vender related pricing sold to various self funded employers or carriers offering insurance in an area.
Per Diem Maximum
A Per Diem Maximum is typically an in-patient hospital coverage in a stop loss or reinsurance contract limiting the carrier's exposure per day for eligible charges. It is generally required in all Provider Excess and HMO reinsurance policies. Special care should be taken to understand how large claims incurred within a small number of days are affected. Expressed as either a Maximum Daily Limit or Average Maximum Daily Limit, this coverage usually reduces the total eligible hospital charges reimbursable in the policy. The Average Daily Maximum Limit is richer coverage and should be sought.
Per Visit Deductible (PVD)
A term used to describe an out of pocket cost to the insured member receiving care at an outpatient medical facility.
Personal Injury Protection (PIP)
A complex law governing auto insurance liability, and providing PRIMARY coverage response for property or medical claims without assignment of fault. I.e. each party gets paid by his own policy up to $10,000 per person, and $20,000 per accident. i.e. "No-Fault insurance". Legal remedy may also be available where damage are severe and/or excess of the $10,000 per person limit. No-Fault insurance is designed to reduce court congestion on low dollar claims.
Personally Identifiable Information (PII)

Personal Information as defined by HHS within non FFM agency contract: APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant Social Security Number Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant CHIP eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant CSR eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Issuer Member ID Net premium amount Premium Amount, start and end dates Credit or Debit Card Number, Name on Card Checking account and routing number Special enrollment period reason Subscriber Indicator and relationship to subscriber Tobacco use indicator and last date of tobacco use Custodial parent Health coverage American Indian/Alaska Native status and name of tribe Marital status Race/ethnicity Requesting financial assistance Responsible person Applicant/Employee/dependent sex name Student status Subscriber indicator and relationship to subscriber Total individual responsibility amount See HIPPA for uncertainty.

Pharmacy Benefit Manager (PBM)
A Pharmacy Benefit Manager is a company specializing in the administration of commercial, Medicare, Medicaid and/or Workers Compensation pharmacy benefits. A PBM may also be a specialized entity in high dollar Rx such as factor agents for hemophiliacs, cancer infusion, dietary feeding, and an array of infusion therapies.
Physician Compare Downloadable Database
CMS downloadable database for individual eligible professionals (EPs) - means everyone does not have access to it. In addition to the recently released quality data, the Physician Compare Downloadable Database also includes demographic information and Medicare quality program participation for individual EPs, which is updated every two weeks.
Physician Compare website
A CMS generated physician cost and quality comparison website for public access.


Physician Compensation 2017
Source: Medscape

Medscape report

Physician Fee Schedule (PFS)
CMS term used when discussing proposed Medicare Part B QPP related matters.
Physician Hospital Organizations (PHO)
Physician Hospital Organizations (PHO) are physician and hospital joint ventures typically organized to attract members from HMOs and self-insured employers. Many PHO’s become employed doctor practices acquired by hospitals or larger multispecialty groups.
Physician Incentive Plan Guidelines
These are federal mandates requiring physician groups with less than 25,000 capitated members to purchase (PEL) stop loss.
Physician Quality Reporting System (PQRS)
See QPP, MIPS, etc 2018 Physician Quality Reporting System (PQRS) Downward Payment Adjustment Notification The Centers for Medicare & Medicaid Services (CMS) will soon begin distributing letters to Physician Quality Reporting System (PQRS) individual eligible professionals (EPs), EPs providing services at a Critical Access Hospital (CAH) billing under method II, and group practices regarding the 2018 PQRS downward payment adjustment. The letter indicates that the recipient did not satisfactorily report 2016 PQRS quality measures in order to avoid the 2018 PQRS downward payment adjustment and, therefore, all of their 2018 Medicare Part B Physician Fee Schedule (PFS) payments will be subject to a 2.0% reduction. The 2018 PQRS payment adjustment letter being sent to individual EPs includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination; the adjustment applies only to the individual EP associated with the TIN/NPI noted within the letter and not the clinic or facility. The 2018 PQRS payment adjustment letters being sent to PQRS group practices include a TIN only and applies to all EPs who have reassigned their billing rights to the TIN. Please check your letter in the upper left-hand corner to determine if it contains your TIN or TIN/NPI. For the 2016 reporting period, the majority of EPs successfully reported to PQRS and avoided the downward payment adjustment CMS anticipates that successful trend to continue under the new Quality Payment Program. The Quality Payment Program began January 2017 and replaces PQRS, the Value Modifier program, as well as the separate payment adjustments under the Medicare Electronic Health Record (EHR) Incentive Program. The Quality Payment Program streamlines these legacy programs, reduces quality reporting requirements and has many flexibilities that allow eligible clinicians to pick their pace for participating in the first year. To prepare for success in the Quality Payment Program we encourage EPs to review your PQRS feedback report, Annual Quality and Resource Use Report (QRUR) and visit to learn about the Quality Payment Program. If I received the payment adjustment letter, what are my options? If you believe that the 2018 PQRS downward payment adjustment is being applied in error, you can submit an informal review request within 60 days of the September release date of the 2016 PQRS feedback reports. Informal review closes on at 8:00 p.m. Eastern Standard Time on the 60th day from report release. We will notify EPs of the report release via listserv including information on how, where and by what date they need to submit an informal review, if they so choose. CMS will investigate the merits of your informal review request and issue a decision within 90 days of receipt. All informal review requests must be submitted via a web-based tool on the Quality Reporting Communication Support Page. PQRS informal review decisions which result in the removal of groups or individual EPs from the PQRS downward payment adjustment file may also result in a change to their automatic downward payment adjustments under the Value Modifier program. For PQRS decisions that result in changes to the Value Modifier payment adjustments, groups and solo practitioners will automatically have their 2018 Value Modifier automatic downward payment adjustments adjusted. For more information about the 2018 Value Modifier and how to submit an informal review request for it, please visit 2016 QRUR and 2018 Value Modifier website. EPs are encouraged to access and review their 2016 PQRS feedback reports and 2016 Annual QRURs prior to submitting an informal review request. The 2016 Annual QRUR provides information about the 2018 Value Modifier payment adjustment for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists billing under your TIN. CMS will announce the availability of the 2016 PQRS feedback reports and 2016 Annual QRURs via the Medicare Learning Network (MLN) Connects Provider eNews, PQRS listserv, and other CMS-related listservs. CMS would also like you to know that there are no hardship exemptions for the PQRS downward payment adjustment. The 2016 PQRS program year began January 1, 2016. Reporting during 2016 impacts any 2018 PQRS payment adjustment you may receive. Please visit the PQRS webpage for complete information on how you could have participated in 2016 to avoid the 2018 downward payment adjustment. Additional Resources • For details regarding the 2018 PQRS downward payment adjustment, please see the PQRS Payment Adjustment Information webpage. • For more information regarding the Quality Payment program, please visit the Quality Payment Program website. • For information regarding other Medicare physician quality programs that apply payment adjustments, please see the 2016 QRUR and 2018 Value Modifier website and/or the EHR Incentive Program web

Point Of Service Plan (POS)
A Point Of Service (POS) Plan is a program of commercial or Medicare health insurance which offers the customer two options of how they can receive care-in-network and/or out-of- network plan care. In-plan care allows members to save 30-40 percent of out-of-pocket expenses when they receive care from a provider within the panel of contracted providers. Point of service plans are designed to provide members greater choice of medical provider selection. POS plans typically insure out of network care, and are not the same as HMO, EPO, or “National Network” offered plans.
Population Health Management (PHM)

A term with roots in disease management (DM) related historically to managing hospital admissions and readmissions from the same diagnosis or DRG. Population Health today typically refers to medical encounter data screened by medical diagnosis with a goal to improving medical outcomes at lower cost.  Contentious debate surrounds what is effective medical care versus revenue maximizing medical provider behavior.  Despite the rhetoric, many useful desease state managemetn medical protocols have, or are being established.  Getting rank and file physicians to donate time to established refereed EBM care remains extremely challenged where the outcomes compete with revenue generation, or a perception of "cookbook" medicine.


Commonly sited population health measures include management of: Cardiac conditions, Hyper tension, Diabeties, prenatal care, Asthma, obesity, knee replacements, lower back pain, etc...


ACA structures federal position and referee to mandate clinical data submission (HIPPA compliant).  2018 is designated first year of penalizing non compliant physicians who choose not to participate, thereby resulting in Medicare Part B reimbursement reductions.

Portfolio Aggregate Reinsurance
Portfolio Aggregate Reinsurance is coverage that responds when the expected claims value on a book or "portfolio" of coverage exceeds a specified percentage above the Expected claim value, typically between15%-25%. It is a layer of protection to the primary insurer for a catastrophic year on a specific block of business intended to cap the maximum probable loss on a book of business. Coverage typically responds at 115%-125% of the expected claims value.
Predictive Modeling
A statistical method used to analyze data sets of targeted high cost medical procedures and/or conditions, and whose goal is to identify and treat conditions prior to onset of severe illness attack. Many "population based management" (i.e. Disease Management) approaches have been used over the years - with many falling short of accurately producing cost savings or better medical outcomes.
Preexisting Medical Condition Medical Plan (PCIP Plan)
A now defunct GOVERNMENT plan that was created in the first days of ACA that allowed sick people to enroll in insurance prior to federal exchange and state marketplace enrollment availability. The plan was eliminated with the Federal marketplace was established. Key is its cost data derived whish is cited with ambiguous new Trump ACA replacement initiatives centered on giving block grants to states to prevent the un-insurability problem (at any price of premium) public protections fixed by ACA passage. ($32,108 PMPY plus administrative/sales costs per CCIIO in 2013)

Prepaid Health Plans (PHP)
Prepaid Health Plans (PHP) sometimes referred to as MPHP's (Medicaid Prepaid Health Plans) or LHSO's (Limited Health Services Organizations), are state-approved organizations which accept a capitation for services rendered to Medicaid members. An LHSO can be just about any special state-authorized entity approved to insure a limited risk, i.e., psychiatry HMO, dental HMO, etc. It is possible to include commercial and or Medicare lives as permitted by law/regulation.
Professional Employer Organizations ( PEO's)
A corporation that derives its income from providing traditional Human Resource services (i.e., employee benefits) to a client employer on an outsourced basis. The PEO corporation may be the same employer, and lease the employees back to itself. The PEO can be a completely separate corporation selling their outsourced HR services to multiple employers in the area too. Less expensive liability and health insurance are typically attributes of "leasing" one's own employees. If the health insurance is to be provided on a partially self funded basis, either an ERISA or MEWA type plan is typically used.
Programs of All-Inclusive Care for the Elderly (PACE)
Programs of All-Inclusive Care for the Elderly (PACE) for new populations, including individuals with physical disabilities, under the authority provided by the PACE Innovation Act. The PACE Innovation Act of 2015 (PIA) provides authority to test application of PACE-like models for additional populations, including populations under the age of 55 and those who do not qualify for a nursing home level of care, under Section 1115A of the Social Security Act.

ProPublica Treatment Tracker
A report made available by CMS of transactional frequencies between fee-for-service Medicare Providers.
Protected Health Information (PHI)
A HIPPA term used to denote confidential medical information.
Provider Maintenance Organization (PMO)
A Provider Maintenance Organization is a state or federally authorized physician and/or hospital owned entity that owns an HMO. These entities typically enjoy a three year period of not having to come up with the minimum state mandated solvency capitalization required of traditionally licensed HMO's. They may also enjoy a start up period requiring lower reserve requirements (i.e. In GA a PHSCC, Federally a PSO).
Provider Reimbursement Review Board (PRRB)
HHS board assigned to regulate and decide issues of medical provider billing rules and regulations. See 73 Fed. Reg. 30190. Recent procedural victory for hospitals alleging underpayment for Medicare outliers. (Meaning they do not have to file a cost report at the time of billing to get more money from the feds.)

Provider Sponsored Organization (PSO)
A Provider Sponsored Organization (PSO) is a federal designation under Medicare Part C - given to physician and/or hospital groups which accept capitation for services rendered to enrolled Medicare members.
Public Health Services Act (PHS)
The Affordable Care Act reorganizes, amends, and adds to the provisions of title XXVII of the Public Health Service Act (PHS Act) relating to group health plans and health insurance issuers in the group and individual markets.
Public Option
The public option is an ongoing progressive movement to create a government health plan that competes directly with commercially provided plans, and that would be available to both individuals and businesses. Medical Provider Reimbursements have been proposed at 100% of Medicare allowable causing little physician support.


Qnet (QNet)
CMS hospital quality reporting program. Federal reporting of hospital quality that will eventually be publically available in meaningful assessable measures people can use to guide their care.

Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
Federal law H.R. 34, the 21st Century Cures law - allowing (qualified small) employers to give individual employees up to $4,950 (pretax - like a section 125 plan HRA group medical and/or ancillary benefit employer paid funding) in reimbursement for INDIVIDUAL (not Group medical) major medical premiums for 2017, and up to $10,000 in reimbursement for family coverage premiums. The intent of the law is to allow employers provide pretax funds to employees to buy INDIVIDUAL insurance on the Marketplace. The problem is that Group plans allow EMPLOYEE enrollment (without Preexisting medical condition exclusion) within 60 days of employee eligibility, and the Marketplace Rules apply to INDIVIDUALS applying during OEP and SEP.

Quality and Resource Use Reports (QRUR)
Quality Clinical Data Registries (QCRD)
Quality Data Model (QDM)

See; eCQM

Quality Improvement Organization (QIO)
The QIO Program is the largest federal program dedicated to improving health and healthcare quality at the local level for Medicare beneficiaries.
Quality Improvement Organization (QIO)
Terms used by "physician advisors" tasked with managing better care with higher reimbursements. See MOON See CDI
Quality Medical Care
The least expensive legally defensible care supported by EBM.
Quality Payment Program (QPP)
The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). MIPS has replaced three Medicare reporting programs: • EHR Incentive Program (Meaningful Use) • Physician Quality Reporting System • Value-Based Payment Modifier The Quality Payment Program listserv will provide news and updates on: • New resources and website updates • Upcoming milestones and deadlines • CMS trainings and webinars The Quality Payment Program’s first performance period began on January 1, 2017 and ends on December 31, 2017. Participation in MIPS can start as early as January 1, 2017 or as late as October 2, 2017. The first payment adjustments based on performance go into effect on January 1, 2019. CMS Finalizes Quality Payment Program Rule for Year 2 to Increase Flexibility and Reduce Burdens Quality Payment Program Year 2 Policies are Gradually Preparing Clinicians for Full Implementation On November 2nd, the Centers for Medicare & Medicaid Services (CMS) issued the final rule with comment for the second year of the Quality Payment Program (calendar year 2018), as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as well as an interim final rule with comment. CMS listened to feedback from the health care community and used it to inform policy making. As a result, the Year 2 final rule continues many of the flexibilities included in the transition year, while also preparing clinicians for a more robust program in Year 3 CMS wants to ensure that the program consists of meaningful measurement while minimizing burden, improving coordination of care, and supporting a pathway to participation in Advanced Alternative Payment Models (APMs). Year 2 Final Rule Highlights We’ve finalized policies for Year 2 of the Quality Payment Program to further reduce your burden and give you more ways to participate successfully. We are keeping many of our transition year policies and making some minor changes. Major highlights include: • Weighting the MIPS Cost performance category to 10% of your total MIPS final score, and the Quality performance category to 50%. • Raising the MIPS performance threshold to 15 points in Year 2 (from 3 points in the transition year). • Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT. • Awarding up to 5 bonus points on your MIPS final score for treatment of complex patients. • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey and Maria and other natural disasters. • Adding 5 bonus points to the MIPS final scores of small practices. • Adding Virtual Groups as a participation option for MIPS. • Issuing an interim final rule with comment for extreme and uncontrollable circumstances where clinicians can be automatically exempt from these categories in the transition year without submitting a hardship exception application (note that Cost has a 0% weight in the transition year) if they were have been affected by Hurricanes Harvey, Irma, and Maria, which occurred during the 2017 MIPS performance period. • Decreasing the number of doctors and clinicians required to participate as a way to provide further flexibility by excluding individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Medicare Part B beneficiaries. • Providing more detail on how eligible clinicians participating in selected APMs (known as MIPS APMs) will be assessed under the APM scoring standard. • Creating additional flexibilities and pathways to allow clinicians to be successful under the All Payer Combination Option. This option will be available beginning in performance year 2019. The final rule with comment further advances the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery. See MACRA, MIPS, PQRS see:

Quality Reporting Program (QRP)
HHS and IRS mandated medical cost, and detail reporting aka Patient Centered Outcomes Research (PCORI). The $2.17 Tax per enrollee for this federal “umpire on efficacy of care” are charged to Carriers and self funded employers, and set to expire Sept 30,2019. QRP and QRUR are part of the reporting function related to MIPS, and whose goal is to get physicians reviewing each other by GPCI to affect competition and or better cost to outcomes improvements. There is little question, these measures will cost lots to implement, and affect increasing percentages of the Medicare reimbursement dollar.
Quota Share or (Pro Rata)
Quota Share reinsurance sometimes referred to as "Proportional" or "Pro Rata" is coverage providing a specified percentage of premiums, expenses and claims losses between the primary insurer (ceding company) and the Reinsurer. Risk transfer can assume up to 100% of the total premium risk. It is typically a first dollar coverage, where the reinsurer receives the same percentage of premium as it funds claims.


Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act — had passed the House late last year. It directs the Department of Health and Human Services (HHS) to create an advisory council charged with making recommendations on the strategy to support family caregivers.

A term used to convey a companies financial strength and or reputation for paying claims on times. i.e. Standard and Poors, Moodies, AM Best, Fitch, D&B, etc. For insurance, AM best specifically includes reputation for paying claims promptly.
Reasonable and Customary Charge (R&C or UCR)
Reasonable and Customary charges are sometimes referred to as Usual Customary and Reasonable charges (UCR). R&C is not a fee schedule with precise amounts by medical procedure, device, service or hospital charge. Determining R&C can be guided by reasonable location, and relative comparison to various statutory, and/or regulatory fee schedules used to establish reimbursement for purposes of insurance subject to the policy language, policy type, and general convention(s). Reasonable and customary and medical necessity are two separate issues. Many if not all states have at least two statutes guiding two, if not three medical billing limits. Federal regulations can also guide nationally recognized maximum allowable charge limits standard(s). The vast majority of medical insurance plan documents, and medical stop loss policies detail R&C language and/or direct fee schedule reference to avoid ambiguity when it comes time to pay claims. As a general rule, it is not uncommon to see medical billings invoiced at about 4 times (400%+)what most physicians and or hospitals "expect and accept" (after managed care contractual adjustments subject to stated policy coverage limits, exclusions, and/or legislated limits). Coverage for out of network care can be materially reduced posing real problems to members who thought they were protected against unlimited and uninsured medical charges. This is a growing problem - especially in ACA compliant unlimited EHB coverage(s). Balancing the primary promise of reasonable insurance against ACA compliant policy language excluding care, or care received "out of network" can be complicated and contentious. The attached link references a Johns Hopkins study showing median physician charges to "Medicare Allowable" billed was at 2.5 times more. The future looks even more interesting - see QPP and MACRA see bill H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015

Rehabilitation Facilities (IRF)
See CMS or HHS quality reporting
Reinsurance is an insurance which provides coverage for catastrophic medical charges incurred by a plan member. Generally, the three types of medical reinsurance are HMO reinsurance, Workers Compensation reinsurance, and CHAMPUS/Tricare reinsurance. Reinsurance applies to re-insuring an insurance policy. ===================== As it relates to ACA offered GROUP and self-funded ERISA participants - reinsurance charge 2016-2017 program - per United Healthcare Agent Advisory October 2017 "Final Reinsurance Fee Payment Due Nov. 15 for Self-Funded Employers October 5, 2017 The final installment of the Transitional Reinsurance fee is due by Nov. 15 for those employers who selected to pay the 2016 fee in two installments. For the final year payment, self-funded employers who selected to pay in one installment paid the $27.00 per covered life Jan. 17. Those self-funded employers have no further payment obligations. For those employers who selected two installments, the payment schedule is: •$21.60 per covered life – payment made Jan. 17 •$5.40 per covered life – due Nov. 15 Background Under the Affordable Care Act (ACA), the Transitional Reinsurance fee has been paid by health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance Program in place from 2014 to 2016. •For fully insured clients, UnitedHealthcare pays the fee. •For self-funded employers, the employer is required to pay the fee. For the final year, the fee was determined to be $27 per covered life and was based on enrollment in major medical coverage for the first nine months of 2016, regardless of the plan’s renewal date. Employers were responsible for submitting their enrollment count and selecting their payment date(s) on the government portal ( last fall.
Republican Agenda — Healthcare Reform (A Better Way)

Trump Executive Order allowing similar occupational business to purchase "Association" medical insurance across state lines (where state funding standards allow it). Executive order allows carriers to exclude preexisting medical exclusions, and not offer 10 UNLIMITED "essential medical benefits" mandated under ACA to avoid tax penalties. Individual's 2.5% tax penalty is eliminated, but employer tax penalties still apply. Available plans are available only where carriers offer them, or business associations are able to fund plan designs to state insurance compliance standard - meaning association medical plans are an old idea that has been crushed for years by states. See MEWA   Note: This is not tax advice. Recommend specialized CPA tax advice before acting.

In Short: Major Medical Association plans typically require a funded high deductible shared by Association employer-members. Getting reliable employee participation numbers, and up-front deductible (capital) funding among small employers is next to impossible. Short term plans cost way less, because they are not true catastrophic (Major Medical) plans. These are currently widely available - including plans offering 12 months of guaranteed renewable coverage, but with sub-standard annual benefit limits that include: maximum fee schedule limitation, preexisting medical condition exclusion, and no pharmacy coverage, etc. See: Final Rules, CSR, MACRA.


906 page ACA Law - Certified
55 Page ACA Law- Certified

Retiree Drug Subsodie (RDS)
A tax subsidy program available to fully insured and self funded employers. Audits are required that offset costs savings.
Return of Premium
An insurance policy provision allowing for all or part of premiums being refunded where the policy coverage was never accessed by the insured, These are not uncommon in Long Term Care policies. Sometimes the provision is combined with a term life insurance death benefit payout offering both LTC payout to the insured, with up to 20% of death benefit inuring to the beneficiaries. Read the policy carefully.
The probability of gain or loss associated with a choice or investment. Contrary to Merriam Webster's definition... it implies both gain or loss.
Risk Corridor
A term typically associated with ACA and related to federal cost sharing payments by the federal government to insurers. Payments are funded by participating Individual Marketplace carriers who paid reinsurance premiums, and agreed to the required 3% profit limit with MLR requirement. Risk Corridor is not CSR. 2017 estimated reimbursements are estimated at over $8 BILLION. Future reimbursements are not assured and have caused market instability. Risk corridors are not the same as the federally guaranteed reinsurance program.

http://See ACA law, and subsequent administrative rules changes affected by multiple Executive Orders.

Roll Out
The termination of the split dollar (life insurance plan paid for by the employer - SERRP)plan and the resulting transfer of sole ownership to the insured employee is called a rollout. Not the same as roll-up, which is typically a term used when describing interest rate performance in an annuity.
Rule 8424 fiduciary exemptioin
A Dept of Labor issued exemption from a fiduciary standard disclosure requirement related to facts and circumstances surrounding investment advice or recommendations involving qualified money. (untaxed income, or funds used from retirement accounts - i.e. some IRAs, 401, etc.). Investment recommendations involving qualified accounts DOES require separate sign off and management from a registered financial advisor or institution. Many Federal cases are in litigation now, and the compliance targeted for Jan 2017 has been delayed. See current DOL advisory.
Run Out
A Run Out is typically used to define the length of time claims are adjudicated and paid when carriers decide to end an insurance plan. Typical lengths of time may be statutorily defined, and are contingent upon carrier solvency, and/or court receivership assignment/management.
Rural Health Clinics (RHC)
See Federally-Qualified Health Centers


Safety Net Providers (ODF )
CMS term for Safety Net Providers. The “Low-Income Health Access” Open Door Forum (ODF) has been renamed as the “Safety-Net Providers” ODF. A forum for issues of concern to Medicare and Medicaid providers and suppliers who furnish services to low-income and vulnerable populations. Federally-Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Tribal Clinics, Hospitals, and others are encouraged to participate on the calls.
SBM-FP - State-based Marketplace on the Federal platform (SBM-FP )
Second Dollar Risk
Relative to "specific" medical stop loss coverages, it can be the amount of eligible claims excess of $50,000 per person per year. The amount is subjective by type and line of insurance.
Section 125 Plans
Medical benefit plans employers can establish to pay for eligible insurances with pretax funds, and thereby save approximately 7.65% of payroll taxes. Many eligibility rules and regulations apply to maintaining tax preferred funding of employee benefits. Section 125 plans are different from HRA accounts. Section 125 account balances NOT spent on eligibile medical expenses during the policy year DO roll over to subsequent years, and can be used in retirement too. Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys.
Self Funded Plan
A plan typically operating under ERISA that offers medical insurance to employees. Sometimes referred to as "Self Insured", a Self Funded insurance is a statutorily compliant plan of insurance characterized by high deductible. These plans are typically less expensive and more flexible than buying "Fully-Insured" medical plans with lower deductibles. Self funded plans take many forms, and contractual structure. Self Funded Plans are typically characterized by deductibles (to the employer, not the individual employees) over $35,000. Most common are ERISA (employer) Group plans, General Liability, Professional Liability and Workers Compensation self funded plans, etc. Many payment rules, statutes, regulations and standards apply to claims settlements. See Fronted and Reinsured Assignments.
Self Insurance Political Action Committee (SIPAC)
A republican lead committee whose goal is protection of ERISA self funded plan interests.
Self Insured Plan
See Self Funded
Service Area (Blue Cross Blue Shield defined)
Blue Cross defines, " service area means 1) the geographic area certified by the Marketplace through QHP; or 2. if not a QHP, the geographic area approved by the Agency for Health Care Adminstration (AHCA); and in which rates have been approved by the Florida Office of Insurance Regulation (OIR)."

Shared Decision Support (SDS)
A CMMI program

Shared Risk
Federal Report of how the reinsurance provided to commercial carriers by the federal government for Marketplace INDIVIDUAL plans responded. I. Highlights of the Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2016 Benefit Year The transitional reinsurance and permanent risk adjustment programs functioned smoothly for the 2016 benefit year, as the Patient Protection and Affordable Care Act-compliant market continued to grow. • The reinsurance program provides payments to issuers of non-grandfathered, individual market plans subject to the federal market reforms established under the Patient Protection and Affordable Care Act. • The risk adjustment program applies to any health insurance issuer offering plans in the individual or small group market, with the exception of grandfathered health plans, group health insurance coverage described in 45 C.F.R. § 146.145(c), individual health insurance coverage described in 45 C.F.R. § 148.220, and any plan determined not to be a risk adjustment-covered plan in the applicable Federally certified risk adjustment methodology. • A total of 767 issuers participated in the reinsurance and risk adjustment programs for the 2016 benefit year, of which 726 established EDGE servers. • Of 496 issuers participating in the reinsurance program, all issuers successfully submitted the EDGE server data necessary to calculate reinsurance payments. • Of 751 issuers participating in the risk adjustment program, 710 submitted EDGE server data to calculate risk adjustment transfers. The default risk adjustment charge was assessed to 1 of these issuers for failure to provide HHS with access to the required data and to an additional 41 issuers that did not submit EDGE server data. The transitional reinsurance program continues to provide significant protection to individual market issuers with exceptionally high-cost enrollees. • The initial, estimated reinsurance coinsurance rate for the 2016 benefit year is 52.9 percent.1 • For the 2016 benefit year, as of the date of this report, an estimated $4 billion in reinsurance payments will be made to 496 issuers nationwide. Both the transitional reinsurance program and the permanent risk adjustment program are working as intended in compensating plans that enrolled higher-risk individuals, thereby protecting issuers against adverse selection within a market within a state and supporting them in offering products that serve all types of consumers. 1 As stated in 45 C.F.R. § 153.230(d), “if HHS determines that all reinsurance payments requested…for a benefit year will not be equal to the amount of contributions collected, HHS will determine a uniform pro rata adjustment.” As such, CMS can update the coinsurance rate after HHS determines the total amount of reinsurance payments requested. The initial, estimated reinsurance coinsurance rate for the 2016 benefit year is subject to change -- and may increase or decrease – in light of differences between projected and actual reinsurance contribution collections, discrepancies and appeals

Shared Savings Program
See QPP See CSR Shared savings is a term typically used to describe the ACA rules and payments to carriers to help people earning between 100%-250% FPL, that lowers individual deductible and max out of pocket member costs from what is stated on each persons plan. Does not apply to Medicare.

Short Term Medical Plan
A term typically used to define a 3 month major medical plan. These plans are typically very different from Limited Medical Plans, or Cancer0Cardiac-Critical care plans.
Single Employer Trust or Association Health Plan
The association health plan is a self funded ERISA major medical group insurance that is exempt from community rating, and operates under ERISA. Advantages include an advanced aggregate reinsurance coverage, lower agent & TPA fees, favorable experience discounts and other significant savings. Typical minimum program requirements include 1,000 lives and retention at $50,000. Pooling of first dollar risk among multiple employers is prohibited (except for possible MEWA where permissible). Favorable experience is rewarded by refunding unused premium and discounting future premium. A single employer trust offers a middle ground between the higher risk of traditional self funding, and the higher cost of a fully insured benefit while providing a fixed monthly premium easily budgeted by the employer. They are different from Level Funded plans by offering higher retention levels which means managing more risk.
Skilled Nursing Facility Quality Reporting Measures (SNF QRP)
The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Review and Correct reports are now available on demand in the CMS Certification and Survey Provider Enhanced Reporting (CASPER) application. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage. These reports: • Contain quality measure information at the facility level • Allow providers to obtain aggregate performance for the past four full quarters (when data is available) • Include data submitted prior to the applicable quarterly data submission deadlines • Display whether the data correction period for a given CY quarter is “open” or “closed” (Source: CMS)
Small Business Health Insurance Options Program (SHOP)

A failed federal medical insurance program generally available to small business under 50 FTE's (who average under $50K income excluding business owners), that offers potential BUSINESS tax credit up to 50% of what the employer contributes towards an employee’s premium. Tax credits are offered up to two years: 50% year one, and 35% credit year two to qualified employers under 25 lives. Enrollment is 100% electronic, and premium payments must be in no later than the 15th of each month. Federal and commercial efforts to enroll small employers has essentially failed under the current non-commissioned agency structure.  They built it, and they did NOT come.  Most commercial carriers have abandoned SHOP offerings.

To be eligible for the SHOP, employers generally must be "small employers" and have at least one employee on the first day of the plan year. Estimating employer size can be complex and agents and brokers should refer to official Department of Health & Human Services and Internal Revenue Service (IRS) guidance on this topic before advising employers regarding their size.

Generally, an employer is a "small employer" if it had one to 50 full-time and full-time-equivalent (FTE) employees (one to 100 in some states) on average, on business days during the preceding calendar year.

When counting FTE and full-time employees, do not include the following:

  • Sole proprietors
  • Partners in a partnership
  • 2% S corporation shareholders
  • Leased employees
  • Real estate agents
  • Direct sellers
  • Individuals with health coverage under the Department of Defense TRICARE or the Veterans Health Administration program

Under this methodology, a full-time employee is one who is employed for, on average, 30 hours or more per week. An FTE employee is a combination of multiple part-time employees whose combined hours total 120 hours per month.

If an employer was not in existence throughout the preceding calendar year, the count of full-time and FTE employees is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year.

The SHOP coverage must be offered to all full-time employees (full-time employees are those employed for an average of 30 hours or more per week). Employers may offer coverage in a combination of Federally-facilitated SHOP Marketplace states and State-based SHOP Marketplace states, including State-based SHOP Marketplaces not using the federal platform.

Minimum Participation Rate Requirement

For an employer group to enroll in SHOP coverage, a certain percentage of employees must enroll, unless the enrollment occurs between November 15 and December 15 of each year. This is called the minimum participation rate (MPR). In most states, during the months when the MPR applies, at least 70% of the business' or group's full-time employees must accept the employer's offer of SHOP coverage or be enrolled in certain other coverage before the group can enroll. A few states with a SHOP Marketplace have set a different MPR, which can be found at

The MPR is determined by first adding the number of full-time employees accepting coverage offered by a qualified employer to the number of full-time employees who, at the time the employer submits the SHOP group enrollment, are enrolled in coverage through another group health plan, government-sponsored coverage (such as Medicare, Medicaid, or TRICARE), the individual market, or other minimum essential coverage. This number is then divided by the number of full-time employees offered coverage to calculate the participation rate.

The MPR is only calculated at the time of initial enrollment and upon renewal. From November 15 to December 15 of each year, eligible small employers can enroll in SHOP coverage without meeting the MPR requirement.

Levels of Coverage and Choice

The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care. For purposes of establishing a “employer GROUP” standard, the lowest cost Bronze level plan by zip code region is used.

The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care

  • Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40%
  • Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30%
  • Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%.
  • Platinum. The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%.

            Very few carriers offer SHOP plans making it almost impossible for employers to consider them.  Existing Agent Commissions on groups under 4 lives have been reduced or eliminated completely, thereby eliminating the line of business for many agents.

Small Employer Tax Credit
Small Employer Tax Credit Small employers (those with fewer than 25 full-time employees) may be eligible to receive a tax credit for premiums paid for employee health insurance coverage. The credit may be carried back one year and forward 20 years. The available credit is subject to limitations based on:
- the number of employees - the average annual wages paid to employees The maximum small employer health insurance premium credit available to eligible small (For Profit)employers is 50 percent of workers’ health care premiums paid by small employers and 35 percent of such premiums paid by small tax-exempt (Not for profit) employers, such as charities. It is only available if an employer obtains coverage through a Small Business Health Options Program (SHOP) in the ACA Healthcare Marketplace. Source: Florida Agent Licensing Exam Course
SNF Quality Reporting Measures
Special Enrollment Period (SEP)
Under ACA, A special enrollment period is a 60-day period during which individuals may sign up for permanent major medical insurance coverage through the health insurance marketplace. A special enrollment period must be triggered by certain qualifying life events or extraordinary circumstances. SEPs that require pre-enrollment verification include: • Loss of qualifying coverage • Move • Marriage • Gaining or becoming a dependent through adoption, placement for adoption, placement in foster care, or a child support or other court order • Medicaid or Children’s Health Insurance Program (CHIP) denial after applying for Medicaid/CHIP during Open Enrollment, or after applying for Marketplace coverage during Open Enrollment or following another SEP-qualifying event. Individuals who miss open enrollment generally cannot sign up for coverage until the next open enrollment period begins, unless they qualify for a special enrollment period due to a qualifying life even.t such as: • getting married • having or adopting a child • placing a child in adoption or foster care • involuntary loss of other health coverage due to: o divorce o turning age 26 under a parent’s coverage o termination of employment o expiration of COBRA coverage o loss of Medicaid or CHIP eligibility o closing of a plan year o decertification of a health plan • moving one’s residence out of the area served by an existing plan • becoming newly eligible to sign up due to: o gaining citizenship o gaining status as a member of an Indian tribe o leaving incarceration • if already enrolled, having a change in household status or income that affects eligibility for subsidies However, individuals who qualify for Medicaid or for the Children’s Health Insurance Program (CHIP) can enroll at any time of the year. Also, small business owners (those with 50 or fewer full-time employees) can obtain employee coverage through the Small Business Health Options Program (SHOP) Web site ( at any time of the year. Carriers offer 0% commission and rely on the Marketplace personnel to explain and enroll members. Where members have carrier issues, they do not have an advocate.

(Source CMS)

Specific Stop Loss/Reinsurance
Specific Stop Loss is insurance which pays for medical charges above a selected deductible for an individual person per policy year.
Stage 3 Meaningful Use (Meaningful use)
See CMS on Meaningful use. Stage 3 refers to requirements under QPP related to Hospitals inclusive of avoiding Medicare Part A & B (physicians charges for hospitals based doctors) reimbursement reductions that will require certified EHR technology (CEHRT) in the ONC Health IT Certification program for Stage 3 Meaningful Use.
State Based Marketplace (SBM)
A term referring to states that operate their own separate INDIVIDUAL and or SHOP health insurance on line entity charged with selling ACA compliant medical plans.
State Data Resource Center (SDRC)

Steerage refers to managed care procedures that direct members inside a contracted network of providers. Sometimes referred to as repatriation, Steerage also refers to the effectiveness of utilization review functions to get out-of-area members back into the local contracted network. This is especially important to the management of transplant, burn, rehabilitation and neonatal patients.
Stop Loss
Stop loss is an insurance which provides reimbursement for catastrophic medical claims incurred by a self-funded employer's employee or by a capitated HMO member. There are two primary types of medical stop loss - employer stop loss and provider stop loss (provider excess loss).
Subhealth Plan (SHP)
Meaning set forth in 45 CFR 162.103
Subrogation is the right of recovery of one party against another party. This can refer to the rights of the HMO or provider group to recover additional monies from a second insurance policy. In managed care, it refers mostly to an obligation of the provider group to use all legal remedies to repay the reinsurer for any claims paid, and whatever else they can collect.
Suitability refers to the appropriateness of recommended transactions when considering the risks and benefits associated with a transaction relative to a customer’s age, assets, current insurance holdings, financial situation (income and net worth), financial needs, and investment objectives.
Supplemental Executive Retirement Plan (SERP)
A retirement/disability/life insurance plan paid by taxed (non qualified)employer funding, that may also allow complete employer reimbursement of the benefit (deferred compensation) at death of a key executive.
Surplus Lines Carrier (Non Admitted Carrier)
Typically refers to an insurance company that is Eligible but not Authorized to write policies in a given state. Surplus lines carriers are usually referred to as "non-Admitted" markets/carriers. Surplus Lines policies do not enjoy State Insurance Guarantee Association support in the event of insolvency. States mandate special disclosure to policy holders of Surplus Lines carrier status. Surplus Lines carriers can be extremely large, and extremely well funded. As a general rule, surplus lines coverage is attractive when the carrier rating is A or better and used when desired coverage terms are unavailable in the "admitted carrier" market. There are entities like Citizens JUA (joint underwriting association) that insures windstorm risk in Florida. Citizens is not a surplus lines carrier, and does not enjoy State Guarantee Association. Citizens is an UNRATED insurer.
Surplus Relief or Finite Reinsurance
Surplus Reinsurance is coverage that effectively transfers premium from the primary insurer to the Reinsurer thereby improving capital reserve ratios and financial ratings. Typically, these reinsurance agreements are in the form of a Quota Share arrangement with profit sharing reverting back to the primary insurance carrier for a risk charge. Coverage typically responds at 125%+ of the expected claims value. See Finite Reinsurance
Sustainable Growth Formula (SGF)
Medicare formula for calculating maximum allowable charges that is now replaced with Quality Payment Program (QPP).
System of Record Notice (SORN)


Tax Tables IRS 2018

TEchnical Expert Panel (TEP)
CMS panel of experts relied upon by CMS to make and update targeted clinical and administrative standards and systems designed to reduce cost and increase medical quality.
TeleMedicine or TeleHealth
Healthcare advice delivered over electronic media and not in person. " Twenty-eight states now require insurers to cover care provided through video calls the same way they would cover comparable care delivered in-person, the telehealth report team found. Only 17 states' Medicaid programs cover remote patient monitoring services." Source LifeHealthpro Daily) Multiple new products and services are being used now, with more being developed. Telemetry is not necessarily telehealth - but does use wireless reporting to advise disease and therapy real-time condition(s).

Sometimes referred to as a Contract Basis, or Contract Period - Term refers to the policy year and claims submission period deadline. A typical stop loss term is for a 12/18 period. Here the policyholder's claimant has 12 months to accrue the claim, and 6 months after the policy year to report it to the carrier. Policies can be written on either a "Reported" or "Paid" bases. The Reported bases is richer coverage. Other Terms are 12/12, 12/15 and 12/24.
The Medicare Access and CHIP Reauthorization Act (MACRA)
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changes the way Medicare rewards clinicians for providing quality care by streamlining multiple quality programs into a new Quality Payment Program tied to Part B Fee-For-Service payments. With the implementation of MACRA and the replacement of the Sustainable Growth Rate, we will pay clinicians participating in the Merit-based Incentive Payment System or Advanced Alternative Payment Models of the Quality Payment Program beginning in 2019
Total Quality Improvement (TQM aka QA aka TQI aka Critical Pathways)
A quality insurance vernacular which is the same or similar to Total Quality Improvement, Medical Pathways, Critical pathways, Total Quality Improvement, etc, and whose goal is to lower costs, and improve outcome of medical care delivery.
Treatement, Payment Health Plan Operations (TPO)
A contractual term used in Plan Documents to denote how HIPPA protected medical information is used for patient care and plan administration.
Treaty Reinsurance (Automatic reinsurance)
Treaty reinsurance is reinsurance of specified types or classes of insured exposures that are automatically "ceded” or accepted by the Reinsurer within the terms of the reinsurance contract or "treaty" without evaluation of each individual exposure. The reinsurance takes effect as soon as the primary insurance is sold. Treaty reinsurance is a general term used to discuss several types of coverages that can include profit sharing features.


Uncollateralized Surety Bonds
This type of financial guarantee bond is placed between the capitating HMO and the provider group as a safeguard against insolvency or bankruptcy. Different from the standard types of surety bonds which require 75% collateral, approved provider groups do not have to freeze their assets through an ILC. It is priced at 2% of face.
Underwriting Death Spiral
Jargon used to describe adverse selection caused by sick (high medical claims) members staying on a plan, and/or healthy people leaving a plan. Generally, most plans will not survive more than 1-3 years in such circumstances.
Uninsured Rates
Report used by CD to estimate uninsured US population rates.


Value Based Payment Modifier (VM)
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Value Based Reimbursement
See Bundled Payments. VBR is an amorphous term used to define various types of "bundled", DRG, per diem, cost per confinement, etc priced care packaged as is deemed "valuable" by whatever index the buyer or seller fines valuable. Its implied goal is to improve medical outcomes at a lower cost, improve medical outcomes, and prevent up-coding single procedures into multiple procedures/charges. see Bundled Payments
A life insurance policy that is typically sold to investors by an insured with less than two years to live. Viaticals offer a terminally ill person access to funds prior to death. There are primary, secondary and tertiary markets for Viaticals. (See LE)
Voluntary Benefits
Benefit offerings paid for by employer and/or employees. Sometimes referred to as “Ancillary Benefits” these insurances typically insure: Life, Dental, Short term Dissability, Long term care, Critical Illness, Accident only, Cancer, Cardiac,stroke/transplanct, long term disability, Hospital lump sum per diem GAP, etc.


Wokers Compensation (Comp)
A state mandated insurance coverage offering: Unlimited Medical insurance, Life insurance, disability insurance, and liability cover. Each state is different. Employers purchasing compliant comp enjoy some liability immunity. Employers not purchasing statutory cover may be guilty of a third degree felony. See MCC, IME, EMA, DWC25 form, MSA, MMI, IW, etc.
Wrap plan
A term used many ways. It can be an umbrella plan, a gap plan or a plan over an EGWP.