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)
See: ACA Compliance. 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.

1099's (Subcontractors)
Jargon used to describe subcontracted workers who are not paid as W2 (IRS tax filers with payroll paid to the state on their pay) employees. It can get confusing when some carriers allow 1099's onto a group health plan, and others prohibit it, or at least prohibit it on paper.
12b-1 Fees ("no-Load" Mutual fund fees)
A term usually describing Mutual Fund fees charged that must be disclosed (like the new Fiduciary standard DOL rule mandates) declaring ALL compensation received by licensed securities entities. All kinds of rules apply to disclosure of fees, and depend on the type of license held by the agent or Broker-Dealer that range from being a simple order taker (most agents), to a fiduciary duty standard on most securities licensed agents. See: BIC, and the DOL best interests rules and pay special attention to a much higher standard for disclosure of fees related to funds coming out of retirement accounts. All funds have expenses, but 12b-1 fees are among the lowest offered to investors buying designated funds. See: Contingency Fees, Profit commissions, production bonuses, etc. It is not straight forward, and many believe the rule is too broad. See: Madoff, Enron, Worldcom, and SEC oversight.
13/26 Rule (Parity rule)
A rule guiding an x-employee's (re-hire) medical plan eligibility. "The two methods are: A 13 Week (or Longer) Break in Service. If the employee is rehired after a period of at least 13 consecutive weeks (26 weeks for educational institutions) where s/he did not work or provide an hour of service, the employer can treat the employee as a new employee. Rule of Parity. If an employer wants to use a break period shorter than 13 consecutive weeks (26 weeks for educational institutions), it can apply this rule of parity. Under this rule, an employee can be treated as a new employee if the number of weeks during which no services are performed is both (1) at least four weeks long and (2) exceeds the number of weeks of employment immediately preceding the period during which no services are performed. For example, if an employer uses the rule of parity, an employee who works for five weeks and then has no credited hours for six weeks may be treated as a new employee on rehire. This rule of parity really only applies to employees who leave before completing 13 (or 26, for education institutions) weeks of service." Source HUB International. There are lots of rules affecting medical plan eligibility and coordinated rules specified in Employee Handbooks, SPD's, part/full-time status of the returing employee who was/wat not insured, and who will not be working 30 or more hours a week, etc.
150% FPL SEP Functionality
There’s a new Health Insurance Marketplace Special Enrollment Period (SEP) available for low-income consumers at or below 150% of the Federal Poverty Level (FPL), which is approximately $19,000 for an individual and $40,000 for a family of four. Consumers who qualify for this SEP may also qualify for more savings. The annual household income at or below 150% FPL varies by state and household size. Source: CMS March 2022


2019 Public Charge Rule
A Trump administration immigration rule stating not to admit any immigrant likely to need health care.
21st Century Cures Act (Medicare Advantage Risk Adjustment Payment Model)
Legislation directing how CMS calculates patient risk scores for Medicare Advantage (Medicare HMO and PPO) reimbursements to medical providers. "In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending 10 percent of the encounter data-based risk scores with 90 percent of the risk-adjustment processing system, or RAPS-based risk scores. In 2017, CMS continued to use a blend to calculate risk scores, by calculating risk scores with 25 percent encounter data and 75 percent RAPS. In 2018, it used 15 percent encounter data and 85 percent RAPS; and in 2019, 25 percent encounter data and 75 percent RAPS. The new model will determine risk scores by adding 50 percent of the score calculated from diagnoses from encounter data, RAPS inpatient diagnoses and fee-for-service diagnoses, with 50 percent of the risk score calculated with diagnoses from RAPS and fee-for-service diagnoses." (Source: Healthcare Finance Magazine January 2019: Susan Morse) See: Interoperability

220 License
License required to represent Property and Casualty insurance in Florida. All states use a P&C license category. Note: P&C licensed agents can also by rule (in Florida and most states) sell most types of major medical insurance. Whereas L&H licensed agents are prohibited from writing P&C coverages.


4-40 license (CSR - Customer Service Rep)
A salaried employee of the generallines (property and casualty) agent or agency that may transact automobile, water craft, home, motorcycle, and pet insurance under the supervision of alicensed and appointed general lines agent. Covid statutes are allowing these people to work from home for a period, and not directly in the same office as the fully licensed P&C agent - (as is normally required).
401 (K) plan (Defined Contribution Plan)
See: Defined Contribution Plan


6055/6056 Forms Guidance


ACA 6055 Reporting
The forms ALE employers must file with IRS, to be in compliance with ACA law and tax regulations. "Affordable Care Act 6055/6056 reporting for 2020 Nov. 12, 2019 Reform and Regulatory Fully Insured and Self-Funded All States UnitedHealthcare will send 1095-B forms to fully insured plan subscribers prior to the Jan. 31, 2020, filing deadline. The forms will begin mailing in mid-December, 2019, and should be fully distributed by Jan. 31, 2020. Complying with 6055 requirements Fully insured groups Under the Affordable Care Act, employees with fully insured plans who were eligible for coverage for at least one month in 2019 must receive a 1095-B form from their insurance carrier. For fully insured customers, UnitedHealthcare sends the 1095-B forms directly to employees; they are not mailed to employers. Employers may not request forms for their employees or receive a report of employees who receive a form. If the member misplaces the form, they may obtain a copy of their 1095 on the® member site. They may also call the customer service phone number on the back of their health plan ID card. Fully insured Applicable Large Employers (ALE) with 50+ full-time equivalent (FTE) employees must also send their employees a 1095-C. Self-funded groups Self-funded (ASO) customers must provide their employees, by Jan. 31, 2020, with a 1095-B if they are a small employer with one to 49 FTEs, or with a 1095-C if they are an ALE with 50 or more FTEs. Complying with the IRS information reporting requirements The following forms must be transmitted to the IRS by Feb. 29, 2020, if filing by paper, or by March 31, 2020, if filing electronically: 1094-B Transmittal of Health Coverage 1095-B Health Coverage 1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns 1095-C Employer-Provided Health Insurance Offer and Coverage Note: Employers with 49 or fewer FTEs are not required to submit a report to the IRS. New state requirements for individual coverage and associated reporting requirements Individuals are no longer subject to a federal Internal Revenue Service (IRS) penalty if they did not comply with the shared responsibility requirements of the Affordable Care Act (ACA), sometimes referred to as the Individual Mandate. The penalties have been removed for those who do not have health insurance coverage. However, some states have initiated their own individual mandate requirement for residents of those states. New: New Jersey and D.C. implemented state individual mandate requirement for 2019 Although the federal level penalties have been removed for those who do not have health insurance coverage, some states have initiated their own individual mandate requirement for residents of those states. Individuals who have resided in New Jersey or Washington, D.C., for any time during 2019 will be required to report if and when they had minimum essential coverage (MEC) on their 2020 New Jersey or D.C. tax returns. UnitedHealthcare will submit the required 1095 forms to the state tax departments by the deadlines below for fully insured groups: New Jersey Tax Department: By March 31, 2020 Washington, D.C., Tax Department: By June 30, 2020 In addition, fully insured ALEs and self-funded groups will be required to submit copies of either the 1095-B (groups 1 to 50 FTE) or 1095-C (50+ FTE) to the state of New Jersey or D.C. tax departments. There are penalties for individuals who have resided in New Jersey or D.C. beginning with the 2019 calendar year if they do not have insurance coverage as required by the state. If needed, a self-funded group may request a custom eligibility report to include month by month coverage that is available for a fee. The group may also request a report for either the New Jersey or D.C. residents. For 2020, the report will include current residence only. Several other states have indicated that they have legislation adding an individual mandate and penalty for 2020 that will require reporting in 2021. UnitedHealthcare will send out information as the states approve the legislation. Summary of UnitedHealthcare’s approach For fully insured groups: UnitedHealthcare will send the 1095 form to subscribers, to the IRS and where required to the NJ or DC state tax department by the due dates. For fully insured ALEs: The group is required to send the IRS 1095-C forms and where required send to the NJ or DC state tax department by the due dates. For All Savers®: UnitedHealthcare prepares the 1995-B forms, which the employer then provides to their subscribers and to the IRS and where required to the NJ or DC tax departments by the due dates. For large self-funded groups: The customer prepares the 1095-C form, which they then submit to subscribers, to the IRS and where required to the NJ or DC tax departments by the due dates." Source: United Healthcare Agent Advisory
ACA Family Glich Fix

ACA Final Rules (CMS issued ACA Final Rules)
Be clear: Without APTC authorized by ACA (and expanded Medicaid), we would have epidemic hospital insolvencies, and physicians would have to figure out how to finance care people fail to prepay (finance) with insurance. AHIP is all for more APTC. "HHS: Nearly 36M people have ACA-related coverage Nearly 36 million Americans have health care coverage through Affordable Care Act marketplace plans, Basic Health Plan policies and coverage enabled through expanded Medicaid eligibility, HHS reports. The percentage of uninsured Americans dropped from 10.3% in the fourth quarter of 2020 to 8.8% in the same period last year, which translates to around 4.9 million people gaining coverage". Source: Beckers Payer Issues 4/29/22 ACA law passed in 2010 is still in effect.  The Supreme Court sided against Trump administration and declared the estimated $12 BILLION CSR, and related reinsurance payments are due to the carriers. In many, if not all states (cant be sure about 50 states) - Cigna, Aetna, United, Humana, etc have abandoned offering SHOP plans. In 2022, Aetna, Cigna, and United started offering Individual plans in several states, but did not publicize if of where they left states too. Cigna recently partnered with Oscar health plan to implement an individual offering, so that is getting even harder to track with Cigna choosing an organization highbred. Aent purchased CVS in ongoing vertical integration. Oscar just advised they will by $0 commission for any SEP enrollments! Cigna and Aetna have very long histories of avoiding individual plans, and small group plans. Under Biden APTC premium expense (to AGI/MAGI percentage bands) rule is now reduced (improved for lower income people) to a maximum of 8.5% of income limit. See: American Rescue Plan (no republican voted for) and is now law. See: PPACA, APTC, COBRA, CSR, Marketplace reinsurance (safety net). See: COBRA effected federal ARP federal payments to employers who pay for their employees COBRA and/or ICHRA medical costs (Premium and eligible medical expenses). Many rules defining how to count stimulus money and ARP (COBRA) payments as income or not... See Florida Mini-COBRA, etc. President Biden's ARPA passed. ARPA enhances eligibility, and increases APTC eligibility beyond 400% (old limit) of FPL to 600% FPL cap FPL, and / or when premiums offered by Employer sponsored (or individual plans, (See: ICHRA) plans exceed 8.5% (not the old 9.8%) of AGI/MAGI, and increasing income eligibility for APTC, making SEP good for all of 2021, and expanding services for new babies and mothers (and state/fed option to extend new mother / new baby Medicaid benefits for up to 5 years after the birth. See the Medicaid rules in your state. Biden wants to allow CMS power to bargain with pharmaceuticals paid for with tax dollars, and to lower the age for Medicare eligibility from 65 to 50. Do the work ("Individual and SHOP" federal Marketplace link is on our home page), and quote what it costs for two 62 year olds ... $25,000 per year premium costs plus any out-of-pocket costs to actually get care. Call your congress-person and tell them to enforce hospital transparency cost disclosures, and APTC and a "buy-in" to Medicare option for people over 60 years old. Its overdue, and it does not mean Medicare-for-All because individual 60 - 64 years olds can buy private insurance (like Medicare Supplemental is, which is NOT government insurance), use the same Medicare contracted providers, and get charged what Medicare authorizes which is about 240% of what the same care costs for commercially insured people (non-medical eligible lives). See: Trumping Healthcare Reform at, Click on - ARTICALS. ACA has not been repealed, but for the individual mandate tax penalty, and most of the taxes charged on premiums that go to HHS to try and design quality metrics people can understand, and that providers accept.  In Dec 2019, most if not all insurance taxes mandated by ACA law were repealed, but the individual Employer tax penalty is still in effect for employers over 50 FTE lives. INDIVIDUALLY offered marketplace plans distributed by the State Based Federal-facilitated Exchanges (SBE-FPs) to enforce FFE standards for network adequacy (re: Medicare lives) and essential community providers. 12-13 states (plus DC) use SB- FFE.  Marketplace navigator budget got severely reduced under Trump, and massively increased under Biden. Good luck finding an unlicensed Navigator for complicated problems after the Navigator is unemployed 45 days after OEP ends. Biden's ARPA passed $80M for Navigator Marketplace sales funding - Stay tuned. Navigators will not give you their DIRECT contact information, (or their managers last name or direct contact number) are pure order takers, and almost without exception will offer no help with provider network access & changes, Rx out-of-pocket estimations, complicated tax issues that do not automatically populate, etc. Not sure if 3.5% user (premium tax on insureds) fee tax still effective on members enrolling within SBE-FBs. SBE-FBs are not FFM. See: Trump EO re: ICHRA's, which is still in force, and a good idea that many employers do not want to deal with - arranging (without an agent to do it), untaxed payments to employees so that the employees can buy Marketplace INDIVIDUAL coverage. SHOP and INDIVIDUAL Marketplace enrollments are now allowed directly with carrier/brokers inclusive of APTC (and eligibility to file for tax credit during the year for SHOP).  0 FFM SHOP plans offered in Florida (most states last we looked) for any small businesses. Trump prohibited states from creating platform to secure SHOP. Commission - flat commission at $20-$30/pmpm to agents has eliminated a profitable commission, for non-boiler room operations offering almost zero follow up services, thereby relegating insureds to fix their own multi-agency and tax credit issues after unlicensed navigator's employment ends after 45 days typical Open Enrollment. See: Executive Orders, Price Transparency, Public Law 111-148, Public law 111-152. Meanwhile, New HHS regulations Trump (Biden is still supporting) EO mandates requiring hospitals to publish their best contracted rates and provide accurate estimates of costs to patients struggling to understand care, cost, and long-term massive hospital bills. Biden is demanding it too. See: Consolidated Appropriations Act signed Dec 2020. See: Balance Billing, ARP It’s been estimated the number of those eligible for a subsidy on the Marketplace increased by 20% with the passage of the ARP.* The ARP impacts current and new Marketplace members in three ways: • Enhanced APTCs-APTC subsidies will be enhanced for 2021 and 2022: Consumers’ required contributions are lowered at all income levels thereby increasing APTC. Individuals earning 100-150% FPL will be eligible for fully subsidized coverage. Additionally APTC eligibility income tax got increased a lot offering even high income earners to get an APTC to pay for premiums (so hospitals dont go insolvent with average people going bare of insurance and incurring large "self-Pay" bills that create big bad debt problems. • People that receive unemployment in 2021 will be treated as earning no more than 133% FPL, unless otherwise eligible for Medicaid: For 2021, individuals receiving or approved to receive unemployment for at least one week will be eligible for fully subsidized ACA coverage at 133% FPL, if they are not eligible for Medicaid. In states that have not expanded Medicaid, people below 100% FPL will also be treated as making no more than 133% FPL for APTC subsidy eligibility. Individuals will need to attest to and provide documentation to prove eligibility. • APTC overpayment: APTC subsidy overpayment in the 2020 tax year will not need to be repaid." Source: Ambetter Agent Advisory 4/2/21 See: MLR, COBRA, PPACA, ARP, EO's, APTC, CSR, reinsurance, etc

Federal Info at HHS:

ACA Risk Adjustment (ACA reinsurance)
A term typically used to describe federal reinsurance to eligible Marketplace carriers, who have elected to participate (buy) federal reinsurance on Marketplace offered plan members, thereby insulating them from adverse selection from insuring preexisting medical conditions. The term is ambiguous and gets confused with CSR and APTC. See: CSR and APTC. The reinsurance applies to reimbursement (indemnity) of claims between $45,000 and $250,000, and NOT to an unlimited amount actually insured by each carrier per ACA QHP mandate. The program also limits (participating) carrier profits on individual marketplace enrolled members to 3% (in addition to mandated MLR rebates to INDIVIDUAL / SHOP plan INDIVIDUAL members whose annualized claims are under 80%/85% of the premium charged.) Over $10 Billion (CSR) payments has already been paid since 2017 (under the Obama managed ACA). Exactly what has been paid is not certain, however the supreme court recently sided with the carriers April 2020 demanding $12B in reinsurance payments, and that the Trump administration denied. Blue Cross was owed an estimated $5 billion.

ACA waivers (Marketplace plans reinsurance)
CMS issued four new waiver concepts aimed at helping states develop options for using Section 1332 waivers under the Affordable Care Act, and in context to 14 states volintarily participating states in the federal reinsurance offering over marketplace offered plans sold in their states. The waiver concepts, which follow Section 1332 waivers guidance released by the CMS, includes account-based subsidies, state-specific premium assistance, adjusted plan options and risk stabilization strategies. CMS reviews each state's "guard rails" of where each state's marketplace plans are on the hook for paying claims, and where the reinsurance attaches. "The 2022 user fees are now expected to be 2.75 and 2.25 percent of monthly premiums, resulting in an increase of about $200 million in user fees for 2022. Even with this increase, the proposed user fee for 2022 would remain lower than 2020 and 2021, when it was 3.0 percent and 2.5 percent." Source: Health Affairs, August 2021 Source: AHIP Agents Smart Brief. See: APTC, CSR, MLR, etc. Ex: "In the Denver Metro area, for instance, insurers will have 43 percent of their claims costs reimbursed when the claim is between $30,000 and $400,000. In contrast, in the two areas of the state with the highest health care costs, insurers will have 73 percent of these claims reimbursed. The insurance commissioner can continue to adjust the payment parameters in new rules each year." Source: Health Affairs 8/17/21
Accelerated Underwriting
A term used in life insurance underwriting for applicants typically under 50, and with death benefits under $1M. It means they will provide a binding proposal for life insurance expeditiously.
Accellerated Death Benefit
A life insurance feature that allows a terminally ill diagnosed person to collect part of the death benefits before they expire. See Viatical and Life Settlements for a potentially better option(s) (for some terminally ill insured)s.
Accellerated Payment
See: CMS re C19 $175 payments to providers being suspended after $100 Billion distribution. Can also mean a Life insurance Death Benefit partial payout to the insured where death is eminent. Not to be confused with Viaticals or highbred life-LTC policies with Continuation of Benefits provisions guide LTC payments/m benefits - where the life defined LTC benefit/m is paid out until the Death Benefit face amount is exhausted, then COB provision kicks in and pays up to the defined 4, 5, 6, 7, 8 year period, or to death *following what the insured purchased in the policy. See: Inflation riders
See: SORN and application to an individual's right to access his PII, and/or direct who can use it. Access is historically a central federal policy issue guaranteeing right to healthcare coverage at an affordable price by ACA law, and longstanding intervention and obligation.
Accidental MEWA
See: MEWA. A term used to describe an ERISA plan allowing insurance to 1099 subcontractor eligibility, and that may violate individual state's MEWA prohibitions. Historically, some carriers would allow 1099's (subcontractors) to be eligible for the employers same plan, and counted towards "participation" requirements. Recently it appears that carriers are citing 30 hour work requirement, and/or 50% employer contribution rules.... There are participation and contribution rules (that are usually followed- i.e. 70% participation and 50% contribution) relative to member-employer plan eligibility, but if the carrier will allow it, they are the risk takers making final decision to make 1099 subcontractors eligible or not. ERISA dominates state laws, but states will fight any MEWA without a Certificate of Authority. See: Trump's Executive Order on Associations and know it would have taken off a long time ago if it offered capitalistic opportunity - insulated from state authority - regardless of cross state "Executive Order" authority.
Accountable Care Act of 2010 (ACA)
See: Patient Protection and Affordability Act See: Republican Agenda

Accountable Care Organization (ACO)
See: Next Generation ACO's An organization allowed by CMS that allows medical providers to enter into risk /non-risk bearing contracts to care for assigned Medicare lives. ACO’s generally provide full range of medical services. Central to ACO purpose is to transform provider payment to a value based system that copensates providers for keeping members well, and revamping fee-for service production incented compensation by episode/procedure.  Central to ACO purpose is the elimination of traditional FFS provider compensation within optional "Shared Services" at-risk 3 year term contracts. (See: Direct Contracting changes that do not affect previous ACO's yet) FFS contracts are also offered by demonstration project (HHS, CMI, LAN CMMI initiatives) approval for multiple "chronic" (expensive) care-managment catagories (knee replacements, diabetes, back pain, hypertension, asthma, etc.). ACO goals are said to 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.  See Federal healthcare policy with goal of value based reimbursement (i.e. exiting FFS and moving to EBM outcome enphasizing keeping people healthy versus incenting production of medical procedures, and keeping hospital beds full at any cost.)  

ACO Risk Contract/CMS Fact Sheet

Accountable Health Communities (AHC)
A model of healthcare delivery that attempts to include not for profit with for profit entities with goal of improving medical outcomes at lower costs. It harkens from Canada's "Healthy Communities" (30 years old) concept that merges social services, religeous communities, volunteer organizations, etc, with existing quasi-free market (Medicare, Medicaid, Tricare, etc) programs that get paid for by the state and federal authorities, but are run by commercial (free-market-private corporations like United, Aetna and Blue Cross) and individual people with religeous (churches, social workers, AARP) call to serve the needy. C.” The Accountable Health Communities (AHC) Model assesses whether bridging the gap between clinical care and social services can reduce health care utilization and costs for high risk Medicare and Medicaid beneficiaries. In November 2019, CMS convened 29 bridge organizations participating in the AHC Model and key partners for the second annual AHC meeting to brainstorm and share promising strategies to address beneficiaries’ health-related social needs. performance period. See: ACO To view a list of the Assistance and Alignment Tracks bridge organizations, please visit the Accountable Health Communities Model web page. (Source CMS) See: SDOH, QPP, MACRA, DRG, etc N

ACO Next Generation (Next Generation ACO)
A term referring to medical provider organizations accepting Medicare managed care risk contracts exposing them to 40%-100% of "shared savings" budget over-runs (after typically 3 years) for NOT effectively managing care.

ACO Performance
ACO's are CMS's term for demonstration projects whose goal is to eliminate FFS, and contract various bundled services within a Shared Savings contract that through EBM cause better medical outcomes at lower cost to CMS. There are six types of ACO's currently in such contracts: Participant TINs, Pysicians and Non-physicians, Hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHSs), Critical Accss Hospitals (CSHs)


ACO Risk Adjustment
The CMS mechanism designed to encourage competition in medical care benchmarking used to measure ACO efficiency and effectiveness. See: Shared Savings, ACO. "With a common maximum risk score improvement cap of 3%, organizations new to optimizing around risk adjustment will often target exactly that as their metric for improvement. Unfortunately, that leaves out three critical variables that must be accounted for to succeed: inflation and its impact on benchmark calculations, national risk score trends, and coding intensity factor. " "INFLATION AND BASELINE CALCULATIONS Effective risk adjustment in any year doesn’t happen in a vacuum. The prior years, and regional and national trends are each accounted for in the final calculations. It starts with a historical benchmark. Using PY2020 as an example: [ (2017 Costs x 2019 Risk Score) x (2017 Regional Trend) x (2017 National Trend) x 1/3 ] + [ (2018 Costs x 2019 Risk Score) x (2018 Regional Trend) x (2018 National Trend) x 1/3 ] + [ (2019 Costs x 2019 Risk Score) x (2019 Regional Trend) x (2019 National Trend) x 1/3 ] = Historical Benchmark Calculation for PY2020 Benchmarking is the value by which progress is measured each year. It’s part of additional incentives to improve risk capture (and therefore care) by way of an ongoing, annual comparison by CMS of every organization’s progress in a given year vs. itself and its peers" See: An EDIFEC EBOOK Part 2


ACO Stop Loss (Stop Loss)
A medical excess of loss coverage purchased by ACO in track 2 or 3 of the Medicare ACO shared risk contract. It is typically viewed as a type of Provider Excess Loss (stop loss).
Actively at Work
A SPD provision stipulating eligibility for medical benefits.
Activities of Daily Life (ADLs, LTC coverage triggers)
Physical/mental conditions an insured cannot perform that when present can trigger a Long-Term-Care benefit. Most policies demand at least two conditions being present to trigger coverage. Conditions include bathing, incontinence, dressing, eating/feeding, toileting, transporting one's self to the toilet/shower, and severe cognitive impairment like Alzheimer's disease. Coverage may mandate a treatment plan by a licensed entity. See: Pure LTC policies, and hybrid LTC-Life policies
Actuarial Hope (Career Insurance)
A term coined by Ann Richards of Fidelity Investments used to establish an estimated investment (interest) return on a modeled outcome. In context to stop loss trend and risk factors, it is the percentage of premium increase an actuary bumps premium to insulate future outcome pricing variability falling below minimum (forcasted) profitability, or below solvency. See: Actuarial Fudge Factor
Actuarial Rule 49 (AG-49)
A life insurance illustration rule designed to conservatively estimate future INDEX growth and a (FIXED) loan interest charge to 1%. The essence of Actuarial Rule 49 is to limit the difference between the FIXED loan interest rate charge, and the ILLUSTRATED (i.e. S&P) future INDEXED percentage return to no more than 1% (over one's entire lifetime - i.e., up to age 90? years average - point being way more than 10 years. In finance, everything follows a term of context. In context to actual S&P average returns from 2002-2022 being about 21%, the rule materially illustrates (shows lower cash values) lower Accumulation Value available to borrow against using IRS compliant (tax preferred IUL) loans in retirement. As of 02/2002 one major carrier limits S&P future estimated growth to 5.54%. The rule limits illustrated S&P index growth estimates (Feb 2022) to only 5.54% and materially understates actual S&P historical returns, and therefore less informative to higher probability future experience averaging much higher actual S&P returns over a 10 year's period. Note: Understanding how selected products perform using the rule must be in context to that product's Bonus provisions tied to loan interest type (fixed or variable) elected at time of loan. This gets a bit complicated to see in a typical illustration, as some illustrations show the same cash value for both Fixed and Variable loan assumption, but with the fixed loan assumption illustration, it removes the loan amount from earning what the entire cash value states. ====Past performance is no guarantee of future performance, so if the S&P leaves a 30-year pattern of massive S&P growth, then the policy loans could reduce Cash Value by the Fixed (or variable) loan interest rate charge for each period without offsetting S&P interest earned credit. That said, just one year at say 10% S&P index interest crediting on the loan amount, makes up for over 3 years of just getting back 3%-3.9% Fixed loan interest Bonus credit/year. See: NAIC life insurance illustrations Model Regulation #582

Actuarial Value (AV)
An MLR legislated ACA MLR (percentage) value requirement of "metallic" level plan pricing. I.e. Bronze, Silver, Gold, Platenum level plans. Means, that claims/premium = MLR. Currently, businesses (over 50 FTE) are required to offer a QHP minimum plan coverage equivelent or greater then the lowest Bronze level plan offered by employers in the "region". "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). See: MLR Source: Source: MLM training by CMS. Percntages can change, so look them up. 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 45%. •Silver. The health plan covers about 73% of the total costs of care on average. An average enrollee can expect to pay about 30%. •Gold. The health plan covers about 87% of the total costs of care on average. An average enrollee can expect to pay about 20%. •Platinum.The health plan covers about 94% of the total costs of care on average. An average enrollee can expect to pay about 10%. By Trump Presidential order, HHS is instructed to change ACA and/or previous HHS AV, and multiple ACA minimum coverage standards to gut the law, without passing a new law. Businesses are now subject to their respective state's minimum AV standard that can now be based on the lowest plan (EHB and/or QHP) coverage offering in any state. President Biden is reviewing and eliminating many Trump EO's. Stay tuned... See: EHB, ERISA

Adjusted Clinical Groups (ACGs)
Johns Hopkins Adjusted Clinical Groups System
Adjusted Gross Income (AGI)
The earnings amount used by a single person to calculate tax credits (APTC) to people earning between 100%- 400% of FPL. AGI is reduced by child support and student loan interest. See: EO
Administrative Services Agreement (ASO, MSA)
In context to ERISA eligible plans: A term generally used to describe TPA functions that include at minimum: claims processing, and perhaps case management, eligibility determinations, stop loss acquisition and management, etc. ASO options are many. Some carriers refer to the actual contract as a MSA for "Level-Funded" (ERISA) plans stipulating services and programs scheduled by fees charged. MSA can also mean Medical Savings Account.
Admitted (Authorized)
A term used to describe a carrier that is both Eligible and Authorized to issue insurance in a specific state. See: Surplus Lines. Surplus Lines is eligible but not authorized, and can legally issue policies in a specific state, that have not been specifically approved by that state. See: contrcts of adheason, and surplus lines process assigning agency liability on unpaid claims in the event of insolvency.
Advance Beneficiary Notice (ABN)
See: Dual Eligibles
Advance Beneficiary Notice of Noncoverage (ABN)
A CMS declaration to an individual Medicare beneficiary an individual provider (i.e. physician) being no longer participating (in Medicare), and that if care is received, it is not insured. See: PFFS and Medicare Part C
Advance Funding
See: ASD - These Stop Loss provisions are subject to contingencies. In some instances, it can amount to a kind of waiver of an ASD for purposes of paying a "specific" claim without the ASD (second deductible), but while the ASD has already reduced the cost of the stop loss policy.
Advance Payment
A term CMMI uses for payments to providers subject to the type of contract (risk versus FFS) related to Direct Contracts managing either total care or just primary care.
Advance Payments of the Premium Tax Credit (APTC)
A federal payment directly to a carrier that pays for an individual's or famiy's (Marketplace) medical plan insurance. The APTC lowers the cost of health insurance for individuals and families. earning between 100% - 400% of FPL. Individual or Families earning between 100%-250% of FPL also get CSR relief. See: Periodic Data Matching (PDM), CSR, FPL, ACA eligibility
Advanced Aggregate
Advanced Aggregate is a sophisticated funding and reinsurance coverage combination provided applied to ERISA exempt entities, and other well-staffed organizations capable of managing it. It essentially advances an aggregated reinsurance recovery on a loss that happens early in a year (and whose associated Specific reinsurance recovery is inadequate to meet the liability) based on an annualized-trended aggregate attachment point. Claim is adjusted on a prorated bases to give the client funds to pay part of a massive bill on what an underwriter believes will be an aggregated claim attachment event trended for the entire 12-to-18-month period (whose event happens early in the year before aggregated accounts are fully funded by the policy owners). In context to ERISA, it is reinsurance over a single or multiple self-funded employers is provided by advancing aggregated recoveries for risk between specific retention and a percentage of the fully funded and underwritten major medical insurance premium. It can apply to many forms of organizations, coverages and programs able to effectively fund the "entity's" SIR, and/or group funded common deductible(s). These are pretty rare. See: Inner Ag which is not the same thing.
Advanced Alternative Payment Models (APMs or Alternative Payment Contracts)
A CMS compensation model whose goals are for better medical outcomes at lower cost by getting medical providers to commit to a different compensation method and focus on preventing disease instead of treating it after occurance. ===== Qualifying APM Participant (QP) Threshold Update On December 27, 2020, the Consolidated Appropriations Act, 2021 was signed into law. Under this law, the Quality Payment Program’s Qualifying Alternative Payment Model (APM) Participant (QP) thresholds for payment years 2023 and 2024 are frozen at 50% for the payment amount threshold and 35% for the patient count threshold for performance years 2021 and 2022. The partial QP thresholds have also been frozen at the same levels used for the 2022 payment year and 2020 performance year. See: QPP, MACRA, ACO's

Advanced Premium Tax Credit (APTC, or Applied Premium Tax Credit)
ACA authorized entitlement Tax credits that reduce the members monthly premium costs by the amount of credit. Credits are paid directly from the Federal Government to the private commercial insurance carrier. Enrolled members earning between 100% - 400% (but now under Biden its up to 600%) of Federal Poverty Level (FPL) are eligible for the credits. It can also refer to Medicare eligible beneficiaries that may also be purchasing a tax-credited eligible commercial plans. APTC is not CSR, Cost Sharing or Federal Marketplace reinsurance. Total advance premium tax credit payments increased to $20 billion, from $12 billion in 2014. (Source: Think Advisor May 2017) APTC is not CSR or Federal Reinsurance. FYI: given the cost of buying private insurance is massive, elimination of the APTC would surely mean massively less people buying insurance and showing up in the ER. We have already seen a kind of epidemic of insolvent small hospital closings because their communities fail to pay for insurance or the care they demand. See: American Rescue Plan

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
Affordability (Insurance Affordability Program)
A federal percentage of AGI/MAGI that when exceeded qualifies Individuals/Families for APTC. For 2022 -for Individuals (AGI) or Families (MAGI household income), APTC applies where insurance costs exceed 8.5% of income (for Individuals and Families). For employers insured with SHOP plans, the EMPLOYEE'S group medical plans, and the employee's GROUP insurance premium contribution exceeds 8.5% (AGI) to participate, then the employee qualifies for the tax credit (ICHRA). (If the employer is bigger than 50 FTEs, and the employee also enrolls in an FFM INDIVIDUAL plan with an APTC, then the employer faces a penalty tax of a flat amount for each individual (over 50 FTE with the first 30 FTE not counted). This gets complicated with 30 employees being exempted, and FTE being defined at 30 hrs/w. --- For Individuals, it's an ACA (HHS) legislated/regulated term defining eligibility for Marketplace APTC on QHP purchased "On- Exchange" or "at Marketplace" plans. See: ATPC. Citizens and non US citizens who file tax returns are eligible. Or, a Legislated maximum percentage rate (of AGI / MAGI) set by CMS to determine APTC for individual plans, and up to two years tax credit for groups under 25 FTE (SHOP plans). See: SHOP tax credits which are essentially for the first two years of a GROUP plan. We recommend you confirm liability with your CPA. Check employer penalty rules and conditions. Rules and employer penalties related to employees electing to buy INDIVIDUAL marketplace coverage over "unaffordable" (as the employee's contribution to the premium) employer offered coverage are different, and also have a (ALE - Applicable Large employers over 25 FTEs) penalty. Employer penalties were not repealed, but individual penalties were repealed. See: Applied Premium Tax Credits, ALE and ACA law. "Some states rely on for all ACA exchange services. Others, such as Nevada, have been using enrollment and account administration systems but manage their own marketing programs. managers want to cut the user-fee that plans charge issuers 3 percent of premiums, from 3.5 percent, for issuers in the states in which handles all exchange services, and to 2.5 percent, from 3 percent, for issuers in “partnership” states. Cost-sharing (see: CSR) and affordability limits: Here’s what could happen to some parameters that affect whether your clients have access to coverage considered “affordable,” and what out-of-pocket costs for an exchange plan user might look like. Employer plan affordability cut-off: Self-only coverage will be considered affordable if it costs up to 8.39 percent of projected household income (MAGI), up from 8.3 percent this year. See: State Medicaid Program under title XIX of the Social Security Act, CHIP under title XXI, and State basic health program established under section 1331 of ACA act. Eligibility for a Marketplace Catastrophic (Catastrophic plans are offered only under special enrollment - hardship, and not generally available to Individuals) plan kicks in if the lowest priced coverage available costs more than 8.27% of AGI or MAGI as applicable. GOOD LUCK figuring it out for a $25 per month commission.

Affordability Contribution Percentage
Term used to calculate if a Group (QHP employer offered plan) is affordable for purposes of avoiding an employer tax penalty, or Individual employee eligibility for a ACA available tax credit. If an employee's medical insurance contribution is more than 8.5% AGI, than the employee becomes eligible for APTC, and the employer may get a flat tax for each employee (over 30 lives exempted in groups whose total size exceeds 50 FTEs) Means if an employee earning more than about $13,000, and whose health insurance contribution is more than about $93/m for QHP insurance, that employee becomes eligible for INDIVIDUAL marketplace tax credit, and the (ALE) employer gets fined about $3,500 for EACH employee getting who actually buys an INDIVIDUAL receiving a marketplace plan APTC.
Affordable Care Act (ACA, PPACA, Obama Care)
The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA/Obama Care. The ACA (Affordable Care Act) is an 800+ page law encompassing all medical care in the US, but with very limited application to Veteran's affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 minimum essential benefits (MEB) without annual benefit limits (that comprise a QHP), tax credits for individuals earning below 400% of Federal Poverty Level (FPL), Cost Sharing for people earning between 100%-250% of FPL and reinsurance safety net. CRS and reinsurance were/are regulatorily enforced, and not part of original ACA. CSR lowers deductibles and max-out-of- pocket costs for individuals and limits personal total annual health expense (spend) from (about) 2% to a maximum of 8.5% AGI/MAGI. (Biden increased it under special COVID need and authority). Small employers (under 25 FTEs who are not ALE's) are offered tax credited plans through SHOP, where commercial carrier sponsor offers them (which is practically nil). 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. Source: AHIP SmartBrief: " 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. We recommend all tax questions be directed to CPA's or Licensed attorneys specializing in tax. See: MLR, APTC, ACA final Rules, etc.
Age Compression Rule (spending cap ratio, Age Banding)
A provision in the Patient Protection and Affordable Care Act (ACA) that mandates (commercially insured marketplace plans - not Medicare) premiums be not priced more than 3:1 difference between a 21 year old's rated premium and an older adult. Meaning, ACA QHP premiums charged to older people (i.e. aged 55-64) cannot be more than three times the price of premium charged to a young person. (i.e. age 21) . See Medicare-for-all, and Medicaid-for-all. FYI there is no agreement on what the rule is called, and the Trump administration did allow the carriers to price plans in violation of ACA precedent. See: Silver Loading. Pere 2022 Marketplace Agent Exams: Federal Age Rating Standards use 0-14, and 15-63 where premiums cant be greater difference than 3:1. Age Banding... (per ACA regulation) States can establish their own age curve or default to the federal age curve. Federal age bands: 0-14 One-year bands between ages 15-63 64 and older Its a work in progress where the standing President's regulators can adjust age bands.
Agency Resourse Management Systems (ARM)
See: CRM. These are systems that come in all sizes and shapes but rarely are the end all to a complete long term customer interface from introduction to sale, to accounting, renewals, commission, etc... Most do well at either managing the actual book of business and its renewal, or identifying the prospect through sale, payment processing, coverage binding and policy delivery.
Agent Statement of Enrollment Correction (ASEC)
A group employee census form required by some commercial carriers to finalize open enrollment (renewal or policy change and replacement).
Aggregate Claims Bases
(In context to a liability contract) A liability policy coverage term defining if the policy limit applies to all claims, or to each and every claim event (restored limits for each loss) incurred in a policy period. Some Policies also detail separate limits for "incident response" as a separate limit to the policy limit. Same would apply to most if not all defense costs that may be stipulated by state law as insured, but not attributable to policy limit. Aggregate in stop loss, reinsurance or excess of loss is not the same definition. In general, when aggregates trigger in excess of loss types of contracts, the specific coverage turns off, and claims are payable at 100% of every dollar of loss. These are very rare events in employer stop loss policies offering one or both coverages (Specific and/or aggregate only) of less than 1:1000. This does not hold constant for stand-alone aggregate policies. Aggregate stop loss or reinsurance is very rare in some kinds of policies, and typically requires Specific stop loss commitment to offset substantially higher carrier losses if the aggregate attaches.
Aggregate Pharmacy Reinsurance
Aggregate Pharmacy Reinsurance is stop loss or reinsurance coverage triggering at 110%-125% of last year's trended claims history. Second dollar coverages in pharmacy policies can be highly complex, and have many carve outs, and PBM duties and functions. Typically, not all Specialty drugs are insured. Infusion therapies, cost bases, administrative fees, and reimbursement schedule(s) can dramatically effect coverage. See: AWP, PBM
Aggregate Stop Loss/Reinsurance
Typically it is a second-dollar insurance triggering payment after (typically) 125% of last year's trended medical claims history. Some risks can attach at 105%-110%, if its big enough. It is a per population per year coverage, that once triggered pays out without additional (specific) deductible application - this can be a career-killer for a VP. Competing premium offers brokered can range more than 100% in cost for same ERISA related coverage. Aggregate Stop Loss can provide coverage against an entire population's budget overrun in a calendar year. Typically, Aggregate coverage is not available without also purchasing Specific coverage. See: Pharmacy Aggregate insurance which is available without Specific cover.
Aggregating Specific Deductible (ASD, Inner Ag, Split Funded Arrangment)
A "second" deductible on top of the "specific" deductible that must be paid by the insured to "itself", and that must be satisfied before a policy owner gets stop loss or reinsurance recovery paid by the carrier. 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 stop loss claims excess of $50K until it reaches $100K. At that point, the reinsurer then reimburses "all" eligible claims excess of $50K to the terms of the stop loss policy. Properly done, the insured "self-funds" (deposits in a separate personal account each month), an amount equal to 1/12th of the $100K ISD to be available for "expected" claims payment. This process effectively eliminates: Premium tax, agent commission, and carrier overhead and profit margin, reinsurance costs, and actuarial fudge factor thereby lowering "expected" costs" on an additional $100K of premium (that was not directly paid by the employer to the carrier to fund the first $100K of stop loss claims. There are derivatives of these arrangements where the stop loss premium is "fully funded" (entire premium is paid at the single deductible level) each month, but that a portion (equivalent to the ASD rated premium - "second deductible trigger" part of the discounted-premium) is held by the reinsurer instead of the insured to pay claims timely. See: Finite reinsurance, but don't make too many parallels, in context to if it meets minimum risk transfer GAAP or other standards.
Alarm Fatigue
A term used to describe medical providers simultaneous monitoring of multiple high technology alarms, and becoming numb to which one(s) that require immediate intervention. As the iOT - 5 billion devices become connected over the next two years becomes reality, AI programed alerts promise some solution to alarm-fatigue.
All Other Perils (AOP or Open Risks Policy)
In context to property policies (typically residential), means All other perils, or causes of loss. Depending on the state and/or policy (HO3, HO4, HO8, HO5, DP1, DP3, etc) perils (sometimes referred to as hazards) may be excluded, or specifically included in their own separate coverage (and added premium) under separate deductible SIR. For example, a house policy would have Wind/Hail (hurricane) coverage AND AOP (that includes fire, but not Flood coverage).
All Risks (Direct Physical Loss)
See: Homeowners insurance, Commercial Property polices. Know that most "All Risk Policies" insure theft, as apposed to "Named Perils" policy that do insure it (and potentially others coverages not insured by an "All Risk" property policy form.
All-Care Readmission (ACR)
All-Payer Claim Dadabase (APCD)
See: Colorado - Medicare
Allostatic Care or Influence
A term usually referring to food insecurity's relationship in older adults, but significantly affecting outcomes of care and cost. "The researchers determined allostatic load by evaluating nine biomarkers that indicate dysregulation of the inflammatory, cardiovascular and metabolic systems. Allostatic load scores ranged from zero to nine, with higher scores indicating a greater risk for physiologic dysregulation. Participants were considered moderately food insecure if they reported that they did not always have enough money to buy food in the past 2 years, while those with severe food insecurity reported the same experience in addition to eating less than they felt they should in the past year due to financial struggles." Source: Helio

Alternative Payment Methods (APMs)
A general term used in affording medical care and tied pretty strongly to people actually getting the care to restore their health by complying with prescribed treatments - and generally proven to improve medical outcomes at a lower longer-term cost. These can be a medical credit card, individual provider created payment plans, coordination of medical benefits (especially with MA plans), manufacturers rebates and freebees..., etc.

Alternative Payment Model (APM)
See: MACRA, QPP, ect

http://2020 QP Notice for APM Incentive Payment zip file

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 (that almost never traditional Medicare DRG, Medicare allowable FFS, etc), 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 accountability and reimbursement incentives. One goal is to try to change prevailing medical provider FFS procedure maximization behavior driving premium costs beyond what is affordable. Primary contracting types include: Fee for service, Management Fee, Bundled Payment, Shared Savings or Shared Savings & Risk, Performance Incentives (See MIPS, QPP, MACRA, Pioneer ACO's, etc)
Amazon Care
An Amazon PPO network available to Amazon employees, and recently being pitched to many large insurers like Cigna and Blue Cross. Works off a phone ap. Focus is on telemedicine, but can also be person to person. Rumer has it the medical provider reimbursements are value based, but likely its discounted fee for service in most cases, and not a subscription fee for the larger carriers being courted to use the network. Amazon would likely be using similar tactics as MultiPlan. Amazon charges the patient a copay. See: VBA
Ambulatory Care Sensitive Condition (ACSC)
Ambulatory Payment Classification (APC)
Ambulatory Payment Classifications (APCs)
Ambulatory Surgical Center (ASC)
What CMS calls outpatient surgery centers. The term can mean an off-site surgical care suite, or a physician owned surgical center, etc. Many payment rules apply by line of coverage and limitations.

American Association of Insurance Services (AAIS)
An agency that standardizes P&C policy forms. See: ISO
American Families Plan
President Biden's healthcare (and more) agenda.

American Health Insurance Plans (AHIP)
A lobbying and commercial trade group comprised of health insurers who strongly support APTC.
American Hospital Association (AHA)
American Medical Association (AMA)
American Medical Group Association (AMGA)
See: AMA, AHA, MGMA, etc
American Rescue Plan Act of 2021 (ARPA)
Federal Legislation signed by President Biden in 2021 directing: "President Biden signed the American Rescue Plan Act of 2021 (ARP) into law on March 11, 2021. ARP makes major improvements in access to and affordability of health coverage through the Marketplace by increasing eligibility for financial assistance to help pay for Marketplace coverage. The new law will lower premiums for most people who currently have a Marketplace health plan and expand access to financial assistance for more consumers. Below are some answers to how this act will take effect for members enrolled on and at the bottom have provided links to separate FAQs for our WA and CA members. Information is updating constantly, we will continue to communicate changes as they occur. Frequently Asked Questions for Enrollments When will the increased subsidies be available? • Extra tax credits will be available to preview and opt into beginning April 1st on • 2021 Special Enrollment Period (SEP) in response to the Covid-19 pandemic runs from 2/15 through 5/15 • New enrollments and plan switches can only occur through 5/15 • Individuals can opt into the additional subsidies at any point throughout the year outside of the SEP period • These expanded subsidies will be available to clients with on-exchange plans throughout all of 2021 and 2022 What does a member need to do to take advantage of these new subsidies? • Currently states they will NOT automatically update premium tax credits on behalf of current enrollees, so members will need to go back into their account and opt in to determine their APTC eligibility Does a member need to opt in by the 15th of the month for the new subsidies to take effect by the 1st of the following month? • No, the subsidy redetermination process follows the same deadline guidelines as the current Pandemic SEP, so a member needs to opt in by the end of the month for the subsidies to take effect the first of the following month, e.g. April 30th for a May 1 start date What happens if a member doesn’t opt into the expanded subsidies in 2021? • Tax credits will be reconciled when on-exchange members file their 2021 taxes in 2022 What happens if a member isn’t enrolled in an on-exchange plan for 2021, can they still get the new subsidies? • Members have to move to an on-exchange plan by 5/15 in order to be eligible to receive the expanded APTC. Off-exchange plans do not qualify for APTC reconciliation on their taxes. What if a member is on-exchange plan for 2021, but didn’t provide their income because they didn’t qualify for subsidies at the time, will they qualify for subsidies now? • They will need to update their income on-exchange and opt-in to have their income verified on their taxes What impact will this have on consumers? • The subsidy increases are large enough that people with incomes at: • 100-150% of the FPL will have $0 monthly premiums if they select most Bronze plans or 1st or 2nd lowest cost Silver plan in their region • 150-250% of the FPL could see their subsidies increase by 50-70% • 250-400% of the FPL could see their subsides increase by 30-50% • Greater than 400% of the FPL will be eligible for subsidies for the first time ever if their insurance costs exceed 8.5% of their income (Gross or net).=========== What about members under 100% FPL? • Unless these members received Unemployment Insurance during one week of 2021 they will not be eligible for What plan determines how much subsidies a consumer will receive under the new law? • The second lowest cost Silver plan in a region will continue to be the benchmark plan for subsidies If an employer offers dependent coverage without financial help for those dependent premiums can those dependents now qualify for the expanded APTC? • At this time the new law does not change the eligibility for dependents who are offered coverage as long as the coverage offered to the employee only is considered affordable, which not means it has to cost less than 8.5% of their household income What happens if a member received Unemployment Insurance in 2021? • Individuals who are approved for or receive an Unemployment Insurance benefit during any week in 2021 will have their income treated as 133% of the Federal Poverty Level (FPL) for purpose of calculating their tax credit eligibility, regardless of their total annual income • This means they will be eligible for $0 monthly premium if they select most Bronze or the two lowest cost Silver plans • These subsidy increases will expire after 2022 and will revert to current levels Will this law change deductibles or out-of-pocket maximums? • No, not unless a member enrolls into a different plan. If they enroll into a different plan type with Molina we are working to get any out of pocket costs already paid credited to your new plan’s accruals towards the deductible and out of pocket maximum. Will this law change the CSR (Cost Sharing Reduction) Silver plans? • No, the FPL guidelines for these plans will not change under this law If a member changes plans or opts into the new subsidies will this change the Agent or Record on file? • No, the AOR should stay the same. The AOR would only change if another broker assists the member with their plan change or redetermination and the member updates the AOR. What about members’ 2020 taxes if they received too many subsidies? • Members will not be required to back additional subsidies they received on their 2020 taxes • If they have already filed their taxes and paid back 2020 subsidies, they should file an amendment What about members on COBRA? • ARP will allow up to six months of temporary COBRA subsidies to cover 100% of the premium cost, beginning no earlier than April 1, 2021 and ending no later than September 30, 2021, depending on current COBRA eligibility" Source: Molina Broker Advisory

American Sign Language (ASL)
Annual Benefit Limits
A maximum annual insured amount specified in the policy contract. Within context to ACA law defining QHP, 10 essential healthcare benefits (EHB, aka minimum healthcare benefits) are unlimited. The Trump administration ignored ACA law prohibition and allowed STM plan, and the Biden administration is not demanding stoppage QHP plans. See: Scheduled Medical plans Plans, STM plans that also exclude (ACA prohibited) cover of preexisting medical conditions.
Annual Enrollment Period (AEP)
A CMS defined period allowing people to enroll in ACA compliant medical plans. Enrollment periods are not the same. Group plans administering "Open Enrollment Period" is not the same.
Annual Notice of Change (ANOC)
The required annual update made to CMS insured lives explaining changing conditions of coverage, and network access. See: OON
Annual Payment Update (APU)
Annual Payment Update (APU) is calculated. See the Hospice Quality Reporting Spotlight webpage for details related to nursing home reimbursement rates and updates (HQRS)
There are two basic types of annuities: Fixed/Fixed-Indexed, and Variable. Fixed cannot crash when the stock market crashes. Variables can crash when the stock market crashes. Generally, a fixed annuity guarantees a flat interest (i.e. 2%/yr over 10 years). A Fixed-Indexed annuity contractually promises an interest crediting range (i.e. 0% - 10% cap/yr) (IUL policies also have a Minimum Guaranteed lifetime interest rate too). Variable annuities contractually promise to credit interest based on (typically) a stock market ETF (NASD, S&P, Russell 2000, etc.), and ARE directly invested in the stock market. Variable annuities can be capped or uncapped, and typically offer vastly higher crediting (capped and uncapped with many variations and option features), but are exposed to stock market crashes that can lose "principal" (Cash Value or Accumulation value). People traditionally buy Fixed, and Fixed-Indexed annuities for safety and hedge against inflation risk, (but at 2% interest GUARANTEE, and inflation at 2% or more, that hedge, or net value over time may not be optimal, let alone be more than inflation). Like any state authorized and licensed insurance product, Annuities are guaranteed by their AAA rated company (recommended), and each state's Guarantee Insurance Association. Each state's guarantee association has its statutory limits, so confirm the limits with your state's DOI. Annuities can be complicated and offer several features and guarantees. A key feature of many annuities is an "Income for Life" provision option that can protect against running out of money in old age. The provision contractually allows disbursements (i.e., 4%, 5%, 6% of annuity value depending on the age payments start) every year until death. Typically, Income for life features have a separately running contractually GUARANTEED ANNUAL interest crediting promise at (now about) 6%-8%. (Some entities call this an income roll-up or GMIC) The same annuity has a separately running GUARANTEED minimum 2% over its LIFETIME interest guarantee, so think of two separate columns accumulating value. If Income for life is elected at the end of the original (i.e. 10 year) annuity period, the amount earning interest in the future is far greater than what a standard guaranteed minimum fixed interest is at say 2%. Income for life features typically require FORCED ANNUITIZATION which means once it gets elected and the payments start, it is fixed for life (to death), and the annuity cannot be liquidated. Meaning, you cant cash-out of the annuity if a big sum is needed unexpectedly. If an individual is insurable with life insurance, an IUL typically (contractually promises) offer massively higher interest crediting cap (range (i.e. 0% - 10% or even higher) with essentially the same safety, but with the added protection of life insurance many people already are incurring/insuring the cost, but not leveraging for maximized "pension" (not taxed as income) distributions (taken as IRS compliant loans) at retirement. Ex. 2% interest crediting on a 10-year fixed. Fixed annuity growth distributions are taxed as INCOME, whereas IUL growth (using IRS compliant) loans are not taxed as income. Ask any financial planner what your after-tax return will be if you follow their advice and listen carefully how investing in taxable things massively costs more over a 10-30 year period. And, in most cases, most alternative securities-investments require taking market-crash risk. Do the numbers, and work to ask questions until you understand it, or don't do it. IUL will force you to consider tax effects which can radically change what you get to enjoy in retirement over a 20-30 year term. Not sure if your agent or fiduciary is informed? Ask him/her, How do the loan interest charges work in the first 10 years of an IUL, and thereafter? Call for the other acid-test questions that will allow you to know if your agent, or fiduciary is fully informed on the product before you buy. Prepare to be shocked by expected income tax payable in the future. (i.e. If you spend growth of $100,000 income each year for 20 years (from age 65 to 85) = $2,000,000 x .25% sample income tax rate on growth from = $500,000 income tax) See: IUL === Annuities and IUL alternatives can be complicated, so prepare to spend the necessary time to understand the moving-parts. i.e. Guaranteed minimum interest rates (2%) over the entire policy term, contractually promised annual interest crediting range caps from 0% - over 12.5% or more historically, Guaranteed lifetime income interest crediting rates (6% - 8%), many kinds of Bonuses (profit sharing payments to you from the carriers not unlike Dividends in whole life policies or shareholders), term riders, Income Tax considerations, etc. Always read the entire annuity and ask questions until you understand it. Many companies offer different features, guarantees, bonuses, and contractually promised interest crediting cap features and terms. Do the work to understand the moving parts and features available of the entire lifetime, and ask questions until you understand it, or dont buy it. We offer this information as a courtesy to people struggling to understand annuities, and their close cousin - IULs (which is essentially a life insurance policy attached to a Fixed-Indexed annuity, but with massively higher contractually promised annual point-to-point interest crediting caps. We recommend working with experienced agents that can bring multiple carriers to the table for competitive offer. We only quote AAA rated carriers. This is not tax advice, so confirm any tax questions with a licensed CPA or attorney.
Annuity Best Interests Rule (NAIC Model Rule 275)
An annuity rule directing BIC standard in some states.
Annuity Model Rule 275 (Applies AZ, AR, ID, MI, RI, DE, OH, VA, TX, MT)
As part of BI contract and regulations in context to (agents not financial advisors), agents: Know customer's financial situation, understand applicable options, believe its in the best interest of the customer, and communicate basis or bases of recommendation. See: senior suitability, suitability and good luck complying with understanding product offerings an agent is prohibited from selling without a securities license, or products an agent is not appointed (or yet trained yet) to sell.
Anthem (Anthem-Blue Cross-Elevance)
Anthem relates to (at last count) 14 states where Blue Cross Plans are sold. The other states have an independent Blue Cross plan with a commonly shared Blue-Card program offering contracted rates OON, and where the patient, or self funded plan may be contractually prohibited from questioning anything Blue Cross pays, or questioning Blue Cross payment for experimental services, and/or Blue Cross case management/oversight, fiduciary duty/contracted case management/etc. See: Eligible and insured care, experimental procedures coverage, BIC, including PBM. Anthem is rebranding (2022) to Elevance from Anthem.
Anti-Concurrent - Causation Theories (ACCD)
In context to property policies and theories of recovery - it is a rule or policy provision denying coverage when the sequence of an uninsured peril causes an insured peril's loss. Means, none of the loss is contractually insured. Some states limit or prohibit the rule. A provision limiting or denying coverage when an uninsured or excluded peril causes an insured peril to trigger a loss. It assumes the initial cause of loss is known. See: EPC & CCD.
Anti-Money Laundering (AML)
See: Florida complance for many different kinds of licenxed professionals.
Antitrust Healthcare

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.

Application Programming Interfaces (API's)
A term CMS uses when describing interoperability and Patient Access Final rules related to data exchange through secure portals.
Applied Medical Software (AMS)
Applied Premium Tax Credit (APTC or PTC)
An ACA authorized tax credit paid by the federal government directly to a commercial carrier that reduces premiums for INDIVIDUAL enrollees earning between 100% and 400+% of FPL (or paying more than about 8.5% of AGI/MAGI (employee contribution) for their employer's policy). CBO estimates $920 Billion (taxpayer's cost) for 2021. Actual numbers are reported at $8.3 B for 2020. SHOP tax credits are totally different. See: SHOP APTC is not CSR, or federal reinsurance (on Marketplace participating plans). Form 1095-A (for Individuals) 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. See: ACA Forms See: COVID rules re: APTC and workers comp, unemployment comp, etc. Talk to a CPA. "The new temporary COVID-19 emergency rules have made affordability calculations more generous, increased the size of the premium subsidies, and removed the 400% of federal poverty level eligibility cap. If calculations show that an exchange plan would cost too much to be affordable for an individual with income at 800% of the federal poverty level, that person could qualify for some premium subsidy help." Source Think Advisor March 2022

Appropriate Use Criteria (AUC)
In context to ERISA, it is contract provision in the SPD mandating disputes be settled by an arbitrator versus a court. Some courts have held it is enforcible, and others not. Depends alot on who has right to sue under ERISA, and if the member was provided adaquate notice, or informed conscent.
Area Health Resources File (AHRF)
ARPs (Association Retirement Plans)
See: Secure Act, MEP. PEP, MEWA Essentially an ARP must meet certain criteria to be a "qualified" (pay whose payroll taxes are deferred) plan. Plan must be bonified with formal organizations documents expressing control over the ARP. PEO's may now sponsor such organizations. We recommend prudence. See: PEP
Artificial Intellegence (AI)
An new generation of "learning" software able to detect, garner, and update it's own data sets, and purpose (goals) maximization. Lets pray its designers program safeguards preventing machine learned conclusions identifying humans as the minimized value preventing optimized goal(s).
ASC Quality Reporting (ASCAR)
See: Medicare, QPP
Assignment of Benefits (Assignment)
A contractual insurance policy provision allowing payment for services directly to the medical provider, and not directly to the insured. See: AOB The term can have additional contractual requirements/meaning within accepted P&C policy terms.
Assistance Eligible Individuals (AEI)
In context to pandemic relief efforts and ARPA passage, and extenteded workers compensation payments, it relates to who gets what amount of payments, and how not to count unemployement compensation into AGI/MAGI calculation for APTC credits "estimation". See: ARPA
Association Health Plan (AHP)
See MEWA HHS Final Rules under President Trump's Executive Order allowing expanded "association" health plans operating across state borders, and without solvency standards established under existing state law. A recent federal court ruling has placed an injunction over such plans declaring they violate existing state laws - i.e. ERISA (federal and combining state laws) authority, are still subject to state compliance and prosecution regardless of federal agenda. 12 states are suing DOL for overstepping their ERISA administration authority, (and not enforcing ACA law) and to stop these kinds of plans from offering plans that do not offer unlimited EHB and QHP compliant insurance coverage. See: MEWA That said their are Association sponsored health plans that follow ERISA guidelines, and that are not prosecuted by state authorities. Many types of plans are sponsored by various "associations" including limited medical plans, etc. Major Medical (QHP) plans must be heavily scrutinized by competent expertise to assure against uninsured perils.

Automated Clearing House (ACH)
A payment method Typically referring to automatically paid items by checking account or credit card granted authority.
Automatic Extreme & Uncontrollable Circumstances Policy
See: MIPS re: Covid
Automatic Extreme and Uncontrollable Circumstances (Risk Factor)
See: MIPS, DRG Modifiers, Severity levels, etc.
Automatic Reinsurance
See: Treaty Reinsurance A reinsurance policy that automatically accepts each new policy or risk written by an authorized underwriter, agent, agency or carrier. In other words, each new policy (addition to the reinsurance policy) sold does NOT require reinsurer approval. Sometimes there are risks that must be vetted and separately approved by the reinsurer, prior to binding if they materially violate the character, underwriting protocols or treaty risk transfer terms. See: "retrocessionairing" related to third tier risk transfer.
Average Rate of Return (ROR)
The gain or loss on an investment over a specified time expressed as a percentage. Know what you are doing comparing any percentage change against a resulting asset ($) value stated in dollars. If you are not sure, ask questions until you are sure. See: CAGR
Average Total Number of Employees (ATNE)
The number of employees used to calculate MLR for purposes of premiums rebates to customers. i.e. Plans not paying at least 80% (individual plan members) of premium towards claims are mandated to rebate the difference to plan members. The feds target a 3% profit margin for carriers insulated from Sherman and Clayton antitrust.
Average Wholesale Price (AWP)
Term used to calculate regional drug pricing, that is also associated with a total cost per script filled inclusive of an administration fee typically at i.e $.5 + per script. Medicare Pharmacy is a different story using ASP or Average Sale Price. This gets complicated when manageing both commercial, medicare and/orMedicaid Rx - especially with power to automatically replace Brand Name with Generic drugs. Amazon just advertised $6 for 6 months of some Rx. See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing bing applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter. “CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.”

Avoidable Hospitalizations
CMS MA Member analysis (Humana MA lives). "Adjusted analyses showed: The rate of emergency department visits per 1,000 patients for two-sided risk models was 375.8, compared with 434.1 for fee-for-service. Compared with fee-for-service, two-sided risk models were associated with a nearly 16 percent reduction in avoidable hospitalizations, compared with about 4 percent for all-cause hospitalizations. No significant differences in use were found between beneficiaries cared for under upside-only risk models and fee-for-service for all outcomes." Source: Beckers Payer Issues 3/22/22 See: CMS VBP


Bad Faith
Intent to decieve. In context to insurance: A legal term describing a carrier's intentional, obstructive, and/or inappropriate act(s) to avoid paying a legitimate claim. ERISA eligible Associations and Joint Underwriting Associations cannot be sued for Bad Faith. In other words, an association member cannot sue (himself), even if he personally does not have anything to do with claims administration. Carriers convicted of Bad Faith face treble damages, and ratings downgrades if the violations(s) are severe. See: ERISA
Balance Billing (Chapter 167, Bill aboves)
Congress passed a law to end some balance billing (commercial plans) in December 2020. Balance billing is the difference between a (out of network - non contracted) billed charge, and a contracted rate insured, accepted and paid by the carrier, and whose difference is charged to the insured (patient). Balance billing does not occur for in-network care. Balance billing does not occur in uninsured patient billing. Balance Billing is prohibited on Medicare and Medicaid patients. Many laws and rules apply by most states, and plan types. CMS published interim rules detailing bans on: ER services, OOA for ER and non-ER services mandating coinsurance be the same as in-network care, OOA for non-contracted physician services in in-network facilities, and several OOA charges without advance notice. (Good luck with the last one) - Interim rules are effective 1/1/22, but most carriers have actively been adjudicating these disputes for a long time. Balance billing amounts do not attribute to deductibles, out of pocket expenses, or maximum limits in a policy, and can create substantial uninsured liability for commercially insured members receiving Out Of Network (OON) care. Balance billing issues can be very contentious, and complicated by several federal and state laws extending certain periods of informed notice, and limiting provider UCR billing authority. Recent federal law (no surprises act, etc) prohibits many practices, but essentially requires the "Buyer to Beware", with recouse over violations going to either the DOL or Department of Treasury, or state grievance agency who may, or may not enforce consumer rights. Multiple Supreme court decisions have been made involving medical billing, as well as long standing MDR fee schedule judicially directed policy and pricing standardization methods (see: SUNY program and history over United Healthcare losing their court decision and SUNY being the independent arbitrator calculating R&C) for commercial (individual and most group plans) billing. It is a very good idea for all medical providers to stay informed on various Buy-in to Medicare, and Health Cost Share offerings shaping their target-markets. See: UCR, R&C, ERISA, Medicare Allowable, statutorily set fee schedule limits by "coverage" type by state, subrogation, etc. I.e. Medicare, Medicaid, Workers Compensation, PIP, contracted rates and terms, MDR, HIAA, "Average Regional Charge/accepted charge", GPCI, etc. See: Chapter 167 Florida law, and Consolidated Appropriations Act 2020 (APR). See: Trump EO that Biden did not eliminate.
Florida synopsis

Basic Health Plan (BHP)
See; NY and MN SBE available medical plans enjoying enjoy APTC, See: Enrollment.

Benchmark Plan
A federal Marketplace term with two meanings. 1. The second-lowest-cost Silver plan, and/or, 2. a plan insuring EHB each state has right to define. See: QHP, and EHB and know states have a say if they step up to create their own exchanges and manage it.
Benchmarking (Reference Based Pricing)
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.
Benefits Coordination & Recovery Center (BCRC)
See: Medicare BCBC, MSP, NGHP

Benefits Coordination & Recovery Center (BCRC)
Best Interest Contract (BIC)
See: Fiduciary duty, and know it is not the same for insurance agents, and broker dealers. Florida Insurance Agent Standard of Care A Florida insurance agent has the following standard of care: An insurance agent1 owes a duty 1) to use reasonable skill and care to procure insurance that the insured specifically requests or to timely notify the insured if such coverage is unavailable, 2) when providing insurance-related advice, to do so in a non-negligent manner, 3) to obtain insurance coverage which is clearly warranted by the insured’s expressed needs, and 4) as a fiduciary, to inform and explain the coverage secured at the insured’s direction and to make no unilateral changes without advising the insured. In addition, a recent decision from a federal court has articulated a duty to advise where the agent and insured share a “special relationship.” An insurance agent may also owe a standard of care to the insurer to act within the scope of authority granted by the insurer." Source: Agents E&O Standard of Care Project Florida Survey April 2014 === On April 6, 2016 the DOL published the Conflicts of interest - retirement Investment Advice regulation Implementation of a fiduciary standard for investement advisors, AND plain insurance agent's duty was determined by DOL without distinction to products that can, or cannot crash in the (stock) market, or that are, or are not guaranteed safe by each state's Insurance Guarantee Association. Authorized insurance policies are guaranteed safe (to each state's Insurance Guarantee Association limits). Marketable securities (Stocks, bonds, etc,), are not guaranteed safe, and do crash in bad markets. The after shock caused at least two investment houses to stop offereing (marketable securities) services to non-wealthy people who ironically are the same people that need advice the most to avoid running out of money in old age. A fiduciary standard recognizing no distinction between products at risk to market crashes, and those guaranteed safe by state insurance guarantee associations, along with contractually promised interest crediting (i.e. 0% - 10% range S&P ETF) promises (like life insurance products with fixed and fixed indexed annuities - IUL) - or, practically makes impossible - defending an allegation that, "It should have earned more interest" 5-30 years down the road - from the same person who cannot remember what they had for dinner, let alone what they considered and accepted 10+ years prior. Our strong recommendation is take the time to ask questions about any investment (or insurance coverage you consider important) with or without (Guarantee Association) safety, or contractually assigned interest crediting. If you do not understand it, ask questions until you do, or don't accept the offering. As always, caveat emptor applies. Do the work.

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

BIC (Best Interest Contract)
A term whose meaning has come under extreme review by state and federal authorities to determine a financial planner's obligation, or duty to his client - especially in context to retirement account rollovers and advice. "Reg BI" is the DOL higher obligation, versus a lesser obligation when state-level fiduciary rules are considered. "Both Reg BI and the DOL’s fiduciary standard require "advisors" act in the client’s best interests, but the two standards are not exactly the same when it comes to (retirement account balance) rollover recommendations. Each rule requires that the advisor conduct a detailed analysis to determine whether the rollover is in the client’s best interest—meaning that the advisor must evaluate "all" potential options, such as taking a distribution or leaving the funds in the current plan, in comparison to rolling the funds into another "plan", in light of the client’s goals and financial position (suitability). Insurance professionals are not under the same standard. See: Senior Suitability in context to annuity sales and explicitly required (by most states) completed forms that must be processed detailing key questions. However, the DOL rule applies only if the advisor, or firm is a fiduciary to the plan in question, or a "fiduciary" with respect to the plan participant. Reg BI, on the other hand, applies anytime that a rollover recommendation is made to a retail investor, regardless of fiduciary status and regardless of whether the plan in question is an ERISA-covered plan. Further, if the rollover recommendation could trigger a conflict of interest, Reg BI requires that the advisor deliver Form CRS to the customer. Form CRS is a short—no more than four-page—summary detailing the relationship between the advisor and client, the applicable standard of conduct under Reg BI and the fees and compensation structure generally associated with the relationship. CRS is not a Senior Suitability form. Form CRS must also contain a section detailing the firm’s disciplinary history and direct the client where to look for additional relevant information. (I have not seen one of these yet) Under the DOL standard, conflicts of interest are generally not permitted at all—regardless of disclosure—unless a specific exemption applies (remembering that the best interest contract exemption was vacated along with the rest of the most recent DOL fiduciary rule). If no exemption applies, the receipt of additional compensation because of the fiduciary recommendation could cause the advisor to commit a prohibited transaction." (Source Think Advisor September 2019, "Reconciling Rollover Advice With Reg BI and DOL Fiduciary Standard.") See: Fiduciary, Senior Suitability. This is not legal advice. Pay a lawyer to get that advice.

The latest term used in workers compensation (and most other health insurance) case management that identifies a holistic approach to treating injuries by condition, and by each patient's unique social and economic condition to improve medical outcomes.
An ambiguous section of ACA law creating a kind of regulatory path for "copies" of expensive, already FDA-approved biologic drugs to reach the market. Biologic drugs are among the most expensive medications and treat life-threatening ailments such as cancer. See: Orphaned Drugs, PBM, etc

Blockchain Insurance
An as yet amorphous configuration of on-line offered insurance (mostly small business classes of P&C at remarkably low cost) products, services and payment options for simple coverage needs, primarily designed by 25 year old's who believe they can know what can, and cannot be issued without material liability to the agent, insured, carrier and or reinsurer. The immature-goal is to replace the agent which sounds simple, until a claim gets denied, and the insured has no experienced advocate, and must rely on themselves to navigate complex claims and coverage events. The jury is out as to if crypto-currencies can or cannot be used for premiums, but probably not at this time. Depends on the risk bearing entity, and private (off shore) capital backs massive risks now.... Like the early attraction to Bitcoin, blockchain may offer a democratization of insurance distribution and administration (perhaps) removed from central government monitoring and "regulation" - outside of the primary policy parties. See: permission-based centralized blockchain, centralized and decentralized immutable records, smart contracts on blockchain being immutable on public domains, enterprise blockchain, claims filing without an advocate, and irreversible decentralized blockchains available to the public. We recommend caution, but recognize many A rated carriers actively in the on-line policy solicitation and procurement on-line community.

Boarding (ED Boarding)
Emergency Department Boarding is a term used when patients requiring "med-surg" or an "inpatient" hospital room bed are kept in the ED (emergancy Room) because of bed shortages. FYI: most policies have very different coverages for care recieved in the ER only, versus if the patient is admitted. THere are also many other step up rooms that are not considered, or may not be insured as a clearly defined "inpatient" admission bed, and that carriers require massively higher deductibles and out of pocket patient cost sharing. It get complicated, and hospitals almost always bill the highest amount they can, even if the patient is not seen for 12 hours.
Boiler and Machinery
Insurance for this exposure covers loss caused by mechanical or electrical equipment breakdown. Most agents and carriers refer to this as Mechanical Breakdown insurance (or rider).
Book of Business (BoB)
See: Borderough report
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.
See: CMS Measures Management (Good Luck!)
Borderough Report (Borderough)
A common term used by carrriers to describe a monthly detailed report of their book of business. No one knows the origin of the term.
Breach Analysis Team (BAT)
CMS entity that determines if PII inproper disclusure has occured. BAT determines if significant financial harm occured. See: PII
Breach Analysis Team (BET)
See: CMS HIPPA procedures
Breach of Fiduciary
See: Fiduciary Duty
Brittle Well
Term referring to people with multiple co-morbities that are currently well (and not being monitored). See: Remote Patient Monitoring
Brokers are licensed agents who represent multiple carriers, and who are legally obligated to serve their client’s best interest.
Broker General Agent (BGA)
See: LOA
Brokerage General Agencies (Organizations) (BGO)
See: FMO, IMO, MGA, MGU, Master Producer, NMO, GA, etc
Builders Risk Insurance (Course of Construction Insurance)
(Zurich's definition: September 2019) "Its coverage protects a person’s or organization’s insurable interest in materials, fixtures and/or equipment to be installed during the construction or renovation of a building or structure should those items sustain physical loss or damage from a covered cause." Policy coverages and limits apply. We dont have a active quoting link for this coverage for our web site, so call Stephen Geroge. This coverage can be a negociated process for best results. See: Course of Construction endorsement

Bundled Payments or Care Payments (BPCP's)
A single medical reimbursement amount defined however a medical provider wants to offer there services, or a payment amount CMS, (or any insurer, or payor) wants to contract its providers - typically focusing on a specific procedure or defined outcome. See: DRGs Success and efficiency can be hard to track down because of differences in care, comorbitities, and procedures that can make determining efficiency (cost effectiveness at better outcomes) difficult. Areas of higher success stories are in: Obstetrics, Knee replacements, some spine surgeries, Diabetes management, hypertension, some cardiac procedures, asthma, obesity treatment, ESRD, CABG, and several surgical procedures. Services are typically stated in terms of a fixed reimbursement amount (DRG, or a defined case rate that may or may not include outpatient Rx, and follow up care) by specific diagnosis, or episode (period of time defined) of care. Some refer to them as "full value-based reimbursement". Implied goals of the "value-based" amounts are tied to EBM directing healthier outcomes of care at lowest cost, and certain incentives to not provide unecessary services where not really needed to affect high quality outcomes. The Trump Administration has unilaterally decided by CMS regulatory rule to bundle payments for ALL Medicare beneficiaries for 32 types or “episodes” of care. Biden may revoke it, but look to CMS demonstration projects as clear lead to what the feds will encourage. (I.e. CABG Geisinger, Primary care, etc) See: DRG MACRA, MIPS, PQRS, RBP, VBP, Trump EO mandating transparancy of pricing, and accurate cost estimates, etc. Note a recent decision agreed with a lower appellate court finding that CMS cannot unilaterally change its billing methodology without 60 day mandated public comment period. The drama continues. An appeals court also sided with HHS that hospitals will have to divulge their "preferred" (lowest) pricing they accept from their best "insurers". This is a very big deal, and will expose hospitals to extreme challenge maintaining the "cost-shifting" they have come to rely upon to cost shift Medicare & Medicaid care to the commercial populations - which amounts to massive subsodies for Medicare beneficiaries whose charges are substantially smaller for the same care delivered to an under 65 individual. Its not always bad... see SNF eligibility for qualifying Medicare beneficiaries participating or being treated under qualifying NGACO or Bundled Payments for Care Payments by CMS, the 3 day inpatient care requirement for SNF care is waived. Hospitals win on this one. See: Bundled Payments for Care Improvement (BPCI), VBR.

Business Auto Policy (BAP)
See: BOP, and GL package policies that can include the same coverage.
Business Decision
In context to a carrier's decision to pay a claim: A justification to typically pay an ineligible claim to insure policy holder satisfaction and / or policy renewal. There are many types of business decisions. Policy contract(s) govern coverage terms and limits, but if the case is big enough, senior executives sometimes elect to pay all orpart of individual claims to assure renewal, and/or avoid expensive legal disputes, that result in even higher overal costs. See: Forbearance
Business Insurance (BOP)
A generic term typically used for insurances purchased by most business. Ex. Workers Compensation, General Liability, CGL, CGL-BOP, Commercial Property, etc. Sometimes, payroll functions are heavily tied into it with PEO's where getting a favorable MOD for workers comp discounted premiums, along with the PEO payroll services costs less. Many however are not aware of the risks with sharing experience with other member companies. This gets may get squirrelly and requires experienced brokerage to effectively and efficiently extricate oneself, so ask lots of questions until you fully understand what happens (especially timeliness) with bad experience guiding renewal rates, and your options.
Business Interuption (BI)
In General Liability policies, its Business Interruption, sometimes called Business Income. In context to financial markets, its Best Interest related to broker representing the clients best interests, or BIC.
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.


C- Statistic (Correlation Coeficient)
CMS may define it differently: "The C-statistic is used to assess risk-adjusted models, it indicates the ability of the model to discriminate between one event and the other. If a model discriminates randomly, c = 0.5. If the risk factor modeling predicts the outcome well, then discrimination increases. The higher the c-statistic, the better the predictive power of the model. " In other words, a 1 means a predictable direct cause from an action. See: ASA, FSA
C-19 Vaccine Mandate
A Presidential Order applying to the military, federal workers, and any employer with 100 or more employees, to either show weekely proof of negitive virus status, or get vaccinated as a condition of employement.
Cadallic Tax
Jargon used to describe a 40% ACA tax on far richer benefit plans offered to senior executives. (i.e. overfunded life insurance policies, expensive disability insurance the regular employees are not offered, etc.) THis tax authorized by the original ACA law, was repealed along with many other taxes, including the individual penalty mandate. See: Golden Handcuffs.
Cafeteria Plan (125 plans - FSA Plans)
See Section 125 plans

Calorie Counts
ACA registered and required values printed on menus as mandated by ACA law.
Cap Buy-Up
A provision in some IUL (Life insurance with essentially what amounts to a fixed-indexed annuity attached, but with higher caps while offering security). See: IUL
Cap Buy-Up
A provision in some IUL (Life insurance with essentially what amounts to a fixed-indexed annuity attached, but with higher caps while offering security). See: IUL
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.
Capital Reserves
The amount of Assets less Liabilities. (ie.Net worth)
Capital Surplus
See: Capital Reserves. The statutorily defined funding minium mandated for eligible and authorized carrier solvency. It is also a term frequently used in "off-shore" risk bearing entities (i.e. Captives?), whose meaning may be defined very differently than "on-shore" eligible and authorized carriers working in compliance with state insurance solvency laws and regulations. Pay special attention to how assets may be accounted as liabilities, and how surplus reserves may not be liquid, or anything close to on shore regulated risk assumption. Be conservative.
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. See: Medicare Advantage Capitation Payment. SEE: Direct Contracting, TCC, PCC. DCE receives monthly amount representing the estimated total cost of care less a withhold. CDE's receive 7% of the benchmark, divided between the Base primary Care Capitation and the Enhanced Primary Care Capitation, which enables DCEs to invest in expanding their primary care capabilities. See: Risk Corridors (Stop loss Global or Professional options offered under Direct Contracting)
A risk bearing entity regulated "eligible" (not typically "authorized") by each state, whose organization is located in a sponsoring state (DE, SC, VT, etc), and/or an offshore island (Caymans, Bermuda, Isle of Mann, etc). Captives typically use surplus lines paper, and require annual management fees in additional to capital, capital surplus, and reinsurance. See Fronted and reinsured assignments that may offer better solution for risk transfer than traditional admitted paper. Captives and Captive-cell "rental or leasing" may offer beneficial solution. Captives may offer favorable accounting of taxable asset, liability, and income calculation. We recommend licensed CPA and legal advice before acting. Legal "assessable liability" is a key consideration. We recommend getting licensed legal and/or advice on this in writing. Same goes for Accrued Liabilities, Capital Surplus, and Surplus reserves accounting for purposes of applicable income tax calculation, and asset reserving. If you are not sure, ask questions until your legal and/or licensed accounting advisor responds to your satisfaction.
Captive Agent (Corporate Agent)
An agent who can only sell or represent a single carrier's policy. Or, Some State Farm agency agreements call their agents Corporate Agents. The term can mean many things, and range from an agent who only represents a single carriers insurance products, to the same agent who is also allowed to be compensated on sundry carrier products and services - relational to how the prospect is identified, assigned, sold, serviced and commissioned. other kinds of agents can be an: Exclusive agent (captive agent), non-exclusive agent, Independent agent, MGA, GA, MGU, etc. See: FMO
Captive Cell (Micro Captive, Rent a Captive)
Call for details. Captive options are many.
Cardiovascular Disease Screenings (CVD's)
A term CMS uses for preventive care targeting Medicare beneficiaries.
Care Management Organizations (CMO's)
An aligned primary care physician network that actively engages specialist physicians in targeted chronic (and expensive) patient care treatment plans. See: Disease management
Career Limiting Move (CLM)
A Career Limiting Move is defined as bankruptcy or insolvency. Stop Loss and reinsurance policy holders have an obligation to understand the coverages they buy, and to adequately fund any self insured retention.
Carrier (Insurance Company)
In context to a competently run company: A risk seeker, not taker.
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. The exclusion my insure the risk under the primary contract of insurance, or but exclude it under the managed care contract or stop loss agreement. In context of SPD's, it typically refers to things like surrogate pregnancy benefits, fertility treatments, dependent children paternity, coverage of wife after the insured dies, etc. - and now with ACA final rules out circumventing (or giving green lights to states to allow plans that do not insure) ACA EHB QHP expensive care - each grouping of agreements will determine coverage and liability. Many laws interact with this area (ADA, ACA, FMLA, Presidential Executive Orders, EEOC perhaps workers compensation, etc.
Case Management
A process directed by a licensed nurse or physician, or an unlicensed administrative specialist trained to manage, coordinate, and/or influence efficacious and efficient care in conjunction with an insured member’s physician. Goal is to increase patient well being, improve medical outcomes and reduce cost. Conflicting contractual prohibitions/interventions questioning medical necessity, and billing pose extreme challenge, liability and dilemma. Out-of-Network care/billing is forefront, and contentious.
Case Manager
A qualified nurse, physician, or trained professional overseeing medically care as defined by the plan document, administrative services agreement, subject to additional managed care provider contracts delineating specific disease state management to contracted payment terms.
Case Rates
A fixed hospital reimbursement by episode or diagnosis, and inclusive of all care. Outlier codes for extra complicated cases can and do increase payments for recognized comorbidity issues and challenges. Typical case rates are promulgated by HHS on Medicare patients as defined Diagnostic Related Group (DRG codes). See: bundled payments One standard does not exist, and multiple entities continue refining contracted reimbursements with EBM.
In context to commercial Property/liability policies typically refers to a third party (not the insured, or the carrier) incurring the loss, and the legal liability insured by the policy.
Cat-in-Circle (First Generation)
See: Parametric Insurance (property). a first generation (insured peril and loss trigger) which pays when the hazard exceeds the trigger point by location. I.e. A hurricane being insured after winds exceed 75 MPH or that becomes a named storm. See: Second generation triggers. The best outcome is to use publically available sources to define intensity and if the trigger triggerred.
Caveat Emptor
Greek for, "Let the buyer beware". Do the work.
Information and instructions for the Medicare Secondary Payer (MSP) Group Health Plan (GHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 MSP Mandatory Reporting GHP User Guide (GHP User Guide). See: GHP, MSP

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)
See: CFR 155.20
Center for Medicare and Medicaid Services (CMS)

Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)
CMS office concerned with negative disparities by race.
Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)
Centers for Medicare and Medicaid Innovation (CMMI or Innovation Center)
A federal agency under HHS that is run by CMS and tasked with improving medical outcomes at the lowest cost to tax payers. That means MACRA, QPP, ACO's ETC. "Under the authority of the Affordable Care Act, CMS established CMMI to design, implement, and test alternative payment and care delivery models that aim to reduce costs, improve quality, and support patient-centered care. Since its inception, the Innovation Center has implemented 37 models, including the Medicare Shared Savings Program (MSSP), Bundled Payments for Care Improvement (BPCI), and the Comprehensive Primary Care (CPC) Initiative. The models have involved approximately 18 million CMS beneficiaries and individuals with private insurance as well as over 200,000 providers. A 2018 Government Accountability Office (GAO) report showed that only four of the alternative payment models run by the Innovation Center had reduced costs while maintaining or enhancing care quality, or improved care quality while maintaining or decreasing costs." Source Revcycle Intellegence. Jaquline LaPointe. See: Link of 90 payment models from CMMI

Centers of Excellence (COE)
Medical centers offering, primary care, on-site primary care, disease and/or specialty-procedure specific care that are known for favorable medical outcomes and/or pricing. i.e. Transplants, Cardiac, Cancer, ESRD, obstetrics, lower back pain, Neonatal, trauma, etc. These centers are typically defined by "condition specific nurse case management teams' that can also include hands on reinsurer personal "support" and steerage. Reliably quantifying such "COE" is not standardized in most circumstances. Be aware some sectors may want to define care by an episode, some by cost outcome and readmission rates, some by average surgeries avoided, etc. Be clear that very few dedicate much weight to patient satisfaction. See: MACRA, EBM, QPP, bundled Payments, etc.
CenterWell Pharmacy (Humana's branded pharmacy)
The Humana pharmacy brands that now combines: Humana Pharmacy and Humana Specialty Pharmacy.

Certificate of Coverage (COC)
A term that can mean many things, but is typically used by primary insurers to describe a 1-3 page document detailing the insured's name, address, policy number, coverage, and dates of coverage. Sometimes, it can mean a policy issued by an authorized and eligible carrier licensed in a state.
Certificates of Public Advantage (COPA)
See Thirteen states have laws allowing cooperative agreement that create conditions that merged entities must abide by post merger, including limits on rate increases and investments in the community. See TN, VA, and W VA actively use COPA's. Source: The Source: State Policies on Provider Market Power Feb 2020 report
Typically means carrier acceptance of liability in context to a received claim. Certification of a claim is not verification of a claim.
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
Certified (CEHRT)
Certified Application Counselor (CAC)
See: Marketplace Navigators
Certified Associate Healthcare Information & Management (CAHIMS)
Certified Associate Healthcare Information & Management. Its one of many certifications available to people forecasting medical care claims costs. See: FLMI, CPU, CPCU, ARe, FSA, ASA, etc
Certified EHR technology (CEHRT)
See: interoperability
Certified Health Record Technology (CEHRT)
See: Interoperability CMS

Certified Property & Casualty Underwriter (CPCU)
See: Insurance Professsional certifications. There are many. CPCU typicall takes to years of exams to complete. There are others that take more and less time. See; FLMI, CLU, ARe, etc. There are other organizations trying to be the standard as well.
Chained CPI
A calculation not typically used in managed care contracting. --------------- A calculation used by IRS to pushing tax payers into higher tax brackets caused by pay increases following inflation over longer periods of time. ====================Social Security uses COLA to increase payments to beneficiaries. Many contracts account for annual price increases tied to inflation, especially where guaranteed renewal provisions govern premium rate increases.
Change Review Process (CRP)
See: eCQM

Charge Master (Super Bill)
Relative to hospital billing, it is an arbitrary schedule of maximum charges billed to a customer. Charge Master amounts are limited to contractual limits agreed to by hospitals. Customers without insurance (PPO contracted providers) get hit with the maximum amount which can exceed 300% - 1000%+ more than a typical contracted rate charge. Hospitals routinely "account" inflated superbill charges for indigent care. A charge master can also refer to the schedule a provider is obligated to accept as full payment aka the "contracted rate". See UCR, R&C or referenced based pricing.
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.
Chief Medical Officer (CMO)
An executive level position occupied by a physician who may or may not be actively treating patients too. See: VP Medical Affairs, Hospitalists, PHE, etc. These guys are the one's CEO's love to give the politically difficult medical administrative issues to negotiate - especially with a hospital's surgeons.
Child Health Insurance Program (CHIP)
A medicaid program for uninsured children under 19 years of age for families that make too much income to qualify for Medicaid. Different states call it different names. Medicaid coverage is unique by state.
Child Rider (CIR)
Child Insurance rider is a life insurance endorsement typically insuring a dependent child.
Chronic Care Management
A program of medical care usually directed at members with: asthma, diabetes, high blood pressure, ESRD, back pain, obesity, SDOH, and/or high cost or chronic disease conditions. The goal of these programs is for early intervention and management to improve medical outcomes at lower costs. ================== Term used by CMS to accurately code for a reimbursement. CMS has many programs touting success for what they deem chronic care for things like Knee replacements, and other high cost - high frequency procedures demanded by beneficiaries. See CAC, JAMA

Chronic Comorbidity Count (CCC)
The sum of "selected" medical conditions (diagnosis) grouped into six categories.
Chronic Condition Data Warehouse (CCDW)
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.
Citizens Assessment
Citizens Insurance
A Florida property insurer that is technically a Joint Underwriting Association (JUA), not a rated carrier, or an "admitted" carrier insured by the Florida Insurance Guarantee Association. The JUA is assessable for underfunded (premiums to losses) losses against its members - unlike authorized and admitted insurance companies. JUA does not enjoy Florida Insurance Guarantee Association fund protection. The JUA cannot be sued (by it's own association member) for bad faith, so limited legal recourse is available to it's insureds in claims disputes, but it is sponsored by the state of Florida, so total insolvency status limits is a difficult issue to vet. Current rules (Jan 2019) mandate Citizens is not required to offer coverage where comparable coverage is available under 115% of Citizens pricing. "Citizens Property Insurance Corporation Citizens’ Assessments Citizens Property Insurance Corporation (Citizens) provides property insurance for individuals and businesses unable to obtain such insurance in the private market (Florida Rules Chapter 2012-80). Citizens has three discrete funds providing coverage for personal lines, and coastal accounts. A new law (HB 1127) has altered Citizens’ ability to raise money by adjusting: · the conditions under which assessments can be levied · the type and amount of assessments · the mechanics of the payment process · the ability to raise money by issuing bonds While Citizens may raise money through premiums, investments, and issuing bonds, it may still experience deficits because its mission is to cover high-risk properties at a manageable, predictable cost. Prior to the passage of the new law, Citizens used three assessment methods for raising funds needed to cover deficits in each of its three funds: Policyholder assessments of up to 15 percent of current premiums on Citizens policyholders, paid in the current year as policies renewed and new policies were issued. Assessments apply independently to each of the three funds. Regular assessments of up to 6 percent of current premiums on all insurance policies issued by private insurers (other than Citizens), which are of the same coverage type written by the relevant Citizens fund (personal, commercial, or coastal). Assessments apply independently to each of the three funds. Emergency assessments of up to 10 percent for each of the three funds may be applied to all policyholders throughout the state (Citizens and non-Citizens premiums) owning the applicable class of policy. Unlike regular assessments, these assessments may be spread out over multiple years. Citizens collects funds as policies renew and new policies are issued. The Florida legislature was concerned about the impact regular assessments would have on the solvency of insurers in what had become a less than robust property insurance market. Regular assessments depleted insurer reserves because they were paid in advance. Private insurers then had to recoup assessments over time from policyholders in a single year, which negatively impacted policyholders. The new law changed the assessment process as follows: · It eliminated regular assessments for the personal lines account and the commercial lines account. · It reduced the maximum 6 percent regular assessment on the coastal account to 2 percent (HB 1127, Florida Statute 627.351). Overall, the new law significantly reduced the amount of prepayments and spread the impact of severe losses over time. In addition, the law allows Citizens to make assessments based on projections instead of actual deficits, with the idea of improving funding in emergencies by being proactive (HB 1127, Florida Statute 627.351). By obtaining funding in advance of projected deficits, Citizens will be better able to leverage those funds by using them as a basis for issuing bonds for funds to cover the immediate or upcoming needs that precipitated the assessment in the first place. Citizens’ Property Insurance Reform – SB 1770 After addressing issues arising from assessments, the Florida legislature took action to reduce the size of taxpayer risk exposure to property losses from hurricanes and other perils that would be covered by Citizens. This law reduces the amount and scope of coverage Citizens may offer (Florida Statute 627.351, Rules 2013-60, page 16 & 23). Coverage limits – The maximum policy limit for personal residences has been reduced to $1 million from $2 million. This amount decreases further over a three-year period to $700,000. Citizens is also prevented from insuring new condo association construction projects in Coastal Control zones (Florida Statute 627.351, Rules 2013-60, page 16 & 23). Transition to private insurance –The law requires consumers who are offered private insurance rates within 15 percent of Citizen’s rate for a new policy to accept private insurance (Florida Statute 627.351, Rules 2013-60, page 16 & 23). Creation of an exchange – The law requires that an exchange (also known as a clearinghouse) be established through which all new policies and renewals will be evaluated for coverage by Citizens, and, if possible, diverted to the private market. Agents placing policies through the exchange do not need to be appointed by each insurer with whom a policy is placed. (Florida Statute 626.3518 and Rules Chapter 2013-60, Section 10, pages 36-40). Other provisions - Citizens will now offer an HO-8 policy (Florida Statute 627.351). Agents must obtain an “Acknowledgement of Potential Surcharge and Assessment Liability” from applicants. The acknowledgement states that policyholders understand they may be subject to a surcharge if Citizens sustains a deficit as a result of hurricane losses or other reasons, and that policyholders can avoid the surcharge by obtaining coverage from a private insurer. Agents must maintain ownership of records, including policies placed with Citizens (Florida Statute 626.3518). Citizens’ Coverage of Mobile Homes – HB 573 (Florida Statute 626.351). Florida also made changes to the coverage Citizens provides for mobile homes. The minimum insured value is reduced to $3,000, and policies must cover attached structures that are not substantially the same material, including · screened enclosures that are aluminum framed or other materials · car ports that are aluminum or carports · patios that have a roof covering constructed of other materials Changes to License Application and Renewal Procedures Pursuant to Florida Statute 626.171, the state of Florida has made several important changes to the insurance laws and rules, discussed next, which affect agents’ licensing and renewal requirements. Changes to Application and Renewal Procedures Pursuant to Florida Statute 626.171, a person who is applying for a license as an agent or adjuster can now have a third party complete, submit, and sign the application, as long as the applicant agrees. However, the applicant remains responsible for any misstatements or misrepresentations in the application. Previously, third parties did not have authority to complete a license application on behalf of an applicant." Source: CETrack Licensing (CE) Exam material Jan 2019

Citizens Property Insuraance
(Source: 2021 Agent Licensing Exams) • Citizens’ Assessments • Citizens Property Insurance Corporation (Citizens) provides property insurance for individuals and businesses unable to obtain such insurance in the private market (Florida Rules Chapter 2012-80). Citizens has three discrete funds providing coverage for personal lines, commercial lines, and coastal accounts. A new law (HB 1127) has altered Citizens’ ability to raise money by adjusting: • · the conditions under which assessments can be levied • · the type and amount of assessments • · the mechanics of the payment process • · the ability to raise money by issuing bonds • While Citizens may raise money through premiums, investments, and issuing bonds, it may still experience deficits because its mission is to cover high-risk properties at a manageable, predictable cost. Prior to the passage of the new law, Citizens used three assessment methods for raising funds needed to cover deficits in each of its three funds: • Policyholder assessments of up to 15 percent of current premiums on Citizens policyholders, paid in the current year as policies renewed and new policies were issued. Assessments apply independently to each of the three funds. • Regular assessments of up to 6 percent of current premiums on all insurance policies issued by private insurers (other than Citizens), which are of the same coverage type written by the relevant Citizens fund (personal, commercial, or coastal). Assessments apply independently to each of the three funds. • Emergency assessments of up to 10 percent for each of the three funds may be applied to all policyholders throughout the state (Citizens and non-Citizens) owning the applicable class of policy. Unlike regular assessments, these assessments may be spread out over multiple years. Citizens collects funds as policies renew and new policies are issued. Like the other assessments, these apply independently to each of the three funds. • The Florida legislature was concerned about the impact regular assessments would have on the solvency of insurers in what had become a less than robust property insurance market. Regular assessments depleted insurer reserves because they were paid in advance. Private insurers then had to recoup assessments over time from policyholders in a single year, which negatively impacted policyholders. • The new law changed the assessment process as follows: • · It eliminated regular assessments for the personal lines account and the commercial lines account. • · It reduced the maximum 6 percent regular assessment on the coastal account to 2 percent (HB 1127, Florida Statute 627.351). • Overall, the new law significantly reduced the amount of prepayments and spread the impact of severe losses over time. In addition, the law allows Citizens to make assessments based on projections instead of actual deficits, with the idea of improving funding in emergencies by being proactive (HB 1127, Florida Statute 627.351). By obtaining funding in advance of projected deficits, Citizens will be better able to leverage those funds by using them as a basis for issuing bonds for funds to cover the immediate or upcoming needs that precipitated the assessment in the first place. • Citizens’ Property Insurance Reform – SB 1770 • After addressing issues arising from assessments, the Florida legislature took action to reduce the size of taxpayer risk exposure to property losses from hurricanes and other perils that would be covered by Citizens. This law reduces the amount and scope of coverage Citizens may offer (Florida Statute 627.351, Rules 2013-60, page 16 & 23). • Coverage limits – The maximum policy limit for personal residences has been reduced to $1 million from $2 million. This amount decreases further over a three-year period to $700,000. Citizens is also prevented from insuring new condo association construction projects in Coastal Control zones (Florida Statute 627.351, Rules 2013-60, page 16 & 23). • Transition to private insurance –The law requires consumers who are offered private insurance rates within 15 percent of Citizen’s rate for a new policy to accept private insurance (Florida Statute 627.351, Rules 2013-60, page 16 & 23). • Creation of an exchange – The law requires that an exchange (also known as a clearinghouse) be established through which all new policies and renewals will be evaluated for coverage by Citizens, and, if possible, diverted to the private market. Agents placing policies through the exchange do not need to be appointed by each insurer with whom a policy is placed. (Florida Statute 626.3518 and Rules Chapter 2013-
Claims Based Alignment
See: Medicare Shared Risk "Direct Contracting" Re: "Performance Year 1,2,3,...
Claw Back
A contractual provision used in many kinds of contracts. In context to medical reimbursement agreements, is a term typically used to describe funds reduced from future-payable claims to the same provider, as a result of a claim filing overpayment, or inappropriate payment process. Some examples are:1. Upcoding, the practice of consistently coding services at a too-high level 2. Technical denials, wherein a payer, sometimes automatically, rejects a claim out of hand for an administrative reason 3. Overpayment clawbacks as an expected budget line item on the part of payers 4. Stacking post-payment audits, wherein multiple programs audit the same claim or set of claims, duplicating requests for the same backup material (often using multiple outside vendors or contractors) Source: Change Healthcare, payment Accuracy and the American Healthcare System
Clean Claim
Call for details that may differ from federal regulations on it, IDR, and no surprises act.
Client/Customer Relationship Manager (CRM)
A data base that stores specific information used in the sales and service process. There are big differences in various software application's integration and management functions.
Clinical Communication and Collaboration Platforms (CC&C)
Clinical Communication and Collaboration Platforms are systems of EHR's which accomodate effective inter-intra medical provider coordinated information that improves EBM.
Clinical Data Integration (CDI)
See: FDIR, and new approaches to achieve real results or effect at scale.
Clinical Decision Support
An amorphous term that (should) mean, a system (personnel, electronic, telemetry, Rx, multi-physician diagnosis clearing house - supporting, offering, coordinating, warning, and/or optimizing medical treatment plans to both physicians, patients, ancillary medical personnel, and/or a patient's care givers. See. AI, VBM, EBM, etc.
Clinical Document Improvement (CDI)
Term used by "physician advisors" who work with physicians in recommending better care for better EMB outcomes and reimbursement.
Clinical Integrated Netoworks (CIN)
See: IDS, CMO, Episode Based Care (EBC), DM.
Clinical Practice Improvement Activities (CPIA)
Clinical Quality Language (CQL)

See: eCQM

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

CMS Date Services Hub (CMS Hub)
CMS managed system "service" designed to share and verify PII among multiple federal agencies (HHS, IRS, Medicaid (and who knows who?) for primary purposes of confirming: income, APTC, CSR, Medicaid eligibility, Marketplace insurance eligibility, etc. See: PII, and Authorized Representative in context to 45 CFR 155.27
CMS Final Inpatient Payment Rules (IPPS - Inpatient Prospective Payment Final Rule)
An annual rule by CMS that typically increases the amount of authorized reimbursement for acute care hospital charges. (I.e. $3.6 BILLION for 2021) It also addresses compensation for residents paid to hospitals to subsidize their training, etc. See: IPPS

CMS Final Rules 2020 Benefit Payments
(For federal Marketplace Individual and SHOP plans) "Rule lowers user fees for first time, encourages use of lower cost generic drugs, promotes market stability and consumer choice The Centers for Medicare & Medicaid Services (CMS) today released the final annual Notice of Benefit and Payment Parameters for the 2020 benefit year, also known as the 2020 Payment Notice. The rule reduces user fees for plans offered on, and encourages the use of lower-cost generic drugs, while improving market stability and consumer choice. “The rule issued today will give consumers immediate premium relief by reducing the Exchange user fees in the Federally-facilitated Exchanges (FFEs) and State-based Exchanges (SBEs) using the federal platform for 2020 thanks to successful efforts to improve the efficiency of the Exchange,” said CMS Administrator Seema Verma. “At CMS we have improved the operations of the Exchange to deliver a better consumer experience at a lower cost.” Generally, Exchange user fees are passed directly on to the consumer in the form of higher premiums, and this reduction in the user fee allows issuers to pass along savings to consumers in 2020. The 0.5 percent reduction in the user fee rate comes as a result of CMS’ focus on reducing costs through increased operational efficiency, including successful efforts to upgrade IT functionality, a more efficient approach to outreach, and investments focused on proven methods to achieve a seamless enrollment experience and high consumer satisfaction. This follows the first ever 1.5 percent drop in average premiums for plans selected through for the 2019 coverage year. With consumers facing rising premiums and limited choice in their health coverage leading up to 2017, the Trump Administration introduced a series of actions to encourage competition and bring down the price of healthcare for people in the individual market. The final 2020 Payment Notice builds on these prior actions to further strengthen America’s health insurance markets. Building on the President’s American Patients First blueprint, the final rule also supports lower premiums by promoting the use of lower-cost generic drugs. Drug companies can offer consumers coupons to incentivize them to purchase the company’s brand name drugs even when an appropriate, less-expensive generic medication is available. This rule allows issuers to stop applying the value of these coupons towards an enrollee’s maximum-out-of-pocket costs in situations where a generic medication is available and medically appropriate, in order to encourage generic use and result in lower drug spending. To improve market stability, a key element of this final rule refines the risk adjustment program to improve the accuracy of the data used to calculate the program’s charges and payments to issuers. This program is designed to reduce incentives for insurers to avoid enrolling people with expensive health conditions. The rule finalizes several proposals regarding the validation of the accuracy of the diagnosis codes, prescription drug data and codifies a number of exemptions to lessen burden on small issuers. This rule also aims to increase the choices available to consumers for trusted enrollment pathways. Last fall CMS successfully launched Enhanced Direct Enrollment (EDE), which allows consumers to shop for and enroll in the Exchange plan of their choice through an approved partner website. In regards to enrollment, the final rule streamlines and updates regulations to accommodate future innovation and improve the consumer experience. The EDE pathway allows CMS to partner with the private sector to provide a more user-friendly and seamless enrollment experience for consumers by allowing them to apply for, and enroll in, an Exchange plan directly through an approved issuer or web-broker without the need to be redirected to In recognition of the new pathway, the final rule increases transparency as well as the privacy and security of consumer data by allowing CMS to require web-brokers to provide lists of the agents and brokers who use their websites. The rule also enhances consumer protections and improves program integrity by allowing CMS to more easily suspend or terminate agents, brokers and web-brokers that violate applicable Marketplace requirements. As EDE continues to expand, to guarantee consumers continue to receive a high level of service, being able to more easily suspend or terminate agents, brokers and web-brokers that violate rules will better enable CMS to ensure agent/broker and web-broker compliance, respond to cases of noncompliance, and to protect sensitive Exchange data and systems. Further, the rule finalizes a technical change to the premium index for the 2020 benefit year in order to better align our premium adjustment percentage methodology with the experience of the individual markets and premiums overall. Under the new methodology, CMS would use the CMS Office of the Actuary (OACT) estimates of projected health insurance premiums for both the private individual and group market (excluding expenditures for Medigap and property and casualty insurance). This change would replace the current methodology which utilizes only employer-sponsored group market insurance (ESI) premiums, which do not reflect the situation of the individual market premiums. This technical change in the premium adjustment percentage methodology will provide a more comprehensive and accurate measure of private market premiums. This change will have little impact on gross individual market premiums, but it will provide savings for taxpayers. Today, CMS also issued the Final 2020 Letter to Issuers in the FFE which provides guidance to issuers that want to offer Qualified Health Plans (QHPs) on the FFE, as well as the Key Dates Charts for the 2019 Calendar Year."

CMS Full Financial Risk
See: A CMS defined term in context to Value Based Reimbursement and minimum 10% value of physician fees being at risk. There are other meanings in contexts to a myriad of SPD's, reinsurance retention, and contracted stakeholder risk appetite, etc. See: Meaningful Downside Risk.

CMS Health Ewuity
The CMS Framework for Health Equity identified high-impact priorities based on stakeholder engagement, a review of the evidence base, and discussions across federal partners. It updates the previous Medicare-focused CMS Equity Plan for Improving Quality in Medicare with an enhanced and more comprehensive 10-year approach to further embed health equity across Medicare, Medicaid, CHIP, and the Health Insurance Marketplaces. The updated CMS Framework for Health Equity also brings focus to CMS’ work supporting health care organizations, health care professionals and partners—providers, health plans, federal, state, and local partners, tribal nations, individuals and families, quality improvement partners, researchers, policymakers, and other stakeholders—in activities to achieve health equity.

CMS Health Risk Score
Scores that affect the rates MA plan enrollees pay for their Part C Medicare Advantage plans. See: SDOH, PHE, non-curable chronic conditions, Health Equity, AMGA
CMS Marketplace security standard (CMS FISMA)

CMS Measure Management (CMIT)

CMS Measures Management (MMS)
The CMS Measures Under Consideration Entry/Review Information Tool (CMS MERIT) is now open! As part of the CMS pre-rulemaking process for Medicare programs under Section 3014 of the Affordable Care Act, measure developers submit measures to CMS for their consideration. The pre-rulemaking process helps to support CMS’s goal to fill critical gaps in quality measurement. See: QPP, etc.

CMS Measures Management System

http://2020 QP Notice for APM Incentive Payment zip file

Goal is to Ensure health equity is embedded in every model of healthcare delivery and reimbursement. This has obvious implications to commercially insured people and not just Medicare, Tricare and Medicaid. See: CMMI, VBR, EBM
CMS-1500 Form (HCFA 150p form, HRS 1500 form)
A claim submission form to carriers detailing many diagnosis, hospital charges, and physician charges codes, billed charges, etc. Some carriers will require these forms, even when they do not apply, or are never generated by the provider, causing lots of issues when people get services, or supplies/DME/scripts at less cost not using their (in or out of network contracted providers) insurance plans. Carrier are very concerned with being charged with bad faith and normally want to do the right thing - especially when it costs them less to do it but have to reimburse their policy holders for PAID for services and supplies that are received/charged/paid for under an insured event. We recommend auditing your claim for proper reimbursement.
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 MOOP. Molina Healthcare defines it as "the amount owed by you, the member, after your deductible has been applied. This is based on the percentage dictated by you benefit coverage."
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. Molina health plan defines it as, "The amount of your copay for certain benefits (i.e., office visit, ER, etc.) This is a fixed dollar amount.
In context to an ERISA plan Plain Sponsor, (and especially) TPA who has accepted co-fiduciary by contract or express performance and/or behavior, and member protection. The issue(s) is/are contentious. This can get squirrely as it relates to RBP, SPD, balance billing, Price Transparancy, etc.
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.
COBRA (in Florida) applies to employers with over 20 employees. In Florida, employers under 20 - See: Mini COBRA. COBRA allows the employee, or their eligible family to continue on with the employers's health plan for 18 months (or more in some states). COBRA requires continuation coverage to be offered to eligible employees (and their family) who are leaving employement with their employer. Those events include the death of a covered employee, termination or reduction in the hours of a covered employee’s employment for reasons other than gross misconduct, divorce or legal separation from a covered employee, a covered employee’s becoming entitled to Medicare benefits, and a child’s loss of dependent status under the plan. Those who are eligible may be required to pay for COBRA continuation coverage and are generally entitled to coverage for a limited period of time (from 18 months to 36 months), depending on certain circumstances. COBRA does not apply to employers with fewer than 20 employees. The Department anticipates future guidance on the application of COBRA to AHPs that provide coverage to member employers with fewer than 20 employees. Determination of a COBRA 6 month APTC does not create an individual SEP. Source: DOL See: ARPA, FMLA, FFCRA, Consolidated Appropriations Act: Employers > 20 FTE, the employer files for the tax credit, for employers electing continuous group plan participation under COBRA. Be careful of coverage benefits for pregnant and post delivery mother/child coverage and extentions offered by some states that are not all the same.

COBRA form 720
The form used to claim advanced recoveries per COVID relief
Code of Federal Regulations (CFR)
Cognitive Behavorial Therapy (CBT)
See: EAP
Collateralized Loan Obligation (CLO)
A term used by various entities to describe loans from life insurance policies. A recent article represented that life CLO's represent about 15% of US CLO assets. (typically) "retirement spent loans (to oneself) are not taxed as income because they meet IRS guidelines. Businesses, may also use CLO's outside of life insurance policies to fund various kinds of loans.
Commercial Package Policy (CPP)
Term typically used for GL policies including additional coverages such as commercial auto, Property, wind, etc
Commercial Repayment Center (CRC)
See: CMS - New documents titled Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Recovery Town Hall Questions and Answers and Commercial Repayment Center (CRC) Group Health Plan (GHP) Recovery Town Hall Questions and Answers Overview

Commission Ordinary Tables (CSO)
A new concept for compensation disclosure in Life insurance policy agent compensation. See: BIC, and try to keep up with what DOL is suggesting, mandating, or requiring in context to potential fiduciary standard(s). The trend is generally to sometimes require gents, or advisors declare their compensation - especially when dealing with retirement account sources of funds. See overrides, contingency fees, profit commissions, profit share, etc.

Commission Standard Ordinary (SCO/PBR)
• The 2017 Commissioners Standard Ordinary (CSO) Table — a new mortality table used in Life insurance) product pricing. • Principle-Based Reserving (PBR) — a new or different way of calculating reserves to pay future claims specific to each carrier. See: Underwriting.
Commissioners Standard Ordinary Table (CSO)
One mortality table used by some underwriters started about 2017.
Community Health Access and Rural Transformation (CHART)
Community Health Access and Rural Transformation (CHART) Model. Another Trump EO providing wider access to telehealth covered services for Medicare members in rural communities.

Community Health Access and Rural Transformation (CHART)
See: CMS

Community Health Worker (CHW)
See; SDOH, etc
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) group medical premium underwriting rating method based on claims history by region (zip code). These rules can appear amoupous by state and federal standard, with various strategies used to get the group out of the higher priced rating methods to secure lower priced medical premiums. ACA promulgates rules employers (over 50 FTE) MUST apply (higher priced) community rating, thereby eliminating potential premium discounts associated with favorable claims experience. In Florida the rules apply (so I am told by Humana reps) to groups 2-50.
Comparison Group (CG)
See: Covid Orders
Competition - Healthcare Insurers (Monopoly or Oligopoly )
Competition by hospital network regions and insurance carriers is apples and oranges. For the competition among carriers see links. Real analysis means using more sophisticated analysis, but the point here is competition among carriers is less now then a few years back. That almost always means much higher prices, and without reliable increase in quality or access. See: The AMA used measure of market concentration, Herfindahl-Hirschsprung Index (HHI) scores. HHI scores can range from 0 to 10,000, with 10,000 meaning one carrier like Blue Cross monopoly in many rural areas.

Complex and Chronic Care Improvement Program (CCCIP)
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
Compound Annual Growth Rate (CAGR)
In contexed to ESL and Group medical plans: The percentage increase in "large" group medical premiums. "...ESL market has accelerated from a compound annual growth rate of 7 percent from 2006 - 2011 to a 12 percent CAGR from 2011 - 2015, with annual ESL premiums now totaling $17 billion." Source: BenefitsPRO Magazine March 2020 But for brokerage purposes, the trend assumption is always important to challenge in context to competitive bid. As a rule that sometimes gets followed but that most ESL underwriters hang their hat - comparing "1st dollar" medical cost inflation to "2nd dollar" stop loss trend (inflation factors) is roughly double. i.e. If someone quotes a 4% medical cost inflation for fully-insured large group (5,000 lives or more), then the stop loss premium increases is supposed to price at about 8% (actual modeled dollars payout risk). Competition in the markets drastically changes what actually gets accepted in the end. Enter brokers who add real value. This is not simple and straight forward - coverage(s) and price are proportional, and may involve more than front end data, account size, experience of one or more populations insured. In Finance, it essentially means, the total return from an investment (or bank account) earning interest on the principal PLUS earned interest over many years. Note: be clear not to confuse percentages with average actual $ (whole numbers) return. I.e the same 50% gain or loss in the first and second years, does equate to the same whole number returns over the same period.
Compound Annual Growth Rate (CAGR)
The mean (average) annual growth rate typically expressed in dollars for best insight comparing various investments. In other words, percentage comparisons between ROR and CAGR can show them equal in percentage terms, but not equal in (real life) dollar terms over a given period. See: ROR, Internal Rate of Returns, Net Present Value, Effective Rate of Returns, etc. Example, dont get confused with percentages comparing with actual dollar returns. I.e. If and investment goes down 50%, then up 50%, it does not return to the original principal. $1.00 - $0.50 down = $0.50. Year two: $0.50 x 50% up = .25 + $0.50 = $0.75 (not $1.00). This example requires the second year return of 100% to get back to the original amount invested. I.e. $0.50 x 100% = $1.00 .
Comprehensive End-Stage Renal Disease Care Model (CEC)
A CMMI payment/care initiative for Medicare members.
Comprehensive Joint Replacement (CJR)
Term used by Medicare to study and produce EBM at best medical outcome and lowest cost. Joint replacements costs the Medicare fund hundreds of millions each year, and can be expected to increase going forward. "The CJR model continues to demonstrate promising reductions in Medicare payments, while maintaining quality of care. After two performance years, average episode payments decreased by 3.7 percent or $146 million, predominantly by changing post acute care use. After accounting for reconciliation payments earned by participants, the CJR model likely resulted in net savings to the Medicare program of $17.4 million, although we cannot conclude this with statistical certainty. A range of hospitals, with a range of resources and circumstances, can and do respond to the incentives under a mandatory episode - based payment approach. In future reports, we will expand our understanding of how the changes to the model impacted payment, utilization and quality outcomes." Source: CMS

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. Primary Care Plus (CPC+), the Medicare Shared Savings Program, and the NextGen Accountable Care Organization (ACO) program. - See MACRA

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.
Computer Assited Coding (CAC)
Term used by CMS related to coding care for MA patient reimbursements.
Concurrent Causation Doctrine (CCD)
A rule and / or policy provision applying insurance to a loss when both insured and Excluded peril(s) (concurrently) cause the loss. Means, if cause of loss is insured, then sequence of the cause of loss does not matter, and the loss is insured. See: Anti-Concurrent-Causation, Efficient Proximate Cause
Condition of Participation (CoP)
Medicare condition of participation (CoP). See: MACRA, QPP
Conditional Payment Notice (CPN)
See: MSPRP, NGHP recovery

Conflicts of Interest (COI)
COI means many things in many situations. For licensed securities brokers (and/or Broker-Dealers) COI is tethered to the highest legal standard called Fiduciary Duty. For Insurance agents who do not hold a Fiduciary Duty, but a "best interests" obligation, the standard is not the same. Holding a client's best-interests forefront has long been a professional standard by all professionals. Clearly explaining how a consultant gets paid seems to be one of the primary pillars of avoiding conflicts. Trying to read clients who sometimes shirk primary responsibilities of responding timely, directing clear goals, or not asking questions when they do not understand a complex transaction or process takes real patience. You can bring a horse to water but cannot force them to drink.
Congenital Heart Disease (CHD)
Conscience Rule
Jargon termed to describe medical a provider's "right" to choose not to provide medical services (like abortion) they find ethically abhorrent. The practical issue is when care is denied by federally or state supported facilities obligated to follow our constitution and actual law, one person's rule that is not a law (vetted through the separation of powers). A federal judge invalidated a Trump administration rule declaring it was OK to deny services.
Consent to Rate
A strange term sometimes used to convey underwriting of non-ACA compliant (ERISA) plan offerings. The underlying purpose is to get a premium that is about 40% less than ACA QHP rated plans. See: STM
Consent to Settle clause (Hammer Clause)
A provision in a professional liability (E&O) policy requiring an insurd's settlement approval to settle a claim, without trial. Upon adverse trial decision, the provision puts the insured on the hook for amounts over the proposed settlement amount.
Consequential Damages
A legal theory used to sue for damages caused secondarily to a valid primary contract breach.
Consolidated Appropriations Act (CAA effective 2021)
Dec 2020 law signed by President Biden December 2020. See: Balance Billing, Mental Health Parity, APTC, Reporting requirements, Qualifed plan vesting relief (DCP and 401, etc), FSA (section 125 plan) changes, COBRA subsidy, student loan relief, retirement benefits, COVID funds relief on DBP, Employer benefits relief, MEPP relief from age 62 to 59.5, IRA distribution fo disasters relief, etc. "These regulatory compliance activities include, but are not limited to: • Support and calculations for Qualifying Payment Amounts (QPA) for surprise medical billing • End to end management for independent dispute resolution (IDR) • Changes to health plan ID cards, provider directory enhancements • Member notification of new continuity of care rights • Facilitation of an external appeals and review process • Maintenance of network agreements compliant with CAA prohibitions on gag clauses and providing language to support customer attestation • Significant new government and customer reporting requirements • Support related to Mental Health Parity NQTL audits initiated by DOL, HHS or the Treasury" Source United Health care Agent Advisory

Consolidated Appropriations Act (CAA effective Jan 2022)
Federal Law affecting multiple regulations and law updates including IDR (Independent Dispute Resulution) aka "no surprises act" on surprise billings.

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, MIPS

Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Consumer Assistance Programs (CAPs)
See: Surprise Billing, Balance Billing, IDR and good luck. Medical providers must understand their state's billing regulations in context to solving balance billing issues' mandated carrier interface and dispute resolution. In simplier talk, make sure business as usual practices dont expose the practice to statutory /regulatory liability. See: Assignment of Benefits, Surprise Billing, IDR, IRO, etc. As a practical note, expect enforcement of IRO under democratically elected federal adminstrations.

Consumer Operated and Oriented Plan (CO-OP)
he 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 in some states through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace. Source: Marketplace Exam. Many CO-OP's have failed leaving their insureds scrambling for coverage mid year, and leaving area medical providers with large unpaid bills.

Consumer Protections DOL (DOL 2719(b)(2) of PHS Act)
Fir Individual Plans: "These 16 minimum consumer protection standards, as amended, may be summarized as follows:(4) The process must provide for external review of adverse benefit determinations (and final internal adverse benefit determinations) based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit. Issuers (or plans) must be required to provide effective written notice to claimants of their rights to external review. If exhaustion of internal appeals is required prior to external review, exhaustion must be unnecessary if – (a) the issuer (or plan) waives the exhaustion requirement; (b) the issuer (or plan) is considered to have exhausted the internal appeals process by failing to comply with the requirements of the internal appeals process except those failures that are based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the claimant(5); or (c) the claimant simultaneously requests an expedited internal appeal and an expedited external review. The cost of an independent review organization (IRO) to conduct an external review must be borne by the issuer (or plan), although the process may require a nominal filing fee(6) from the claimant requesting external review. There cannot be any restriction on the minimum dollar amount of a claim in order to be eligible for external review. The process must allow at least four months to file a request for external review after the receipt of the notice of adverse benefit determination or final internal adverse benefit determination. The IRO must be assigned by the State or an independent entity, on a random basis or another method of assignment that ensures the independence and impartiality of the assignment process (such as rotational assignment), and in no event assigned by the issuer, the plan, or the individual. The process must provide for the maintenance of a list of approved IROs (only those that are accredited by a nationally recognized private accrediting organization) qualified to conduct the external review based on the nature of the health care service that is the subject of the review. Approved IROs must have no conflicts of interest that will influence their independence. Claimants must be allowed to submit to the IRO additional information in writing that the IRO must consider when conducting the external review, and the claimant must be notified of the right to submit additional information to the IRO; the IRO must allow the claimant at least 5 business days to submit any additional information and any additional information submitted by the claimant must be forwarded to the issuer (or plan) within one business day of receipt by the IRO. The IRO decision must be binding on the claimant, as well as the plan or issuer (except to the extent that other remedies are available under State or Federal law).(7) For standard external review, the IRO must provide written notice to the issuer (or plan) and the claimant of its decision to uphold or reverse the adverse benefit determination within no more than 45 days after the receipt of the request for external review. The process must provide for an expedited external review in certain circumstances and, in such cases, provide notice of the decision as expeditiously as possible, but not later than 72 hours after receipt of the request for external review (and if notice of the IRO's decision is not in writing, the IRO must provide written confirmation of its decision within 48 hours after the date of the notice of the decision). Issuers (or plans) must provide a description of the external review process in or attached to the summary plan descriptions, policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to participants, beneficiaries, or enrollees, substantially similar to section 17 of the NAIC Uniform Model Act. The IRO must maintain written records and make them available upon request to the State, substantially similar to section 15 of the NAIC Uniform Model Act. The process must follow procedures for external reviews involving experimental or investigational treatment, substantially similar to section 10 of the NAIC Uniform Model Act." "Under section 2719(b)(2) of the PHS Act, if a State's external review process does not meet these minimum consumer protection standards, group health plans and health insurance issuers in the group and individual market in that State are required to implement an effective external review process that meets minimum standards established by the Secretary through guidance. These standards must be similar to the standards established under section 2719(b)(1) of the PHS Act and must meet the requirements set forth in paragraph (d) of the July 2010 regulations. Accordingly, there may be external review processes authorized under PHS Act section 2719(b)(1) and paragraph (c) of the July 2010 regulations (hereinafter referred to as "NAIC-parallel processes") and there may be external review processes authorized under statutory PHS Act section 2719(b)(2) and paragraph (d) of the July 2010 regulations (hereinafter referred to as "NAIC-similar processes").
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.
Contingent Insurance
An aviation insurance (and other insurances use the term) purchased by the aircraft/aircraft-part lessee that pays if the primary policy owned by the lessor (possessed policy) does not pay timely or at all. It is typically less expensive than the possessed policy, and can look like a type of reinsurance (insurance on insurance). These get complicated. Contingent insurance can have many meanings, conditions and terms.
Continuation of Coverage Provision
A hybrid LTC-Whole Life policy provision that affects monthly LTC payments after the Life Insurance Face pays out, and for periods up to death. Typically today, most policies offer 4,5,6,7,8 year payouts, and not lifetime payouts. See: Inflation riders, ADL triggers, elimination periods, etc. IF its LTC, be sure if the policy premiums remain constant for life or not.
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.
Continuing Education Unit (CE)
A state authorized edjucation requirement insurance professionals must obtain every two years (for agents with 5 or more years of experiene), to maintain licensure.
Continuous GLucos Monitor (CGM)
A wearable medical device communicating suger levels in diabetics. See: EBM
Contract Holder
In context to stop loss, it usually means the employer.
Contribution Requirements
The minimum percentage of employer paid premium for (QHP) group major medical benefits, typically set at 50%.
Controlled Group
A group containing two or more entities as defined by the IRS code.
Controlled Master Program (CMP)
See Global Master Policy. CMP primarily allows for the placement of locally-issued admitted policies along with a U.S. master policy, while keeping the administration, claims and risk management functions with one single carrier. These are large complex- package coverages.
Controlling Health Plan
See: 45 CFR 162.103
A term usually used when replacing a term life insurance with another type of permanent insurance (UL, IUL, Whole life).=============It can also mean an insured coverage and process of actively helping an HMO member replace or enroll in a new major medical plan after an HMO declares insolvency. Many states require the stop loss coverage.
Coordination of Benefits (COB, COB&R)
See: Subrogation

Copay Assistance (Patient Assistance)
A $0 Copay card from the manufacturer (pharmacy) that may conflict with MOOP attribution in ERISA plans, and rules governing claims processing. Some view it as a PR program to get patient to choose Brand name over Generic, and effectively causing prices to increase for the plan, but not necessarily for the individual member. This gets complicated as the SPD groups drugs by wellness, illness, etc.
Coranary Health Failure (CHF)
A term some care managers use when following up patient discharges.
Core Quality Measures Collaborative (CQMC)

Coronavirus Aid Relief and Economic Security Act (Care's Act)
"Aside from federal spending, which had the most prominent impact, private and public health insurance, out-of-pocket costs, and hospital care contributed to national healthcare spending in 2020. Private health insurance expenditures accounted for 28 percent of total healthcare spending in 2020 but saw a 1.2 decline due to low healthcare utilization. Out-of-pocket healthcare spending also experienced a decline as utilization dropped. Medicare spending was responsible for 20 percent of national healthcare expenditures, rising by only 3.5 percent, compared to 2019 when it saw a 6.9 percent increase. Meanwhile, Medicaid spending accounted for 16 percent of total expenditures, reaching $671 billion and seeing its highest growth rate since 2014 of 9.2 percent. Hospital expenditures accounted for 31 percent of national health spending at $1.3 trillion. There was a 6.4 percent increase in 2020, largely due to federal COVID-19 relief funds and increases in Medicaid spending for hospital care." Source: HealthPayer Intelligence 1/2022

Cost Elements Medical Plans
The actual cost of a medical plan comprised of Premium. Deductible, Co insurance, Copays, and Maximum out-of-pocket costs. Deductible + Co-isurance + Copay = MOOP. Note: Most plans have different in- network versus out-of-network MOOP. Note: some STM plans have no MOOP, and some pharmacy plans insurance Brand Name drugs may not apply MOOP accurately.
Cost of ACA to Taxpayers
According to the Congressional Budget OFfice

Cost of Living (COLA)
The inflation percentage number Social Security uses to increase payments to beneficiaries. See: CPI

Cost Performance Catagory (CPC)
See: QPP
Cost Share Plan
See Ministry Health plans, Healthcare Cost Sharing plan
Cost Share Reduction (CSRs or Risk Reduction Payments)
In context to the enrolled Marketplace member, it is the reduction of deductible, co-insurance and MOOP a member is eligible as directed by the members income level. Remember, premiums are already reduced by eligible APTC. In context to a carrier, CSR is a Federal reinsurance program participating carriers elect to pay premium into (protecting themselves from adverse selection of guarantee issue policies) to receive reinsurance recoveries for claims between $45,000 and $250,000 (not unlimited like ACA QHP insures). April 2020 The Supreme Court sided with the carriers and against the Trump administration to reimburse carriers an estimated $12 Billion. 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 prohibition on plans sold during SEP, Eliminating statutory QHP defined in ACA law, CSR (multi billion)reimpursements that since then the supreme Court rules had to be paid to carriers. Annual cost-sharing limits cannot exceed specified amounts.* (For 2021, the maximum annual limitation on cost-sharing is $8,550 for an individual and $17,100 for families enrolled in individual or group market plans.)

Cost Sharing and/or Cost share
A term which has become ambiguous. In context to APTC subsodized QHP exchange plans, it means CSR. In context to commercially available major medical plans, it relates to out-of-pocket costs for Deductibles, Co insurance, Copays, MOOP, in context to contracted and non contracted provider locations. In context to Medicare and Medicaid plans, balance billing is prohibited, but deductible(s), Co insurance, copays, (totalling MOOP) apply subject to the policy terms and limits. Call for details. In context to Health-cost-share plans subject to state billing laws/regulations, it can mean an unlimited out of pocket cost regardless of what the policy says - especially is the "plan" is not insurance. UHP uses the term to highlight lower out of pocket costs at their specifically contracted medical care sites offering lower member out of pocket costs.
Cost Sharing Reduction (CSR)
See: 45 CFR 155.20 "CSRs reduce out-of-pocket costs, such as deductibles, coinsurance, and copayments, but not balance billing, such as from an out-of-network provider or for non-covered services. Eligibility for income-based CSRs is based on household income and generally requires the individual or family to enroll in a Silver plan category and be eligible for APTC. However, consumers who are members of federally recognized tribes or shareholders in the Alaska Native Claims Settlement Act (ANCSA) Corporations may receive CSRs if they enroll in a plan in any plan category, and those who qualify for a limited cost-sharing plan do not have to be eligible for APTC. CSRs are not available for coverage purchased outside of the Marketplace. Generally, individuals and families with household incomes between 100% and 250% of the FPL may be eligible to receive income-based CSRs. Household income is determined by calculating a consumer’s modified adjusted gross income (MAGI). Consumers who are members of federally recognized tribes or ANCSA Corporation shareholders may qualify for additional cost-sharing benefits" Source: Marketplace Exam See: Risk Adjustment. CSR costs big dollars to fund. April 2020 the Supreme court sided with the carriers and directed the government to reimburse an estimated $12 BILLION. For individuals and families, cost sharing: Annual cost-sharing limits cannot exceed specified amounts.* (For 2021, the maximum annual limitation on cost-sharing is $8,550 for an individual and $17,100 for families enrolled in individual or group market plans.)

Counselor-designated Organization (CDO)
n organization authorized by CMS to deliver advice to people needing help with all kinds of federal programs including Marketplace plans involving tax credits, etc. Good luck.
Course of Construction Endorsement (Change Order Endorsement )
A Builders Risk policy endorsement (rated at 10%-30% of the total completed project value) that can provide additional limits that may be warranted where "completed change orders'" added value is necessary to insure the project to the policy owner's changing perceived (increasing valuation) needs, and at a cost the insured is willing to pay for the added coverage. (Added completed total value can be a squirrelly estimate.)
Coverage to Care (C2C)
A CMS program designed to primarialy inform medicare benificiaries (and others classesof individuals and families) about available C19, and other health care services designed to improve medical outcomes, and to sometimes reduce costs.

COVID Long-Haul (Long Haul Covid)
Many coverages may apply to potential COVID claims, let along the long-term effects (disability?) of Covid. "Even when the pandemic eventually subsides, long-COVID, which affects between ten and 30% of people who contract the virus, will still be with us. The disease, which symptoms include organ damage, fatigue, brain fog and shortness of breath among dozens of other symptoms could have long-term disability implications for the industry." Source: Risk & Insurace Jan 2022. See: OSHA, Workers Compensation, General Liability (negligence) D&O. EYO, Essential Worker, EO's. etc. (Good Luck)
A highly contagious and potentially deadly virus. See: OSHA
Certified Professional in Healthcare Information & Management Systems. Its one of many certifications available to people trying to forecast medical care claims costs. See: CAHIMS
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.
Critical Access Hospitals (CAH)
In 2018, the Centers for Medicare & Medicaid Services (CMS) required that all critical access hospitals (CAHs) use either 2014 or 2015 Edition certified electronic health record technology (CEHRT) to meet the reporting requirements of the Medicare Promoting Interoperability Program and successfully demonstrate meaningful use. The law requires that downward payment adjustments be applied to CAHs that are not meaningful users of CEHRT." See Hardship Exception Application. Source: CMS
Critical Access Hospitals (CAHs)
See: Advance Copy-interoperability and Patient Access Ruls - Admission. These are CMS rules that govern what care is available to who, and where it gets delivered. Remember, the federal government estimates it spends about 30% of the annual federal budget on medical care and administration, with billions going to for profit hospitals. State spending is on top of that (especially for Mediciad, and other indegent populations including refugees).

Critical Illness Plans (Cancer, Cardiac, Transplant plans)
An insurance triggered by a disease specific diagnosis, and that typically pays out directly to the insured in a fixed lump sum, and in addition to (not subrogated) primary medical coverage. Transplant coverage is typically case rated reimbursement directly to the medical provider.
Critical Mass
A term meaning different things in context to the amount of lives managed in a network, contract or insurance treaty. It can mean the amout of lives met to trigger capitation, or the amount of large employers' employees needed to sustain a viable direct contracting relationship, or the amount of lives managed to insure profitability prior to meeting denominotor (N) value in risk based contracts, (and prior to reaching sample size meeting law of large number - etc.
Cross Plan offsets (CPO's)
A contentious issue related to a carrier mixing expenses of their fully insured and ERISA self funded plans to "spread" costs, and that usually results in higher costs to the self funded plans. United Health is getting sued for it. See: MLR, Premium Refunds (rebating mandated by ACA)
Culterally & Linguistically Appropriate Services (CLAS)
What CMS calls "no charge" entitled serves rendered to eligible people seeking entitlements (Medicare, Medicaid, dual eligibiles, marketplace plans, etc) who speak english as a second language. Relates to a cadre of free services offered by many governmental, association, and/or religeous interconneted services, but primarily ends up with translation services. See:
Curbside Consultation
An informal medical discussion between an doctor and patient that my result in a doctor-patient relationship (for purposes of liability), but usually does not without the patient agreeing to be treated in a professional manner at an agreed upon appointment or office visit. These get confusing with tele-medicine visits that may not have a fee charged to the patient but where the doctor receives a payment from an insurance carrier. Remember, there are many policies that are not insurance.
Curbside Visits
See: DOD
Current Procedural Terminoloty (CPT Codes)
Five digit Medical procedure codes CMS defines that are used to submit bills for payment. (This straight from CMS), "To represent “telehealth-eligible” Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for eCQMs in QRDA I, submitters should use the optional qualifier attribute of the encounter code element to send the telehealth modifier code in addition to the primary “telehealth-eligible” CPT or HCPCS encounter code from the eCQM-specified value sets." Or, A 5 digit code for Hospital procedures. See: ICD-10
Current Procedure Terminology
A 5 digit code for Hospital procedures. See: ICD-10
Custodial Care
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, toileting, check writing, shopping, etc. These are formal triggers in long term care policies, and typically not paid for by Medicare. See: LTC
Cyber Security: Medical: HHS Task Force Recommendations


Dark Web
A term used to describe internet based activity by criminals whose identities are difficult or impossible to trace. See: Raas, Cripto Currencies
Data Safety Monitoring Board (DSMB)
See: CMS and good luck.
de novo
A legal term meaning from the beginning - in context to SPD, and Plan Administrator defference.
Deadlines means different things in different policies (I.e. claims submission, enrollment periods, appeals, waiting periods, elimination periods, etc). In context to ACA OEP/SEP, it means December 15th for enrolling in a plan eligible for an APTC. For a Marketplace offered plan not electing APTC entitlement, the deadline is December 31.
Death Benefit Guarantee Agreement (DBGA)
A sometimes offered and/or elected provision in a life insurance policy. See: IUL
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.
Dedicated Privacy Official
See: Marketplace agent/agency PII protection
Sometimes referred to as Retention, or threshold, or self-insured-retention - 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 benefits. Molina health plan defines it as, "the amount applied toward your annual deductible, based on benefit coverage and claim".
Defense Costs and Containment (DCC)
Term state of florida uses to surround litigation costs.
Defined Benefit Plans (DBP (Pension plan))
DBP (457) plans provide a fixed, pre-established benefit for employees when they retire. EMployers can match funds on pre-tax bases. These plans are complicated, typically require a minimum of a year committment to funding them at the same values, harder to install, but allow for more "retirement focused" contributions than Defined Contribution Plans. See: Retirement Plans. Golden Handcuffs, Vesting. See: other alternitives like: 401K, SEP IRA, etc. Do the work to understand tax benefits using IUL if you have over 10-15 years of life expectancy, want life insurance to protect your family, want extreemely low stock market crash risk, and maximized interest crediting on "premium deposits" surplus invested above cost of insurance each month.

Defined Contribution Retirement Plan (401(k) Retirement Plan)
A plan funded with pre-tax dollars from employees, and that can be matched by their employer. Remember, when no-tax is paid on these contributions going in (seeds), then INCOME tax is due when withdrawn in retirement (harvest) - and no one knows what Income Tax will be in 10 - 30 years..? Roth IRA contributions are AFTER tax, and are not taxed as INCOME when withdrawn in retirement within IRS compliance. Traditional 401 and IRA contributions are not taxed going in... See: Retirement Plans (Employer sponsored) For 2020: (Source Benefits Pro) Defined contribution plans: The contribution limit on self-directed workplace retirement plans including 401(k)s, 403(b)s, most 457 plans, and the federal government’s Thrift Savings Plan will increase by $500 in 2020, from $19,000 to $19,500, according to the IRS. The catch-up contribution limit for employees age 50 and over in defined contribution plans will increase from $6,000 to $6,500. Related: IRS announces 2020 HSA limits IRA plans: Individual retirement investors will not realize an increase to the savings limit next year; the limit on IRA contributions will remain at $6,000, and the catch up contribution cap will remain at $1,000. Total DC contributions: The limit on total contributions to a defined contribution plan, including elective employee deferrals, employer matches, and non-elective deferrals, increases $1,000, to $57,000. Cap on SIMPLE plans: The cost of living adjustment to the cap on SIMPLE workplace plans will also increase, from $13,000 to $13,500. –For single taxpayers covered by a workplace retirement plan, the phase-out range is $65,000 to $75,000, up from $64,000 to $74,000. –For married couples filing jointly, where the spouse making the IRA contribution is covered by a workplace retirement plan, the phase-out range is $104,000 to $124,000, up from $103,000 to $123,000. –For an IRA contributor who is not covered by a workplace retirement plan and is married to someone who is covered, the deduction is phased out if the couple’s income is between $196,000 and $206,000, up from $193,000 and $203,000. –For a married individual filing a separate return who is covered by a workplace retirement plan, the phase-out range is not subject to an annual cost-of-living adjustment and remains $0 to $10,000. Individuals and heads of households can contribute to a Roth IRA if their income is below a set threshold. The phase-out range will increase to $124,000 to $139,000, up from $122,000 to $137,000. For married couples filing jointly, the phase out range increases to $196,000 to $206,000, up from $193,000 to $203,000. Defined benefit plan changes: Beginning January 1, 2020, the limit on annual benefits from defined benefit plans will increase $5,000, to $230,000. The annual compensation limit to determine defined benefit payments increases from $280,000 to $285,000. The “key employee” dollar definition in a top-heavy plan increases from $180,000 to $185,000. The dollar limit for defining a “highly compensated employee” increases from $125,000 to $130,000. The level of plan assets that determine whether a collectively bargained multi-employer plan is systemically important increases $38 million, to $1.097 billion. Source: Benefits Pro Some states are offering 401 plans where employers are not, and to give eligible "employees" opportunity to save for retirement.

Democrat Health Policy Agenda
See: Trumping Healthcare in our Articles section.

A term typically referring to age, and gender of a targeted market. See: Market Share. Age Compression Rule.
A term used when 100% of the claim is not paid as billed. See SPD, proper definition and description of what is excluded, specifically stated is insured and at what amount are applicable. We recommend speaking with your attorney about federal fiduciary rules. ERISA plans are allowed to use internal Plan Administrator rules and discretion.
Department of Insurance (DOI, DFS FDFS)
State agency or regulatory authority that, among other things, licenses, oversees, and regulates Issuers, Agents, and Brokers, as applicable. In FLorida, its DFS - Department of Financial Services
Dependency and Indemnity Compensation (DIC)
A veteran's survivor's pension, aid and attendance long-term care, and burial program.

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.
A term typically used in auto claims meaning the lost resale value of a car that has been repaired after an accident. Unless statutorily mandated, many carriers ignore indemnifying the insured more than the actual (actual cash value) repair cost. See: Replacement costs, Indemnity
In context to carrier distribution of their policies, it means writing a policy without a broker or (non-employee) agent. (and an advocate that is not employed by the company). If there are problems, the policy holder deals directly with the carrier's very experienced staff. There is an old adage about if carriers write direct and cut out the agent) - "Its like being pregnant, you either are, or are not." This gets dicey, and the best advice is to have an advocate, not dependent upon employment, representing the policy holder for obvious reasons.
Direct Care Organization (DCO)
An amorphous terms sometime used to describe coordinated medical care within contracted (HMO/EPO/PPO) networks that improves quality and hopes for lower costs. See: DM See: referenced based pricing, concierge medicine, and medical tourism.
Direct Contracting Entity (DCE)
A term that can mean many things. In ERISA self-funding it means contracting directly between the employer and various providers for things like advanced primary care, high dollar procedures frequently used, and/or hospital care from facilities not already under PPO-like contract, etc. See: Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey, 2020 Large Employers Health Care Strategy and Plan Design Survey by National Business Group on Health, Kaiser Family Foundation employer Health Benefits Survey, etc. See: Steerage, Ambulatory care on site care/centers. Medicare: A Medicare contracting term typically describing physician-care under bonus/penalty contract over a defined period of time, and whose goal is to use EBM to improve quality outcomes at lower costs. 2021, traditional Medicare value-based-contracting indluce 53 Direct ontracting entities, that serve "traditional Medicare" beneficiaries in 38 states plus DC. See: Shared Services risk contracting, Geographic Direct Contracting See: DCE (Direct Contracting Entity) re Preferred and Participating providers, and Professional and Global risk contracts (under PCP capitation or not, etc), and choice for just Primary care or total care contracts. See: CMMI, and below. Professional shared risk (surplus) is 100% to physicians. Total Care Capitation (TCC) available to for DCE in total risk (is reconciled), and DCE in Primary Care Capitation (PCP), that is not reconciled at year end against FFS. Advanced Payment Mechanisms offer additional payments by care category, and are reconciled to benchmark. Direct contracting is between PCE and independent providers dependent upon if DCE is Preferred Provider paid $0 FFS (but cap), or DC Participant, or Non Associated Providers (paid 100% FFS). All claims must be submitted electronically to CMS. Lots of reporting required. The term is also used for Commercial and Medicare population(s) contracting of professional services. Contracting can also include facilities charges from hospitals and various medical facilities. The trend is to identify the costliest medical diagnosis/treatments/procedures, establish EBM, and measure improved wellness at a lower cost. I.e. ESRD, Palliative Care, Cancer, Knee replacements, hip replacements, back pain, diabetes management. Medicare is leading this charge, but many commercial and Medicaid contracts have been targeted as well. See: Shared Savings, CMMI, Direct Contracting, DCE, Pioneer ACO, ACO, PMO, DCO, MSSP, NGACO, etc. (From CMS): "Under Direct Contracting, there will be three types of DCEs with different characteristics and operational parameters. These three types of DCEs are: Standard DCEs - DCEs comprised of organizations that generally have experience serving Medicare FFS beneficiaries, including Medicare-only and also dually eligible beneficiaries, who are aligned to a DCE through voluntary alignment or claims-based alignment. These organizations may have previously participated in section 1115A shared savings models (e.g., Next Generation ACO Model and Pioneer ACO Model) and/or the Shared Savings Program. Alternatively, new organizations, composed of existing Medicare FFS providers and suppliers, may be created in order to participate in this DCE type. In either case, clinicians participating within these organizations would have substantial experience serving Medicare FFS beneficiaries. New Entrant DCEs - DCEs comprised of organizations that have not traditionally provided services to a Medicare FFS population and who will primarily rely on voluntary alignment, at least in the first few performance years of the model. Claims-based alignment will also be utilized. High Needs Population DCEs - DCEs that serve Medicare FFS beneficiaries with complex needs, including dually eligible beneficiaries, who are aligned to the DCE through voluntary alignment or claims-based alignment. These DCEs are expected to use a model of care designed to serve individuals with complex needs, such as the one employed by the Programs of All-Inclusive Care for the Elderly (PACE), to coordinate care for their aligned beneficiaries." See: Aggregated Purchasing Models (grouped employers), Cooperatives See: recent advisory from CMS that DCE's cannot split themselves up into to DCE's.

Direct Contracting Entity (DCO)
See: Direct Contracting.
Direct Coverage (contracted)Network
See: COVID and accessing lower cost testing if the contract exists for an ERISA qualified plan. Safe Harbor exists with the contracted network. See: Network Adequacy
Direct Enrollment (DE)
The process of insuring an individual using the FFE. See: EDE
Direct Forgiveness Portal
See: PPP, CAREs Act
Direct Pay
A term loosely used to reference payment directly from the consumer to the medical provider, before the claim is sent into a carrier or TPA for payment. See Value Based Pricing. The history goes back to when HSA's had much bigger deductibles (and supposedly lower utilization keeping premiums down), but todays common deductibles over $5,000 cause patients to act the same way outside of what IRS calls an HSA qualified plan.
Direct Primary Care (DPC)
In context to ERISA self funded plans, relates to eligible medical expenses for all primary care services including telehealth and or some variety of case management "primary care" services and fees. Relates to IRS compliance of eligible medical expenses taken by employers, other plans, etc.
Direct Primary Care
A new term for essentially what amounts to an on-site clinics, or access to a PA, ARNP and sometimes even an MD for medical services that are not serious. The term 30 years ago was Doc-in-a-box, when physicians resisted the idea of easily available healthcare for less urgent care that directly competes with physicians in private practice. History is very clear how the industrialization of many professional services firm has gone (i.e. engineers, architects, attorneys, accountants, etc.) It would be unwise to bet against MD NOW, on-grounds clinics, and Walgreens/CVS urgent care access and efficient alternatitives.
Direct Service
In context to medical insurance, it relates to a provider being the Directly Servicing physician, versus an insurance company being clear they are not providing the actual medical care. (And therefore, eliminating or mitigating malpractice problems beyond their employees who directly provided care - where applicable). See: Indemnity
Direct to Consumers (DTC)
Jargon typically used to describe pharmacy advertising directly to consumers. Recent Federal action seeks to make more transparent drug pricing for therapies costing over $35 a month. See: AWP No question the advertising increases demand for expensive brand name drugs.
Direct Written Premium (DWP)
A term that can mean several things, but typically means Gross fully insured premium. Can also mean gross reinsurance premium. Can also mean premiums written directly by an entity (like a "marketing-underwriter") placing coverage directly with an insured without a broker or agent. The last one is hard to define in a one-liner, and depends on the context of how underwriting is performed, and who identifies in the customer.
Directors & Officers liability (D&O)
A coverage for corporate officers, and board members that is not provided in a standard General Liability policy. Board members may not realize they have a fiduciary duty liability exposure, and fail to purchase coverage that protects them personally from liability exposure, subject to the limits of the policy. See: GL
Discharge to Community (DTF)
A term used by CMS related to rehab facility quality measures (IRF). Let's just say its a work in progress... "Corrected IRF Provider Preview Reports- Now Available An issue was identified with the data display of the Discharge to Community (DTC) [CMS ID I019.02] Medicare claims-based measure on the IRF Provider Preview Reports that were added to each Inpatient Rehabilitation Facility’s (IRF’s) IRF Provider Preview Reports folder in iQIES on 06/16/2020. Specifically, the data for the Lower and Upper Limit Confidence Interval Risk-Standardized Discharge to Community Rate are erroneous. The report should display the Lower Limit risk-standardized rate first, followed by the Upper Limit risk-standardized rate. The display in the recently distributed report shows the Upper Limit risk-standardized values first, followed by the Lower Limit values. Here is an example of the erroneous display: 57.64% (53.73%, 61.39%)." Source: CMS
In context to medical stop loss or reinsurance, disclosure means the transparent presentation of KNOWN "large claimants" (or trigger diagnoses) as guided by relevant document(s), warrantees, and/or standard. Typical reporting includes reporting membership with defined trigger-diagnosis status, or who have exceeded a defined claim amount - in context to retention. "Actively at work" provisions can complicate transparent disclosure, prior to policy offer/acceptance and risk transfer. We recommend having experienced people handling disclosure issues. This information is provided only as a courtesy. Carrier underwriting standards guide accepted disclosure.
See: Deference in context to Plan Administrator interpretation of SPD.
Disease Management (DM, or Chronic Disease Medicine)
A 20 year old term used mostly to describe chronic medical care managed using EBM to improve quality and lower costs. CMS issued a report indicating their study did not show savings, however, most people believe the focused process can and does improve care. See: MACRA, QPP, PQRS, etc.
A recent Supreme Court agreement that ill gotten gains can be taken from the wrongdoer, but that are limited to the profits received from the ill-gotten gain. See: joint and several liability and talk to a lawyer.
Disproportionate Share Hospitals (DSH)
Hospitals who serve "more" of the poor, and in context to a recent supreme court decision upholding a lower court ruling prohibiting CMS from reducing payments to DSH hospitals (by including Medicare Part C lower reimbursements in their calculation), without proper 60 day public notice and comment period.
Dissability Competent Care (DCC)
See: Dual Eligibles, LTSS
A term used to generally describe what employers can do to help employees work in compliance with ADA law. See: ADA law, be sure to have well documented notes, and manager training.
Distressed cases (High Risk)
A risk characterized by a history of high losses, and/or poor risk management. It can be a politically correct way of describing catastrophic claim or loss in a given policy year. Some brokered lines - like workers compensation, have entities that compete very strongly in these "underwritten" cases. I.e. MODS above 1.0, and certainly above 1.3. Distressed can mean different things on first- and second-dollar perils/claims.
Dividend Plans (Premium Rebating plans)
A term used to describe a policy allowing premium refunds contingent upon lower than expected claims. Workers Compensation is one of the most common examples. ACA reinsurance mandates premium refunding back to insureds where MLR is less then 80%/85%. Using terms like Profit Sharing a premium rebate can cause practical accounting issues as to a taxable event upon "income". We recommend experienced brokerage, legal and accounting advice be garnered. This is not tax advice.
Doctor on Demand (DOD)
See: Humana virtual visits for groups 5-100+ (not for individual Humana insureds) See: Curbside Visits
Doctor on Demand
Typically means 24/7 PA/ARNP/MD medical provider access to care over the phone. See: Telehealth
Dollar Cost Averaging
A term with several meanings. In investing of securities, it typically means investing the same amount every month, year after year to try and earn an average return that smooths out market volatility. It does not guarantee any return. In some life insurance policies, it references how premium deposits are held in a fixed interest account and doled out each month (typically 12 periods or months) into policy, and within IRS compliance to avoid a policy becoming a MEC (where growth is taxed as income). See: IUL, MEC
Double Dipper
See: Medicare Double Dipper
Doughnut Hole (Part D (Pharmacy Benefit Plan))
Source: AARP The Medicare pharmacy coverage gap that supposedly dissapeared in 2020 under ACA, however, maximum out of pockets costs associated with tier copays make this a squirrelly issue to tie down especially with beneficiaries dealing with multiple brand name and high cost Rx. Remember, a plan can change the tier copay (and percentage of coverage) during the same policy year, so what it starts at, may not be what it ends at.
Dual Eligible’s
A term generally used to identify an individual eligible, and insured by both for both Medicare and Medicaid. These rules are somewhat complex and may also impact potential social security classification. See: Subrogation
Dual Eligibles Special Needs Plan (DSNP)
Good luck discovering competing plans, eligibility and pricing, let alone how the formularies work, along with premium payment amount and assignment. See: United Insurance Group offerings, HFC, SDOH...

Dummy Codes
Term used by a plaintiff suing Aetna and Optum alleging coding billing deceit whereby Optum's use of codes (and unauthorized transactions) used to make administrative fees look like medical service fees. Supreme Court reverted the case back to state appeals court and denied Optum's attempt to remove class action status.

Duty to Defend
A standard liability policy feature, benefit, provision, or coverage as stated in the policy or defined by state law and the policy form. In most if not all states, litigation expenses are unlimited, and in addition to the liability policy limits, so it is not always straight forward, especially where gross negligence (or intentional acts) is/are determined to be a direct or proximate cause of the loss.


Early Lock Down
A renewal feature offered by some carriers to renew stop loss coverage early, and avoid last minute potential lasers on sick employees 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.
Earned Premium
A term typically used in P&C policies providing notice to the policy owner of being charged (i.e. 25% of the annual premium), regardless of if the policy owner cancels the policy mid year. These get squirrelly if the policy is canceled for non-payment of premium in the first 3 months (25% of the coverage period). Policy terms can be longer than one year. Earned premium is calculated by the number of months a policy is in force, relative to if the premium (for greater than 25% of policy period) has been paid by the policy owner.
EEO - 01 Reporting

EEO - 1 Reporting
The Equal Employment Opportunity Commission (EEOC) announced that it will open the 2021 EEO-1 Component 1 Report on April 12, 2022 with a due date of May 17, 2022. The EEOC’s announcement indicates that both dates are “tentative” and EEO-1 opening and closing dates have been subject to modification by EEOC in recent years.

Efficient Proximate Cause (EPC)
In context to theories of recovery in property policies, and losses caused by multiple insured and uninsured perils, the rule generally applies coverage to the entire loss. In context to property policies, and theories of recovery, it applies to the "chain of causation" or initiating cause of an insured peril and loss. Where the original peril causing the loss cannot be discerned from "concurrent" perils causing a loss, insurance generally applies to the entire loss. See: CCD & ACCD It assumes the initiating cause of loss is known.
Electroinic Data Interchange (EDI)
See :RRE.

Electronic Clinical Quality Measure (eCQM)
The Centers for Medicare & Medicaid Services (CMS) developed and published the 2020 performance period electronic clinical quality measure (eCQM) flows for eligible clinicians and eligible professionals to the eCQI Resource Center. The eCQM flows are designed to assist in interpretation of the eCQM logic and calculation methodology for performance rates. eCQM flows provide an overview of each of the population criteria components and associated data elements that lead to the inclusion or exclusions into the eCQM’s quality action (numerator). eCQM flows supplement eCQM specifications for eligible clinicians and eligible professionals for the following programs: • Quality Payment Program: The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs) • Advanced APM: Comprehensive Primary Care Plus (CPC+) • Medicaid Promoting Interoperability Program for Eligible Professionals These flows are intended to be used as an additional resource when implementing eCQMs and should not be used in place of the eCQM specification or for reporting purposes. Questions on the eCQM flows should be directed to the ONC Project Tracking System eCQM Issue Tracker. Source: CMS

Electronic Clinical Quality Measure (eCQM) (eCQM)
Electronic Clinical Quality Measure (eCQM) Data Element Repository (DERep). See: Data Element Repository (DERep)

Electronic Health Record (EHR)
A computer stored file consisting of a member’s personal medical information. See: Health Care Exchange Interoperability, a term used by CMS to define how different stored data bases communicate or not. According to extelligent Healthcare Media, the federal government has spent over $36 Billion dollars since 2010 on EHR technology, reporting, etc. No question AI can do more here. No question mandatory reporting to the feds has real purpose, but real expense.
Electronic Health Record Modernization (EHRM)
Term used to describe the VA's medical record program and update plan that interfaces with other EHR that uses different standards and values. The VA was the first entity that could share its information among other VA facilities going back about 25 years.
Electronic Inspection Reports (EIR)
Electronic Inspection Reports (EIRs) replacing all Inspection Reports (IRs). These are reports used for life insurance to typically verify income.
Electronic Personal Health Information (e-PHI)

Elevance (Anthem - Blue Cross)
See: Anthem
Elevation Certificate (EC)
A report provided by a licensed surveyer detailing the feet above sea level a property is located. Properties are classified according to a FEMA designation. See: Flood
Eligibility Determination Notices (EDN)
Health Insurance Marketplace explanation of what may qualify for SEP, OEP, etc. It may also be referring to the official letter HHS sends each applicant detailing APTC.
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 (Eligibility)
A term frequently used to describe insured status of perils defined in the policy. See: Certification, Verification
Eligible Clinician ((Replaces Eligible Professional))
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Elimination Period
A defined minimum period (usually in days) after the coverage triggering event that benefits are eligible for payout. These are defined in LTC and Disability policies. A policy can have two elimination periods with one being 0 days and that relate to what type of eligible claim is being triggered.
Emergency Temporar Standerds COVID
A term used by OSHA for just about anything they want to issue as directed by the White House, etc. The COVID 19 ETS mandates employers over 100ee's are required to ensure employees are fully vaccinated, or require unvaccinated workers to produce negative weekly test result. September 2021
Emergency Temporary Standard (ETS)
A temporary order invoked by a federal (like OSHA) or state regulating entity, mandating worker safety employer-actions and protections. See: EO. Good luck figuring out if OSHA fines an employer over 100 lives, if that employer has real problems litigating to get out of the fine that I.e. the Supreme Court recently ruled OSHA ETS unenforceable - Employee vaccination mandate. Gets even more complicated in some states with COVID regs, and other states ignoring prudent responses based on real-science.
Emergency Temporary Standard (ETS)
See: Federal Emergency Temporary Standard, OSHA, EO
Emergency Triage, Treat & Transport (ET3)
"Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth." Source: CMS

Employee Assistance Programs (EAP (workers Comp))
Means many things related primarily to "early intervention" benefits offering more services to employees, but whose costs are usually shared with the employee. Workers Compensation carriers typically tout goals to reduce injuries, get people back to work, and avoid depression caused absences, etc.
Employee Benefits Security Administration (EBSA)
Employee Benefits Security Administration. In Context to C19: EBSA is an agency directed by HHS. "EBSA and IRS officials write in the new final rule draft that the rule will ease the: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) coverage access request deadline. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) group coverage continuation request deadline. The COBRA coverage continuation premium payment deadline. The Patient Protection and Affordable Care Act of 2010 (PPACA) benefits claim decision appeal and external review deadlines. A benefit plan’s benefit claim filing deadlines." (Source: Allison Bell of ThinkAdvisor April 2020
Employee Experience (EX)
Slange used discussing programs aimed at addressing employee burn-out or team building programs.
Employee Retention Credit (PPP)
See: PPP, and cross reference CARES act law. If a company got CARES money, then they may not be eligible for the ERC. Talk to you CPA.

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 laws can be interpretated and enforced differently by different administrations.  Although ERISA law purpose is to create greater choice and savings for employers by superceding various state solvency/capitalization mandates, it also holds language requiring state regulatory solvency/capitalization compliance within various time limits.  Plans sponsored by municipalities may be regulated by the domiciled state. These plans may include Life, Health, Dissability, Gap, Dental, etc as part of the Plan Sponsor offerings. The purchase of Specific and Aggregate reinsurance is optional, but usually done to transfer the risk of unpredictable catastrophic losses. ERISA is regulated by the EBSA (Employee Benefits Security Administration).  ERISA is complex, and typically requires legal advice to negociate wisely.  See MEWA related to President Trump's Association Health Plan initiative.
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
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.
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.
Employer Plans (Group Plans)
In context to medical insurance - An single entity offering medical insurance to W2 employees, and who posses a FEIN #. Trump EO's soften the definition to avail (non-ACA compliant - health insurance "association") plan offerings to regionally located small employers across state lines, and potentially in violation of state insurance law(s). Federal ERISA law is supposed to supersede state law (at least initially), however, states routinely challenge plans not meeting state guidelines. See: State of New York et al. v. the U.S. Department of Labor et al. Case Number 19-5125, AHP, Executive Orders, MEWA, ERISA, etc. We recommend experienced legal, insurance and reinsurance expert assistance be obtained prior to launching an ERISA or Association Health Plan using the Executive Order authority.
Employer Practices Liability (EPL or EPLI)
A stand alone policy coverage, or coverage added into, or part of General Liability "package" policy. When it is automatically offered, as in some Hartford policies, limits are very low at $5,000. EPLI is not workers compensation insurance. Examples of coverage insured in a standard contract may include: wrongful discharge, sexual harassment, sexual molestation, age discrimination, sexual discrimination, disability discrimination, etc. This is by no means a full description of EPLI coverages, limits, exclusions, etc. Complex issues related to umbrella coverage and exclusions may apply. Employers are responsible for determining their exposure
Employer Sponsored Retirement Plans (Pension plans)
See: 401, 403, TSP, DBP, SEP IRA
Employer Stop Loss (ESL)
Employment Private Insurance (EBPI)
A term used by the RAND corporation to survey and report findings in context to a stakeholder. Specifically where medical costs to the employee's family exceed 10% of MAGI. See: ACA law and rules allowing group employees to become APTC eligible where (premium only) ee medical insurance exceeds 9.5%.
End-User Customer Experience (UX)
See: EX, HR, etc.
Engagement Specialist (ES)
What some population health companies call the person who actually contacts the patient for care management, etc.
Enhanced Direct Enrollment (EDE)
A term used to describe a vender's marketplace health plan web enrollment portal that interfaces with IRS for official APTC (that reduces the premium paymment for the eligible insured). These sites offer unlimited health insurance (10 EHB) for both individuals and SHOP.
Enhanced Direct Enrollment
A term used to describe a Marketplace (FFE) on-line enrollment site (and product review site) that includes the federal tax credit(s) that typically reduce out of pocket premium costs.
Enhanced Direct Enrollment System (EDE)
A term use by an "approved" Marketplace FMO that essentially allows people to enroll in ACA compliant medical plans, and receive APTC without directly enrolling in the Federal Marketplace system. In short, you can apply on the site of a private company and still get premium tax credits from or your state exchange. Some of these sites work faster and easier than FFM website enrollment. (They make is easier to see things like SPB, get tax credit, print out formularies, and to compare ALL available plans versus just what an agent is "appointed" to sell.) See Navigator, FFM, APTC. EDE sites can also "complete" enrollment after Open Enrollment within the rules.
See: 45 CFR 155.20 See: Enrollment Reconciliation
A contractually guided function establishing insurance coverage to an entitiy at a specific date and time. The term is different for various kinds of insurance/reinsurance meaning. The issue can get contentious.

Ensuing Loss Clause
A policy provision defining coverage pay out on an individual peril and loss, caused in part by an Excluded (in the policy) and uninsured peril, or loss. In short: The EPC must be an insured peril (cause of loss) , and the ensuing loss must not otherwise be an Excluded peril for coverage to apply. Ensuing Loss Clauses coverage eligibility is guided by the entire insurance policy contract - inclusive of each policy's "theory of recovery", and generally accepted practices and standards.
Enterprice Entity Management (EEM)
HHS/CMS sub agency function involved with Marketplace data security.
Enterprise Identity Management (EIDM)
See PQRS An Enterprise Identity Management (EIDM) account with the appropriate role is required for participants to obtain PQRS Feedback Reports and 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.
Enterprise Identity Menagement System (EIDM)
See: Marketplace data matching
Enterprise Risk Managment
Jargeon used to describe a large organizations coordinated risk management initiatives. It can mean many things.
Episode of Care (Bundled Payment)
A term used to denote a fixed contracted reimbursement based on agreed diagnosis, and tied to "supported and agreed" EBM outcome. Episode of care is the vernacular being used by Payors attempting to fashion reimbursement schedules or contracts with providers inclusive of all services delivered over a treatment period by diagnosis tied to EBM outcome. Key elements involved are definitions of: Episode (by diagnosis, outcome, period of time of treatment, etc), Pre and post care defined bundled Payments, compensation model (actual to target goal), contracted rates (many and varying types including "risk sharing"), triggering event (defined by ICD10 or HCPS/CPT in context to an indexing for severity), warranty period (good luck?), comorbidity/readmission outlier balance on penalty versus additional reimbursement. Ragardless, this is the future for the well managed organizations who understand how (primarily) hospitals are getting forced to "focus", evolve, and coordinate with employers, payers, doctors and patients, etc. Hospitals who have not done the work to configure competitive market driven services that can be sustainably funded will fail over the long term. See: McKesson, Prometheus payment 5.0, and ERC Logic (Evidence-informed Case Rate), Bundled Payments, DRG, Catalyst, etc.
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. See: CMO

ERISA's Prudent Man Rule
ESG Funds (Green Investments)
Environmental, Social and Governance investments supporting an agenda of philanthropic concerns - especially "green" technologies replacing conventional polluting technologies, or organizations that do not promote agenda beyond maximizing stock holder equity. President Biden declares building back better means developing the "next" generation of green technologies ...
ESRD Seemless Care Organizations (ESCOs)
CMS has released a public ACO Care Coordination Toolkit showing the work of ACOs and End-Stage Renal Disease Care (ESRD) Seamless Care Organizations (ESCOs) participating in the Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model. See: ACO
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 (EHB)
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. Note: EHB is not Actuarial Value defined by ACA. See: ERISA

Event Cancelation Insurance
A coverage typically insuring a major event subject to terms and provisions of the policy. See: Anonamous Life insurance, etc.
Evidence Based Medicine (EBM)
Scientifically produced medical care outcomes derived by refereed interpretation of medical treatment and cure data. The goal is to get physicians to accept them in context to tort, and allegations of cookbook medicine claims from decentors. Another goal is to get payors to accept the standards and authorize payment. See: Value Based Reimbursements. Overal goal is to improve medical outcomes at a lower cost. Most common (about 80%) of contracts today include EBM for Diabetes, Hypertension, Heart Disease, COPD and Asthma. See: Medicare demonstration projects, and not 100% of all Medicare payments are value based.
Evidence of Coverage (EOC)
See: Credible Coverage
Excepted Benefits
Insured plans that do not meet ACA rules for QHPs. In other words, any plan that limits a "10 essential benefit". See: IRS, DOL, HHS joint regulations, and ACA Final Rules.
Excess & Surplus Lines (ESL)
Excess of loss insurance or reinsurance typically called stop loss. Second dollar coverage triggering after eligible claims exceed a typically large deductible. Coverage can be specific and or aggregate. Surplus lines is "eligible" coverage sold in a specific state, but is not "authorized" (no COI, and not insured by state guarantee fund)
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.
Excess Provision
An insurance policy provision limiting coverage to the amounts excess of any other eligible policy coverage. These get tricky. Some excess policies mandate "primary" coverage, to trigger a "secondary" coverage (separate policy) eligibility trigger, and other policies will still pay out as the primary policy if no other policy coverage is present at time f insured loss. These are almost always in reinsurance and stop loss policies. Accident only, Hospital indemnity, critical care policies must be read to know if an excess provision applies, or not. Excess provisions is not the same as Excess and Surplus (reinsurance) policy coverage. IMPORTANT: Claims bases used to calculate (second policy excess coverage) reimbursement may not be the same as the mandated primary coverage claims bases, so most people will struggle to figure out if their claims have been paid accurately. Auditing these claims is recommended. See: Subrogation
Exchange (Marketplace, FFE, FFM)
Meaning set forth in 45 CFR 155.20 An 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. All but 14 states manage their own INDIVIDUAL and SMALL GROUP (SHOP) "marketplace" (on line access) to plans. CO-OP or Cooperative may have different distribution, and plan access parameters. Federally Facilitated Exchange means the same thing as Federally Fecilitated Marketplace, or Marketplace. It get complicated with SB- FFM's. See: FFE, FFM, FF-SHOP, FFM, and multiple state based (managed) (SB- FFM) exchanges definitions offering different types of major medical products approved by CMS
Exclusions Homeowners
There are 8 exclusions or sets of exclusions pertaining solely to the dwelling and other structures, including the following. • Property Section Exclusions • Collapse Exclusion • Freezing of Plumbing, Heating, Air Conditioning, or Sprinkler Systems, and Household Appliances Exclusion • Freezing, Thawing, Pressure, or Weight of Water or Ice Exclusion State specific policy form applies: Generally, there are 8: • Theft Involving Dwelling under Construction Exclusion • Vandalism and Malicious Mischief for Vacant Dwellings Exclusion • Mold, Fungus or Wet Rot Exclusion • Wear and Tear Exclusions
Exclusive Provider Network (EPO)
A network of physicians and hospitals offered to members for In Network care. EPO plans typically do not insure care received out of network, and look similar or identical to HMO Gatekeeper model plans. EPO's can also look like PPO plans but typically do not INSURE out of network (non contracted provider) care. Beware what is and is not insured, and for big balance billing issues governed by each state's insurance regulations.
Executive Order (Medicare Executive Order)
See: ACA, ACA Executive Order, price transparency, Immigrant insurance requirement injunction, Conscience Rule injunction, Healthcare Choice plan sales across state lines order, etc.

Executive Order (Presidential)
ACA law applies where "enforced", but without Individual Mandate Penalty. Pay special attention to EHB, QHP, CSR, Open Enrollment, and carrier reinsurance safety net. Read Trump-ing Health Care Reform at www/ and click on Articles. See CRA (Congressional Review Act) that technically can invalidate any EO taking effect less than 60 days after the EO was published. The Biden administration is reviewing all of President Trump's EO's, especially the ones rush in the last 60 days of his presidency. See: Medicare Executive Order

Expected Claim Value
The underwritten expected annual claim value used to rate specific and aggregate insurance premium.
A term used to describe verifiable claims history over a period the underwriter defines as important. It can also refer to the length of time an individual or group has been in the insurance business for purposes of qualifying carrier appointments and wide ranging rating and binding, etc, privileges.
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 credit can sometimes be an underwriting term establishing the weight of the past year's 3-5 claims experience weighting (credibility) to future premium rating.
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. Can be used as an underwriting term for major medical claims data creditability as expressed as a percentage for each years experience.
Experimental care (Quaterinary Care)
Generally, care that is not approved by FDA or as generally practiced by the greater majority of medical providers. Quaterinary care is a term apparently created by bord lawyers/acidemicians to represent sophiscotated and specialized care that is not widely available, or that is considered experimental.
Expert Medical Advisor (EMA)
A highly qualified medical professional accepted by a workers compensation court for purposes of determining the percentage of medical claims an injury event was caused by a work related activity, v the percentage caused by a preexisting medical condition. Expert Medical Advisors report on the "Major Contributing Cause" (MCC) of medical claims loss. Findings of cause being 51%+ work related 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.
Explanation of Review (EOR)
A term used by some repricing companies to describe where they see errors, or potential discounts as compared to other medical pricing schedules.
Expression Logical Model (ELM)
See: ecQM
Extended Non-Network Reimbursement Program (MNRP)
A United Healthcare RBP claims payment protocol.
Extended PIP
In context to Florida No Fault PIP it means PIP coverage must pay up to 100% (as opposed to 80%) of medical treatment/services, plus lost wages, and funeral expenses caused in automobile accident (up to $10,000). See: No Fault, IUM, and exceptional events causing more than $10,000 losses insured with additional limits and coverages.
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.
Extreme and Uncontrollable Circumstances (EUC)


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.
Failure to File and Reconcile (FTR)
A FFM term that generally means the insured did not prove their lower income to qualify for their APTC. It can mean many thins.
Fair Access to Insurance Requirements (FAIR)
Fair Market Pricing
An amount both providers and payers agree to accept for their services/products. See: Repricing, contracted rate, VBR, QPP, etc. Companies offering discounting services can lower the amount accepted but charge a percentage of the fee saved under the billed charge. Lots of litigation and decisions in this area, with the biggest being: Surprise billings laws, along with where United Healthcare lost at trial and had to forfeit authority to set prices it paid to providers who felt UHC materially underpaid or discounted billed charges by hospitals and doctors. United was forced by court order (a SUNY affiliated pricing expert PhD supervised) to establish "fair" reasonable and customary charges by region, and/or pricing going forward. Pricing is guided by plan type, and laws surrounding commercial, Medicare, and Medicaid pricing. Then there are squirrelly issues of what hospitals charge/report for "self-pay" or bad debt patients which can be 100% more then is routinely accepted by hospitals and doctors under contracted rate scenarios.
Fair Rate (Benchmarking)
See R&C. Very contentious
Faith Based Groups (CMS Rules: Faith Based Groups)
Get an attorney to explain this one. This rule is more the Interim Final Rule than the Final Rule given its Executive Order mandating it in Dec 2020. See: CRA

Faith Based Plan
See Ministry Health Plans
Families First Coronavirus Response Act (FFCRA)
Reles affecting groups greater then 50 FTE's, enforced under OSHA, detailing coverage requirements carriers must insure. One was blocked (mandated COVID vacination) coverage for employees), and the other one related to OTC medicines. See: Families First Act (FFA)
Families First Coronovirus Response Act (FFCRA)
An act that expanded Medicaid eligibility and APTC increases for the Individual marketplace market. See: PHE
Family First Coronavirus Response Act (FFCRA)
See: Families First Coronavirus Response Act (FFCRA) In addition to traditional paid and sick leave (PSL - Paid Sick Leave), COVID-19 spurred the passing of the Families First Coronavirus Response Act (FFCRA), which includes the Emergency Family and Medical Leave Expansion Act and the Emergency Paid Sick Leave Act. The FFCRA requires employers with 500 or fewer employees to give employees expanded paid family and medical leave, and emergency paid sick leave. FFCRA lowers cause of action requirements allowing some employees who have been denied their rights to sue their employer for COVID related FLMA prohibited, or mandated actions. FMLA is complicated and applies more than it does not apply, but is contingent upon several facts: State emedical leave rules may be more generous, that telemedicine visits can qualify for illness severity and subsequent leave (three or more days unable to go to school, or seeking treatment from a licensed doctor for serious health condition, that the employee worked for 12 months - not less than 1250 hour the previious year, and at a location where at least 50 employees are employed by the employer within 75 miles. Private employers are subject to FMLA if thay have 50 or more employees in any of preceeding 20 workweeks. Public agencies (federal state, local government, elementary school, secondary schools are covered FMLA employers. National guard, reserve military and uniformed services employement and reemployement rughts apply (USERRA). Employers must continue healthcare insurance benefits during qualified leave. ============HR Directors earning their pay this year - you bet. Check with each state's DOL See: FFCRA, and know that the Supreme Court blocked one of the two requirements - Mandated employee vacination (groups over 50 FTE)

Family Medical Leave Act (CARE's Act)
These are two different laws organized under COVID threat, and designed to help people care for themselves and/or their families, and insuring job security. FMLA has a second law passed making it easier to sue employers by lowering the cause of action requirments. Bottom line: If an employee is sick and or needs to care for a sick relative, that employee must be provided time off to take care of it. In some states, some larger employers are also required to pay the employee while absent. Speak with a attorney or HR professional for details.
Fari Labor Standards Act (FSLO)
See: Detailed Assessment of the (each states) DOL Overtime Rules. Important because of what ACA calls full time (30 hours per week), and what states call full time, and existing IRS alternatives to employ 1099 subcontractors, or PEO... Get advice from a licensed person.
Favored Nations Clause
A contract provisions setting medical claims reimbursement to the lowest accepted PPO (RBS, etc) rate a provider has negotiated and accepted with any carrier for that product or service. These are especially important in stop loss recoveries, and can dramatically reduce reimbursement of eligible charges. In stop loss the idea is to cover the actual cost, and not a profit center. ANother usage to the favored nations clause rlates to President Trumps Executive Order allowing "some" (who knows?) drug prices be comparable (or same?) drug prices from other countries. Lots of issues here... Just a note that ACA repealed the President Bush signed regulation-law prohibiting Medicare and Medicaid from bidding for lowest cost drugs, but somehow, their is another practice or rule that prohibits it? 60 minutes has a great show detailing the 3AM congressional hearing that passed the original law, and the guy that went to work for the pharmaceutical company right after passage at a very high salary.
Fecal Imunochemical Test (FIT)
I lab test that detects colon cancer. If you are 45 or older, a FIT Colorectal Cancer Screening may be covered by your health insurance or Medicare at no out-of-pocket cost when ordered by your doctor. Contact your doctor to explore this option.
Federal Arbitration Act (FAA)
Federal Budget 2017 - 2018

Federal Information Security Management Act (FISMA)
Federal Information Security Management Act
Federal insurance Office (FIO)
"The FIO’s authority extends to all lines of insurance except health insurance, crop insurance, and certain types of long-term care insurance. The FIO is also responsible for: · identifying activities that could pose systemic risk to the insurance industry; · declaring state insurance laws to be preempted by international agreements regulating insurance; · reviewing inconsistencies in state insurance laws that impact the national market and preempting such laws where appropriate; · monitoring whether underserved communities have access to affordable insurance products; · consulting with states about national and international insurance matters; and · coordinating federal efforts and developing federal policy on international insurance matters, including representing the United States in the International Association of Insurance Supervisors.103 · Although Congress gave considerable power to the FIO, it left state-based insurance regulation undisturbed for the most part. Notably, the FIO does not have general supervisory or regulatory authority over the business of insurance, which remains in the province of state regulators. Instead, the FIO focuses on national and international insurance matters, and it is authorized to represent the United States internationally at insurance regulatory meetings." Source: CE Track Agent Licensing Exam Jan 2019
Federal Pandemic Unemployement Compensation (FPUC)
In context to APTC, its important to not include it ($300 per month extra) in FPL calculation that may also include CSR benefit.
Federal Pandemic Unemployement Compensation (FPUC)
2021 federal subsidies that reimburse employers offering unemployment benefits to workers laid off during the pandemic. Confirm it with your CPA
Federal platform for eligibility and enrollment functions (SBM-FPs)
A federal term used to denote various sites the public can access for pricing individual and small group (SHOP) plans that are eligible for tax credits (APTC).
Federal Poverty Level (FPL)
FPL is an income (AGI/MAGI) number HHS defines is above or below "poverty", or sufficient income to afford basic living expenses. In context to ACA, it is the amount where an eligible person seeking QHP qualifies for Medicaid (under 100%), or APTC (income between 100% - 400%). See: President Biden and updated CMS increased subsidies above 400% (to 800%) to qualify for increased tax credits. See Links: ACA law authorizes substantial APTC for eligible people earning between 100% and 400% FPL. People earning between 100% - 250% also qualify for cost sharing that lowers deductibles and MOOP substantially. The idea here is to lower the barrier for poor people to see a doctor for a chronic condition that when left untreated causes a $100,000- $500,000 ICU bill - like older Americans with neglected or ignored diabetic conditions, hypertension, lower back pain, asthma, prostate screenings, mammograms, thyroid super inexpensive meds... See: CSR

Federal Poverty Level Guidelines

Federal Privacy Impact Assessment (PLA)
See: HIPPA, PII, OMG memorandum M-03-02, OMG Guidance for implementing Privacy Provisions of the E Government Act of 2002 (Spet 26, 2003) and good luck.
Federal Provider Penalties (Patient Dumping)
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.
Federal Tax Information (FTI)
Info accessed by the federal government to verify Marketplace APTC.
Federally Facilitated Marketplace (FFM)
First called Federally Facility Exchanges, now called FFM. 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.
Fidicuary Insurance
Yes, it is available for ERISA self funded Plan Sponsors and/or Plan Administrators. Call for details.
Fiduciary Duty (Fediciary "rule" Rule 9550, 4111)
A legally defined standard of service epitomized by selfless noble action(s) in best interests of the client. In context to ERISA medical plans, it is paramount and transparent member protection subject to the SPD (and potentially other important documents guiding benefits, intent, express performance, employment agreements, and accepted transaction(s). Insurance Agents are not Broker Dealers, and do not usually deal with qualified funds (untaxed) retirement investments subject to complex taxing issues. Securities licensed professionals do routinely deal with qualified funds for investments. The latest rule 4111 essentially mandates segregation of funds drawn from qualified accounts (where income taxes have not already been paid on the funds), and that represent a person's retirement nest egg with special protections to the customer), and disclosure of all types of compensation the Broker Dealers receive. The paperwork must be enormous, especially with companywide incentive programs meeting sales goals and triggering compensation to the senior executives the local salesman knows nothing about! ================== DOL issued guidelines April 2021, mostly directed at stockbrokers and broker-dealers licensed to sell securities, dealing with client retirement account investing - especially where larger sums are withdrawn and taxed to then invest into marketable securities (or variable annuities, etc) exposed to stock market crashes, etc. I.e. Recommendations of investments with long periods must make sense in context to the investors age, and financial suitability (there is a required form for Annuity buyers called Senior Suitability) over the clients normal life span. See: DOL link, Senior Suitibility, arbitration of breach of fiduciary duty claims under the Employee Retirement Income Security Act (ERISA) Section 502(a)(2). Insurance agents have long been required to complete Senior Suitability applications to place Annuity products that cannot crash in the market, therefore, its quite important to differentiate products that can, or cannot crash in the stock market with establishing BIC. A licensed insurance agent cannot sell products that can crash when the stock market crashes, without another license granting authority (like securities licenses, or a separate license authorizing Variable Annuity sale, etc) In sequence and context of "best interests" contracts (BIC) it may follow an increasing liability progression standard characterized by an: obligation, responsibility, duty, and fiduciary-duty. Many laws already apply such "standard", like ERISA. Se: Reg BI See: Final Draft from SEC link. (Re: Securities brokers and/or dealers) "D. Broker-dealers (selling securities) and investment advisers have disclosure and compensation reporting obligations under state and federal laws, including, but not limited to, obligations under the Exchange Act, the Advisers Act, and the respective rules thereunder. In general, it applies to not referring clients into investments (especially IRA's, 401s, etc.) that are controlled by the broker making the recommendation), and disclosure of compensation(s) or potential conflicts of interests so the investor can be advised before putting in retirement directed funds, or cashing out (and paying tax on) retirement funds to be used to purchase a recommended security or investment. Broker-dealers are also subject to disclosure obligations under the rules of self-regulatory organizations. Delivery of the relationship summary will not necessarily satisfy the additional requirements that you have under the federal securities laws and regulations or other laws or regulations." Licensed Insurance Agents are not Broker dealers or Investment Advisors. February 2020 Supreme Court ruling detailed opinion on "constructive" versus "informed" knowledge of the plan participant (on how his retirement funds were invested) comprising "actual" versus "constructive" knowledge by the member. All courts have long held Caviet Emptor applicable to personal responsibility in any transaction. The decision detailed "the ERISA participant cannot sue the plan sponsor after the earlier of six years from the time of a fiduciary breach, or the three years after the time the plaintiff had "actual" knowledge of the violation, ..." It should be noted that sending a letter or email that may not get read by the investor does not constitute constructive knowledge. Source: BenefitsPro 2020 ======= Although ERISA's intent is to empower large multi-state medical plans, by superseding more restrictive state laws and uses a standard of whether a state-law interferes with a plan's "central operations", many courts find a delicate balance related to starting an ERISA plan must eventually (within 2 years) comply with state guidelines in context of federal supersession of state law authority. See: MEWA Assigning a fiduciary duty to both a Plan Sponsor, and Plan Administrator is not a given, although many cases fiercely allege both entities hold duty. See: Cooper v. Ruane Cunniff & Goldfarb Inc, Employee Retirement Income Security Act (ERISA) Section 502(a)(2), Coan v. Kaufman, Dorman v. Charles Schwab Corp,Williams v. Imhoff, 203 F.3d 758 (10th Cir. 2000),DuCharme v. DST Systems, Inc., et al., No. 4:17-cv-00022 2017 U.S. Dist. LEXIS 220432 (W.D. Mo. June 23, 2017),Roches v. Dickerson Employee Benefits, Inc., No. 09-04279, 2010 U.S. Dist. 152637 (C.D. Cal. 2010),Hawkins v. Cintas Corps., No. 19-cv-1062, 2021 U.S. Dist. LEXIS 72511, *5 (S.D. Ohio Apr. 15, 2021),Cooper v. Ruane Cunniff & Goldfarb Inc., 990 F. 3d 173 (2d Cir. 2021),Coan v. Kaufman, 457 F.3d 250 (2d Cir. 2006),Hawkins v. Cintas Corporation, No. 19-cv-1062, 2021 U.S. Dist. LEXIS 14766 (S.D. Ohio Jan. 27, 2021)

Fiduciary Insurance
Insurance that transfers fiduciary duty risk. Call for details.
Field Marketing Organization (FMO)
A sales and/or marketing organization typically organized to sell various kinds of insurance policies. CMS call them TPMOs. FMO's can be called by several different terms, and can require exclusively, or non exclusivity of their contracted agents. These organizations can take many forms and functions. FMO's can involve multiple levels of commission splitting, and/or administration - in context to the product-line being managed through a form of GA contract. Latest trends in distributing involve more simplified underwriting (or guarantee issue) policy forms (coverages). The goal of this is streamlined policy placement, and electronic (digital) administration, but many challenges can and do derail that goal - especially in senior care and retirement-like products like Medicare Supplementals, MA, MA-PD, LTC, annuities, etc. Selling complex MA plans, to seniors who fear technology, and have memory issues is anything but easy. Different carriers coin different definitions, and requirements. Almost all of them mandate individual E&O prerequisite. See: IMO, BGA, MLM, SGA MGA, GA, MGU, TPMO, aligned agency networks, and Web-Broker, Fiduciary duty standards.

Final Expense Policy
A policy designed to pay funeral bills, and medical expenses of the insured, but only pays out a percentage of the death benefit based on how long the policy has been in force. In other words, if a person buys a guarantee issue policy, and dies the next year, only a small percentage of the face amount is paid to that person's beneficiaries.
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 Coronavirus Response Act (FFCRA)
The act that also requires employers under 500 FTE to properly handle employees seeking leave for taking care of themselves or a family member. Has both criminal and civil penalties. This peril is related to EPLI coverage many employers never buy, or underinsure. See: FMLA and supplemental federal law affecting same.
First Dollar Risk
A dollar amount most underwriters consider a likely claim value (i.e. under $50,000 for inpatient hospital charges) per calendar year for each insured member. Second Dollar risk is typically medical claims risk above $50,000. Risk like beauty (and retention levels) is in the eye of the beholder.
Fiscal Year (FY)
Flexible Spending Account (FSA)
One of many types of medical plan accounts allowed by IRS that gets funded by employers to pay for eligible medical expenses during the policy year. Funds are deposited pre-tax. It is not an HSA, HRA, MSA. See: FSA, ERISA self-funded plans, HSA, ICHRA, MSA, etc.

Flexible Spending Accounts (FSAs, Section 125 plans)
A FSA is an employer sponsored (and administered) medical spending plan and account that allows employees to pay (usually with a Debit Card) for eligible medical expenses with pre-tax dollars. FSA funds are not available to pay premiums. Defined unused remaining balances at year end are forfeited. A small amount may be rolled over for use in future years. See IRS guidelines, FSA's are not HRA's. FSA's get funded by the employee, and HRA's get funded by the employer

Flood Coverage (Flood)
All Flood Coverages are not the same. "Dwelling coverage up to $2m and Contents Coverage up to $500k with an option to add additional coverages to protect your client for items not covered in the National Flood Insurance Program: Basement Contents (up to $10k) NFIP only covers limited basement contents, such as wall fixtures, elevators, air conditioners, andwasher/dryer. Pool Repair and Refill (up to $10k) The NFIP specifically excludes coverage for swimming pools. With this endorsement, Neptunewill cover swimming pool repair & refill costs. Unattached Structures on Property (up to $50k) Neptunewill pay up to the limit purchased forALLUnattached Structures combined. This limit is in addition to Coverage A. Temporary Living Expenses (up to $10k) If your client is unable to live in their home, Neptunewill reimburse up to $100 each day for temporary housing and up to $35 a day for each family member residing in the home for food during this time for up to 3 months. $1,000 — $1,250 — $2,000 — $5,000 AVAILABLE DEDUCTIBLES: — $10,000 — $25,000" Source: Neptune Flood program.
Florida Insurance Fraud Education Committee (FIFEC)
Font line worker
A person defined by regulation as an essential worker (hospital workers, fireman, etc) whose medical claims fall under special COVID regulated protections. Its very important for TPA's to process claims consistently to SPD, and defined employee handbook (HR policies), especially with regard to appeals (now granted one year for each charge).
Forbearance (Moritoria, Business Decision)
Many meanings. In context of debtors unable to make a loan repayment, its the lender allowing them to miss it under condition of payment under future "informal" or "formal" terms. In context of insurance / reinsurance, it is a typically a business decision by the carrier to pay an uninsured (disputed) claim with tangible expectation of policy renewal or continuance. In other words, the carrier will take a loss now, in hopes of lower claims and profit in the future renewal. This is not uncommon, and broker relationships can and do have real effect.
An intentional act to mislead.
Fraud OSHA
See: Proof of Vaccine

Fraud Waste & Abuse (FWA)
Free Care Centers (Community Health Centers)
Fees for care depend on many factors. This gets complicated figuring out where Medicaid eligibility starts/ends, CHIP, dual eligible (Medicare), etc.

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.
FSA Dependent Care (Dependent Care FSA)
An untaxed contribution up to $5000 per year an employee who has an FSA can contribute to cover the costs of childcare, and other eligible expenses. See: MSA, HSA, HRA and talk to an expert. See: H.R. 6800, H.R. 6958, H.R. 7008, and S. 3972
Fudge Factor
A percentage increase applied to the coming year's premium renewal premium rate by actuaries and/or underwriters (or their superiors). Some may refer to it as employment, or career-insurance. ======================== A slang term used to describe a seventh item used to increase premiums within (and also before) the underwriting process. In other words, an actuary's tenure may be based on accurately pricing premium above a future year's actual expenses. An actuary may (almost always) use a fudge factor as his hedge against underestimating FUTURE claims expenses. (Lower premiums charged than claims liability ... plus the add ons) See: Underwriting. and know it can be different at different carriers.
Full Financial Risk
See: Meaningful Financial Risk, Stark law, Shared services, Value Based Reimbursement, Final Rules and safe harbours/exceptions. Be careful.
Full Retirement Age (FRA)
For Social Security, it is the age where full social security benefits are available without discount. i.e. age 65 - 67+ depending on year of birth. Means many things in context to vesting of investments, Defined contribution Plans, and/or Defined Benefit Plans, and Life insurance policies with high cash values designed into "golden handcuffs" benefits design and within IRS compliance. See: Social Security FRA, DCP, DBP,

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)
Funds Transfer Fraud (FTF)
See: Cyber Liability


Galileo Health Platform
United's member portal focused on fast primary care, urgent care, chronic care access and treatment.

Many meanings: 1. A hole in coverage- be it in time, and/or coverage. 2. A Gap plan is a separate insurance plan from a major medical plan whose purpose is to help reimburse the insured for high eligible out-of pocket medical charges like deductibles, copays and coinsurance amounts. 3. In ERISA related matters, it can refer to holes in (1st or 2nd dollar) coverage caused by SPD conflicts between the plan document and any other document or coverage – including network contracts, ASAs, stop-loss policies, employee handbooks, PBM agreements, etc., 4. Some Accident only plans can be considered a kind of Gap plan. 5. A GAP plan can also be directed to insure or partially insure charges caused by a balance billing event in RBP plan coverage. 6. etc.
Gatekeeper Plan
A term used to identify medical plans requiring a primary care physician referral requirement before accessing specialty physician care. Traditionally, HMO's were well known to employ this extra step to see a Specialist physician, but now we see it in PPO's COOP's and EPO's. See: Open Access plans.
Gene Therapy Solutions (GTS)
A copy righted term used by HCC (Tokyo Marine) related to (genetic) Hemophilia treatment efficacy and insurance eligibility.
General Agent (GA)
A GA is a General Agent for a single carrier. A GA is bound contractually to represent the best interest of their appointing carrier, and sometimes earn commissions, overrides and/or profit sharing. An Agent can be a GA with multiple carriers simultaneously. GA's are sometimes referred to as Managing General Agents.
Geographic Direct Contracting (CMS Direct Contracting)
A new effort from CMS (CMMI) to contract providers in specific geographic regions, and ultimately provide better care for 2%-3% less cost. See: GPCI to get a feel for targeteded centers. "Geo requires participants to take full risk with 100 percent shared savings / shared losses for Medicare Parts A and B services for aligned Medicare FFS beneficiaries in a defined target region. " The Geographic Direct Contracting Model will have two three-year performance periods. The first performance period will take applications in 2021 and have a performance period from January 1, 2022 through December 31, 2024. The second performance period will take applications in 2024 and have a performance period from January 1, 2025 through December 31, 2027." See: Shared Savings "Officials said they expect the test Geo contractors to serve Medicare enrollees in one of 15 communities: Atlanta; Dallas; Denver; Detroit; Houston; Los Angeles; Miami; Minneapolis; Orlando, Florida; Phoenix; Philadelphia; Pittsburgh; Riverside, California; San Diego; or Tampa, Florida." Source: Allison Bell - Think Advisor

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.
Global & Professional Direct Contracting (GPDC)
As part of its renewed vision and strategy for driving health system transformation (PDF), the Center for Medicare and Medicaid Innovation (CMS Innovation Center) is releasing a Request for Applications (RFA) (PDF) for the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model. ACO REACH is a redesign of the Global and Professional Direct Contracting (GPDC) Model in response to stakeholder feedback, participant experience, and the Biden-Harris Administration’s priorities, including a commitment to advancing health equity. Its new name better reflects the purpose of the model: to improve the quality of care for people with Medicare through better care coordination, reaching and connecting health care providers and beneficiaries, including those beneficiaries who are underserved. Further, in an effort to improve transparency, CMS is releasing more information on current GPDC model participants (PDF) and strengthening model monitoring to ensure beneficiaries whose providers participate in GPDC and ACO REACH continue to receive high-quality, patient-centered care. GPDC will transition to ACO REACH on January 1, 2023. Current GPDC Model participants must agree to meet all the ACO REACH Model requirements by January 1, 2023 to continue participating in the ACO REACH Model as ACOs. CMS will be hosting an overview webinar on the ACO REACH Model RFA on March 1 at 4 PM Eastern Time. Please click here to register for this event. Additionally, CMS is announcing the permanent cancelation of the Geographic Direct Contracting Model (Geo). The Geo Model was announced in December 2020 and paused in March 2021 and is being canceled because it does not align with CMS’ vision for accountable care and concerns raised by stakeholders. See: ACO Reach, ACO, QPP

Global Budget Review (GBR)
Global Master Policy (GMP)
See: Controlled Master Policy. GMP's help internationally organized business(es) administer their polices in better affect to varying laws (requiring "authorized" local insurers) in each domiciled location, and tax preferred claims recovery administration.
Global Risk Contract
A fixed budget (or capitated) managed care provider contract that including all, or essentially all care provided to an insured member both in and out of network. PEL is typically purchased to mitigate most if not all of catastrophic expense risk providers accept within these capitated contracts.
Global Risk Contract
A fixed budget (or capitated) managed care provider contract that including all, or essentially all care provided to an insured member both in and out of network. PEL is typically purchased to mitigate most if not all of catastrophic expense risk providers accept within these capitated contracts.
GME (Medicare GME)
CMS subsidy paid to two or more hospitals that combine to train residents.

Golden Handcuffs
See: Defined Contribution & Defined Benefit plans
Goof Faith Estimates
See: No Surprises Act, and good luck. The biggie here is that hospitals and Plans must publish their (confidential - contracted rates) best-"partner" deals, showing the public how much more or less than charge commercially insured people than Medicare people. Change is coming...
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.
Graded Benefit
A term that can mean many things, but is typically describing a policy feature reducing a death benefit over the first 1-3 years of a life insurance policy. Old people use Final Expense life insurance to pay death benefits to cover funeral expenses, etc - and carriers offer guarantee issue policies that reduce coverage if the insured dies in the first 1-3 years. i.e. Graded Death Benefit • 1st year: ROP + 5% (full death benefit paid immediately for accidental death) • 2nd year: 50% of Face Amount • 3rd year: 100% of the Face Amount See: Advanced Death Benefit, Accelerated Death Benefit.
Grandfathered or Grandmothered Plan
An ACA compliant plan allowed that is not ACA compliant (QHP - 10 unlimited EHB) 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 QHP non compliance. Many Grandfathered plans have materially less coverage than ACA compliant plans. Group (employer) 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
Greatest of Three Rule
DOL rule establishing provider reimbursement amount floor related to out-of-network emergency services. New guidance gives states greater (statutory/regulatory) authority to establish reasonableness of charges. Federal Register details, "“The Departments believe that the November 2015 final rule provides a reasonable methodology to determine appropriate payments by group health plans and health insurance issuers for out-of-network emergency services, in light of the statutory language in section 2719A of the PHS Act and the totality of the comments received in response to the June 2010 IFR. The Departments also believe that the three prongs of the GOT regulation are sufficiently transparent.”

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. GHP Open Enrollments are not the same as individual plan OEP or SEP. Medicare and Medicaid plans follow completely different rules.

Group Health Plan (GHP)
How CMS refers to employer sonsored fully-insured and ERISA self-funded (ERISA, Fully insured, groups over and under 40 full time employees). See: subrogation issues related to rights of recovery, and order of payment liability among multiple carrier insuring the same patient. " The Group Health Plan (GHP) Reporting for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act – Frequently Asked Questions and Answers document has been updated and is available in the Download section of the Mandatory Insurer Reporting for Group Health Plans What’s New page on" Source: CMS. See GHP link for CMS mandated Group Reporting. See: MSP

Group Health Plan Alerts (GHP Alerts)
CMS mandated reporting for Group health plans. Recent Section 111 Group Health Plan (GHP) alerts posted since the last publication of the GHP User Guide can be found in the Downloads section below. Information in published Section 111 alerts supersedes information published in the GHP User Guide. To obtain the most up to date information and requirements related to Section 111 reporting.

Guarantee Association (Florida Insurance Guatantee Assoc)
All 50 states have state sponsored insurance guarantee associations. Florida's is called the Florida Guarantee Insurance Assoc. Florida Insurance Guaranty Association "Each state has created mechanisms, called guaranty associations, for protecting consumers if their insurance company becomes insolvent. Florida, like other states, has created several of these organizations geared to the particular needs of the covered lines of insurance. Guaranty associations only cover policies issued by authorized insurers in the covered lines of authority. There are three guaranty associations in Florida: · The Florida Insurance Guaranty Association (Association), which covers general lines of insurance, excluding ocean marine and surety bonds · The Florida Workers’ Compensation Insurance Guaranty Association, which covers workers’ compensation claims · The Florida Life and Health Insurance Guaranty Association Each association consists of all authorized insurers writing the lines of insurance covered by the association. The members are assessed as needed to provide a backstop for consumer losses in cases of insurer insolvency. Coverage Provided The Association covers claims that exist at the time that an insurer is determined to be insolvent, or that occur in the next 30 days, unless the insured replaces or cancels the policy in less than 30 days. In general, the Association covers claims in excess of $100 and less than $300,000. Homeowner’s insurance claims are covered up to an additional $200,000 for the portion of a covered claim that relates only to the damage to the structure and contents. Regardless of the situation, the Association is never obligated to pay out more than the insolvent insurer would have paid under the terms of the insured’s policy. The Association also plays a role in preventing insolvencies. Pursuant to Florida Statute 631.62, the board of directors may, upon majority vote, make recommendations to the Office to help detect and prevent insurer insolvencies." Source CE Tracker Agent Licensing CE exam study. Jan 2019
Guarantee Issue (GI)
A policy feature, provision, and / or coverage offering that is also offering policy issue and/or policy renewal. Terms for these are many, but the take away is to define the percentage increase limit of potential current premium offer stipulated one (or more) years from policy issue date, or at renewal date. Some carriers may NOT stipulate or guarantee coverage remaining constant, so it may it takes a pro to vet. There may also be claims reimbursement issues affecting accurate comparison from original coverage offer...
Guarantee Issue or Guarantee Renewability
A term typically referring to a medical, life, dental or vision plan rates or policy issued without underwriting, and availale to people under 65. On larger stop loss policies, It can mean many things, but usually is used to lock in rates (with or without small rate increase) over 1-3 years. The term applies to any policy be it L&H or P&C. Many laws, and rules apply by type of coverage, insurance/reinsurance. It can be a policy provision specifying renewability of an insurance/reinsurance policy under contingent provisions (i.e. MLR plus administrative load plus actuarial fudge-factor, profit commission, premium rebates, etc) specifying a maximum premium rate increase range relative to a spedified matric. =============ACA offers guarantee issue policies during OEP and SEP each year. Stop loss policies can be offered with multi-year guarantee renewability features as well. i.e. MLR ratios below 60% - 65% with contingent profit share splits, etc, and or renewing premium increases over a 1-3 year time period, Stop loss policy premium renewal provisions specifying range limits. It is a negotiated process on stop loss, reinsurance, captive, captive cell, etc, but a straight forward process on most fully-insured policies if offered at all by the carrier. Brokers can add much value knowing what is, and is not possible in context to placing business in a hungry market. In context to Marketplace offered Plans (FFM), it means offering all types of plans available to all eligible people.
Guaranteed Purchase Option (GPO)
A life insurance rider guaranteeing option to purchase additional permanent protection in the future without providing evidence of insurability.
Guaranteed Universal Life (GUL)
See: IUL, Whole Life
Guideline Premium Test
An IRS test on life insurance policies that allow loan distributions to be taken (loans to self) without being taxed as income, as apposed to a MEC, whose growth is taxed as income. Putting in too much "premium deposit too fast an can convert a life insurance policy to a MEC. IRS has two tests, and (PERMANENT) life insurance policies. The essence of customer benefit here is to compare investing in taxible pension products like: MECs, 401s and most IRAs versus 10-50 years of growth not being taxed as income within IRS compliant life insurance policies (IUL, UL, Whole Life policies that guarantee minimum interest crediting, and/or contractually promissed capped ranges of interest) Do the math: Pay your income tax on a lifetime of interest growth/value in retirement, or pay a very small (net) IRS compliant loan interest charge. Some refer to this as a tax loophole, but it essentially mirrors the same structure as 529's, and Roth IRAs where tax is paid on the seeds, and not the harvest. Rules allow depositing much more than the annual insurance premium charges, and to earn interest on the cash value (sometimes called the Accumulation value). See: Details of EACH policy and the illustration's assumptions. Actuarial Rule 49


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

HAC Scores (HACRP)
Hospital Acquired Conditions and programs scoring good and bad performance by CMS, and that can materially affect Medicare reimbursement(s).

Hammer Clause
A policy provision, typically in a P&C policy replacement stating any claims will be paid at (typically) 70%. These are provisions that protect the carrier when a higher risk insured is offered a new policy, and (typically) whose policy does not match the previous policy's retroactive date. These types of offerings are only made after the person who caused the insured to have a high claims history (or currently disputed claim) is no longer employed going forward.
Hanlon's Razor
A method of explaining cause and effect, and to: Never attribute to malice that which is adequately explained by stupidity. Or: The simplest explanation of direct facts directing cause and effect is superior to a complicated explanation (especially when emotions are involved). See: Ad Obcertum
Hardship Exception Application
Relates to CAH (Medicare and Medicaid). Not to be confused with getting a hardship approval from Marketplace for a catastrophic coverage ACA QHP eligibility.

"A hazard is defined as a condition or conditions that increases the probability of a loss. A hazard can result in increases in the frequency of losses and/or the severity of losses. The three types of hazards are physical hazards, moral hazards, and morale hazards" A moral hazard concerns intentional acts committed by the insured that either create or exaggerate a loss. Moral hazard is measured by the character of the insured and the circumstances surrounding the subject of the insurance." "Morale hazard, as contrasted to moral hazard, does not imply a propensity to cause a loss, but implies an indifference to loss simply because of the existence of insurance. " Source: Florida CE exam course 2021
HCC Risk Adjustment (HCC)
See: CAHIMS, CPHIMS, VBM, MACRA An underwriting tool that measures expected (inpatient hospital) claims for individuals (and possibly groups). Note: Above professional designations are not universally accepted as standard. HCC in context to Medicare and sometimes Medicaid when states choose to use it, or the feds mandate it - means Hierarchical Condition Categories (CMS inpatient hospital data designed to eliminate a switch to encounter data.) See: RAPS, Star Ratings, etc.

HCC Risk Conditions (CMS HCC, or HHS HCC)
A CMS (CMS-Hierarchical Condition Category) list of expensive medical conditions targeting (by both CMS and HHS a little differently) expensive-mostly-chronic-medical care programs, with goal of improving co-morbidity outcomes (EBM), and lowering costs. Examples of disease registries that correlate with HCC conditions include: Arthritis. Atrial fibrillation. Congestive heart failure (CHF) Chronic kidney disease (CKD) Chronic obstructive pulmonary disease (COPD) Depression. Morbid obesity. CMS-HCC Model refines ICD-10 diagnosis codes into 70,000 ICD-10-CD codes, 805 Diagnostic Groups (DXGs), 189 Condition Categories (CCs), and 79 HCCCs. Good Luck! See: Risk Adjustment, outliers, DRG, RAF, HHS-HCC, etc.

Pharmacy billing codes.
HARP log-in credentials allowing access to CMS's MIPS data (if the provider submitted data as a participant). See: ACR - 30 Day ALL-Call Readmission measures, QPP, MACRA, MIPS, etc.

Health and Human Resources (HHS)
Federal Department of Health and Human Resources - the agency charged with managing ACA and CMS, etc.
Health at Scale
Walmart's employee health benefits portal used to manage many types of care.
Health Care and Education Reconciliation Act of 2020 (HCERA)
See: ACA
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 Care Transformation Task Force (HCTTF)
Health Cost Sharing Plan
An association plan that is typically not insurance, and provides referenced based repricing, and claims payment to providers, or directly to the member. Various states may or may not have statutes regulating such entities. ERISA Plan Sponsors are advised to seek licensed legal advice. See: Ministry Cost Sharing Plan. NOTE: This is not legal advice. Claims liability subject to different interpretations of insurance gets complicated.

Health Equity and Advisory Team (HEAT)
See: VBP, LAN, CMS innovation, MIPS, MACRA, and good luck figuring out who is in charge.

Health Equity Index
A CMS created number tasked with creating more transparency on MA plans care for disadvantaged enrollees. See: RUral and urban underserved populations, VBR, MA Plans, Part D plans, QPP, MIPS, MACRA
Health Fanancial Management Association (HFMA)
Health Foods Card (HFC)
What Humana calls the card they issue to Medicare members that pays for Medicare covered food. The about $100 per month benefit is relatively new for Medicare. Medicare finally figured out that poor nutrician can mean old people get sicker more often, and more intensely. Hopefully they also figure out a way to fund poor (or no) Dental care causing higher frequency/intensity/expense diseases.
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 Advisory Committee (HITAC)
(Under GAO) The 21st Century Cures Act established HITAC to provide recommendations to the National Coordinator for Health Information Technology on policies, standards, implementation specifications, and certification criteria relating to the implementation of a health information technology infrastructure that advances the electronic access, exchange, and use of health information. The Act gave the Comptroller General of the United States responsibility for appointing a portion of HITAC’s members.
Health Information Technology for Economic and Clinical Health Act (HITECH)
see: CEHRT, NEHRS, ONC, EHR, MACRA, etc. Digital data review from various EHR designed to review EBM, QPP, and medical outcomes with "interoperability" (multi-discipline cross communication on agreed upon criteria) goal of improving patient care at lower costs.
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 Information Technoloty ofr Economic and Clinical Health Act (HITECH)
See HIPPA, and PHI and how protected private information is to be handled in context to reasonable professional standards of "Business Associates", and law. In short, the laws are not intended to disrupt medical care management or claims payments in best interests of the patient administration.
Health Insurance Claim Number (HICN)
See MBI Health Insurance Claim Number (HICN) in context to a Medicare patient claim patient identifier number.
Health Insurance Claim Numbers (HICNs)
See: MBI Numbers Medicare uses to adjudicate eligibility and claims, that are not MBIs.
Health Insurance Exchange Program (HIX)
means system of records CMS uses in the administration of FFE's, SBE-FP's, See: Privacy Act of 1974, 45 CFR Part 5b, and "routine uses" established for HIX in the Federal Register at 78 .Reg 8538 as amended by 78 Red.Reg. 32256, and 78 Fed.reg. 63211. Good luck!
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 (HIM)
The name HHS gives to Exchange plans available on the federal or state marketplace. See: (Federally Facilitated) Marketplace
Health Insurance Portability and Accountability Act of 1996 (HIPPA 1996)
Federal Law effort originally started to help people keep their insurance between jobs (i.e. Health Insurance Portability), and ended up adding massive electronic personal information (Personally Identifiable Information - PII) 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) See: PHI, PII, PIA

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 Professional Shortage Area
See Medicare A and B, and what each covers. May also relate to what TRICARE will also insure where VA services are inadequate. See: Network Adaquacy
Health Reimbursement Arrangement (HRA)
A tax exempt account used to pay eligible health expenses (now including employers giving "pretax" premium amounts to employees purchasing INDIVIDUAL coverage on the Marketplace), typically paired with higher deductible plans, and funded (tax-preferred) by the employer. (This is the use it, or lose it account, but for about $500+ per year that can rollover to the new year.) It is not HSA, MSA, FSA. Recent HHS advisory effective January 2020 will allow HRA account "reimbursement" to employees for INDIVIDUAL medical insurance for employees not insured under the group plan. See HRA, FSA, MSA, MEWA, Minimum premium plans, SHOP, Small Group plans, MSA... We recommend speaking with experienced broker and CPA before moving. HRA's have been targeted by Trump Executive Order to HHS resulting in loosening rules governing eligible HRA medical expenses, and making eligible reimbursements for non ACA compliant plan premiums and out-of-pocket expenses. See IRS requirements & limitations

Health Resources Account (HRA, Cafateria Plan)
An HRA is a medical savings account funded by the employer on a tax preferred (not taxed) bases. Funds are eligible to pay for (typically using a debit card) medical expenses such as deductibles, co insurance, Co Pays, MOOP, and other eligible out-of-pocket medical expenses during a calendar plan year - that IRS allows such as air conditioning for children with asthma, etc. Funds are typically "use it or lose it" during the year. (HSA's are not, "use it or lose it.") Total annual deposits are regulated and limited per calendar year. Tax considerations and regulations are many, and must be confirmed with Licensed Agents, CPA’s and attorneys. Trump administration has changed the rules to allow use of funds for short term plans, and ICHRA's - see link. Exactly how state and federal authorities will permit use of funds for non-ACA compliant QHP remains to be vetted. We recommend caution. ACA tax credit penalties may apply to unwary employers whose low income employees leave their GROUP plan, and buy a tax credited (FFM) individual plan. See: ACA ALE employer penalties and speak with your Agent, CPA to understand tax liability. Effective Jan 2020, HRA accounts can be funded by employers to pay for INDIVIDUAL ICHRA (outside of a group health plan offering) insurance purchased on the Marketplace as well. See HHS link: HRA's are not HSA's, MSA's, or FSA's.

Health Resources Account (HRA)
See: ICHRA, FSA, HSA, MSP, Section 125 plans, Cafeteria plans, etc. A Health Reimbursement Arrangement is an employer-funded (with pre-tax dollars) account that helps employees pay for eligible medical expenses not covered by their health plans. HRA, MSP, HSA, ICHRA plans and tax programs are not the same. Some use the term to mean Health Risk Assessment involving employee benefit chronic disease evaluation and treatment to avoid higher costs associated with not managing conditions. i.e., Bone Marrow testing CA 15-3 (breast cancer), Chest x-ray, stress testing, serum protein electrophoresis (Myeloma), breast ultrasound, CEO (colon cancer blood test), PSA (prostate screening), thermography, etc. Note: ICHRA allows employers to give pre-taxed dollars to employees who buy ACA QHP APTC eligible plans.

Health Resources and Services Administration (HRSA (HHS))
See: Provider Relief Fund (PRF) I.e. $2.5 Billion paid by Medicare for uninsured COVID. See: STROBE -

Health Risk Assessment (HRA)
A recent term used for smart phone or laptop reported personal information that directly comes from and goes to the patient, and whose goal is to figure out what (SDOH included and things like smoking, mental health, obesity, nutrician, etc) behaviours and medical conditions are accepted by the patient to effect positive change and/or the patient's well being, or objective medical benchmarking comparitive data. In short, if the patient does not want to change, nothing positive happens even if the system shows an eminent health attack. A central component is to what benchmark will a given group, or individual be compared which can be very different in various locations. See: Wellsource
Health Savings Account (HSA)
An individual health savings account (HSA) is a special tax-exempt (not taxed) account an INDIVIDUAL (not Group or employer) establishes with untaxed funds to pay for qualified medical expenses. There are Group HSA's too. When these were established many years ago, they required high deductibles to be considered an eligible plan so employees could use pretax dollars to fund future expected medical bills. ACA "wellness/preventive" care being mandated at no OOP costs by newer ACA law undercuts original HDHP HSA purpose (for lower premium cost HDHP), as does the new reality of massive deductibles many employers make their employees satisfy each year, so the employers can afford to offer a group medical plan. HSAs are typically used in conjunction with high-deductible health plans (HDHPs) offered by many insurance companies that IRS accepts as eligible. GAP, and accident only plans can offset some of the burden. The maximum amount that may be contributed to an HSA is set by law is changes 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. Untaxed money is deposited into an account and accessed via a special debit card. Note: interest on these (sometimes lifetime) accounts is practically nil. See: HRA, FSA (For Groups not individual plans), ICHRA

Health Sharing Ministry Organization (HSMO, Health Care Sharing Ministry)
A "faith-based association health "plan" that costs less than ACA compliant INSURANCE available to Individuals, and perhaps some employers. ====================May go by many names: Faith Based Healthcare, Healthshare Medical Cost Sharing Plan, Christian Medical Sharing, Christian Healthshare, Christian Medical insurance, Christian Medical Cost Sharing, Christian Ministries Healthcare, Christian Healthcare Sharing Ministries =============================== May require signed statement of faith. Plans are typically not QHP ACA compliant, and may not be authorized as traditional insurance, but as a health cost share plan where some states have a specific statute allowing these plans. We are aware of active Class-Action litigation in the space. Agents and customers are advised to be cautious and to clearly understand differences between the four primary types of major medical insurance and discounted reimbursement plan options. Most plans (Like STM, that are typically authorized) offer little or reduced: ER, Rx, outpatient surgery, surgery, etc coverages. PreX is handled differently. See: Ministry Health plans, Limited Medical Plans, Balance Billing, Eligible and authorized plans, Authorized plans, etc. See: PIVOT (at, and scroll down), Reahlm Health, OneShare Health, Aliera, SGH SafeGuard Health, etc. These plans can be insurance, discount plans, health cost sharing, Gap, RBP plans, etc., and take an expert to vet by state guidelines for compliance and coverage. Caveat emptor.
Healthcare Common Procedure Coding System (HCPS)
Effective January 1, 2020, the Centers for Medicare & Medicaid Services and the American Medical Association have approved the use of the CPT Category II 8P modifier with HCPCS codes included in Quality ID #117’s measure specifications to report Performance Not Met. BACKGROUND: In their October 2019 coding update, CMS revised 3 CPT Category II codes that the AMA released on July 8, 2019, for implementation on October 1, 2019. These revisions had a substantive impact on the numerator definitions for Quality Measure 117: Diabetes: Eye Exam. To avoid impact to PY 2020, CMS replaced the affected CPT Category II codes with 3 new HCPCS codes. To report Performance Not Met for this measure, reporters should append CPT Category II modifier 8P to the HCPCS codes found in the numerator. The new HCPCS codes and descriptions for this measure are found below. The QPP 2020 measure specifications contain the correct codes and instructions for reporting this measure. The 2020 measure specifications may be found at Numerator Options: Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (G2102) OR Performance Met: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (G2103) OR Performance Met: Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed (G2104) OR Performance Not Met: Dilated eye exam was not performed, reason not otherwise specified (G2102 with 8P or G2103 with 8P or G2104 with 8P)

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 Inflation (Medical inflation)
A term that can mean several things. It typically refers LARGE group premium increases, and mostly ignores small Group and / or Individual premium increases per year. There are at least 20 million individuals who do not have access to large group coverage or, premiums (and that potentially enroll in individual Marketplace plans). The better index is Healthcare SPENDING inflation that tells the story of what it really costs people to buy health insurance (the premium plus MOOP), access care, and pay their: Deductibles, Co-insurances, Copays, MOOP. Know that over the past 20 or so years, in almost all years, whatever CPI is, quoted healthcare (Group premium) inflation is (200% - 600%) at least double CPI, and that index is understated. Typically, sited Group Health Premium increases are always less than Individual premium increases, and do not add-in out-of-pocket patient responsibility cost each person has to pay to actually buy healthcare, and that are well beyond any wage increases. Sustainable - not? See the linked article for latest CMS (Medicare mostly, but it could be including Medicaid) spending forecasted at $7 Trillion by 2030, and with 2021 spending at about 19% of GDP - massive. (for 2019) Note that in 2019 CPI is well under 1.8%, and for the Obama years, it was 1%/yr every year (8 years) while Group inflation reported was 4%-7%. (ERISA Stop Loss trend is supposed to be double what is first dollar risk is charged) - Means hospitals doctors and pharmaceutical companies, etc., were increasing their prices 400%-700% faster than the rest of the economy's goods and services. For 2019, inflation is about 1.8%, and medical (group premiums) inflation is over 4%. In 2019, my personal Blue Cross Plan premium increased 45% in just one year. Eliminating the massive outlier in one's statistics representation means the reported premium increases can be well understated. "CMS (Medicare not Commercial rate inflation) is proposing an effective growth rate of 4.75%, and an overall expected average change in revenue of 7.98%. 2022 saw a 4.08% revenue increase." Source: Healthcare Finance

Healthcare Innovation Awards (HCIA)
Healthcare Interoperability
A pretty complex term that means the efficient exchange and/or access of (PII) information from multiple sources (Health Information exchange, EHR, Physicians, Hospital recoreds, primary care history notes, PBM data, SDOH, etc) causing better medical outcomes (post-acute-care PAC), at lower costs than typically fragmented FFS systems. See: VBR, MACRA, QPP, etc. Proponents are using terms lime patient-centric interoperability to focus on pre-and-post care regimines inclusive of extreemely expensive (and mostly unaddressed) issues involving pallative and hospice care. See: Healthy Communities
Healthcare Protection Integrety Data Bank (HIPDP)
Healthcare Research and Quality (AHRQ)
An agency under CMS that uses Clinical Classification Software (CCC) to detail co-morbid conditions grouped into six categories.
Healthcare Spending
See: Article. "The country’s national healthcare spending increased by 9.7 percent, which is the fastest rate since 2002. Meanwhile, gross domestic product fell by 2.2 percent, with health spending’s share of gross domestic product increasing from 17.6 percent in 2019 to 19.7 percent in 2020."

Healthcare Spending
Feds spend 36 more in 2021 than 2022 primarily because of COVID:Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the Paycheck Protection Program and Health Care Enhancement Act, and the Coronavirus Response and Relief. "Private health insurance expenditures accounted for 28 percent of total healthcare spending in 2020 but saw a 1.2 decline due to low healthcare utilization. Out-of-pocket healthcare spending also experienced a decline as utilization dropped. Medicare spending was responsible for 20 percent of national healthcare expenditures, rising by only 3.5 percent, compared to 2019 when it saw a 6.9 percent increase. Meanwhile, Medicaid spending accounted for 16 percent of total expenditures, reaching $671 billion and seeing its highest growth rate since 2014 of 9.2 percent. Hospital expenditures accounted for 31 percent of national health spending at $1.3 trillion. There was a 6.4 percent increase in 2020, largely due to federal COVID-19 relief funds and increases in Medicaid spending for hospital care." Source HealthPayor Intelligence Jan. 2022

Healthcare Transformation Task Force (HCTTF)

An organization that evalauates data from over 900+ ACO's to determine their effectiveness in providing effective care at efficient cost and outcome.  See ACO's.

Healthcare Transparancy
See: Price Transparency President Trump calls it: A+ Healthcare transparency.
HELP (Senate Health, Education, Pension Committee)
See: Senate Health, Education Pension Committee
Herfindahl-Hirschsprung Index (HHI Scores)
The AMA used measure of market concentration, Herfindahl-Hirschsprung Index (HHI) scores. THe AMA uses these scores to rank carrier competition by regions. HHI scores can range from 0 to 10,000, with 10,000 meaning one carrier like Blue Cross monopoly in many rural areas.

HHC Star Ratings

Hick Picks (HCPCS)
The Healthcare Common Procedure Coding System "hick picks" is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). These can get complicated - especially for pharmacy.
Hierarchical Condition Categories (HCC)
HCCs will continue to play a role in CMS alternative payment models (APMs), such as shared-savings contracts and accountable care organizations (ACOs). CMS originally developed HCCs in 2004 to adjust capitated payments for its Medicare Advantage (Part C) plans based on risk. See: MACRA, QPP
High Risk Disease Detection (HRDD)
See: ChenMed. Relates to staff model PCP management of seniors in "compliance" with complex CMS quality indices at cost effective practices.
New & increasing tax ($11.3 B) on Fully-Insured medical carriers, but not ERISA plans.
Home and Community Based Services (HCBS)
HCBS is an important benefit for the elderly, the disabled, or individuals with intellectual disabilities. Exactly what does and does not apply to Medicare may not apply evenly to Medicaid insured individuals. These services can get confused with some of the newer Medicare eligible benefits to seniors recieving food, in-home nursing (like LTC but not called that), etc. See: SDOH and know it is smart money to provide $100 of food or "custodial-care" to avoid a $300K ICU hospital bill for a diabetic (or dementia) crash.
Home and Community-Based Services (HCBS)
Term Medicaid uses
Home Health
Medical care delivered in a persons home that may or may not be insured. The term is not related to natural or homeopathic cures and treatments. By most coverage definitions, home health care relates to in-home care needed to fully rehabilitate from an insured event. Home health is not long term (custodial) care. See: CMS final rules for Home health, cut know that what is insured with Medicare may not be insured, or an available option for commercially insured lives.

Home Health Agencies (HHA's)
What CMS calls/regulates/measures quality of entities providing home health services.
Home Health Aid (HHA)
A certified (licensed) aid delivering care in the home.
Home value 85% rule (85% Rule)
A property insurance rule requiring a minimum of 85% of fair market REPLACEMENT COST value be insured. This protects the carrier from taking more than a standard level of risk by insuring the smaller value at lower premium, while insuring the biggest part of the 1st dollar most common loss - when there is a loss.
Hospice Abstraction Reporting (HART)
HART (Hospice Abstraction Reporting Tool) v1.6.0 is now available HART (Hospice Abstraction Reporting Tool) v1.6.0 is now available in the Related Links section at the bottom of the HIS Technical web page. HART is a Java based software application that provides an option for Hospice facilities to collect and maintain facility, patient and HIS Record information for subsequent submission to the appropriate national data repository. HART is free software provided by the Centers for Medicare and Medicaid Services (CMS) and is offered in two configuration types, standalone and network client.
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 Aquired Infections (MRSA rates)
An infection transmitted to a patient, that the patient did not have prior to admission. Medicare sometimes refuses to pay for extremely expensive care that CMS/ HHS perceives to be caused by poor medical manaagment.

Hospital Compare
"First available in 2005 and closely aligned with CMS’s recently launched eMedicare initiative to unlock the power of information for consumers, Hospital Compare provides access to quality measures on more than 4,000 Medicare-certified hospitals as well as Veterans Health Administration and Military Health System hospitals. Easy-to-understand and based on more than 100 rigorously tested measures, Hospital Compare is the go-to resource for anyone deciding where to schedule a surgery or other inpatient or outpatient service." Source: CMS
Hospital Indemnity Plan
A non ACA compliant (QHP) medical insurance plan that typically insures a limited amount of inpatient hospital services. There are may types, and some include sophisticated Section 125 (HRA) tax preferred premium management, and wellness care designed to meet risk transfer, wellness, chronic care medical case management, and what IRS considers legitimate insurance.
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 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. See: Hospital Outpatient Prospective Payment (OPPS) Final Rule (CMS-1736-FC) as an interim final rule with comment period (CMS-1736-IFC).

Hospital Price Transparancy (Transparancy)
Rules effective January 1, 2020

Hospital Readmission Reduction Program (HRRP)
CMS defined 30-day [risk-standardized readmission rates] A (dreaded) Medicare and Medicaid "quality" program that denies or reduces payment for hospital readmissions (with same/similar diagnosis) within 30 days of discharge. In other words, hospitals get paid less when Medicare and Medicaid patients get readmitted with the same or similar diagnosis within 30 days of discharge. "The HRRP aims to lower Medicare and Medicaid expenditures by reducing the burden of preventable repeated hospitalizations within 30 days while simultaneously improving the quality of postacute care." "Among hospitals classified in the lowest socioeconomic-status quintile, 91.64% would have been subject to penalties in fiscal year 2019 using the old method, compared with 77.60% using the new method. The median net penalty payment decreased from 0.46% in fiscal year 2018 to 0.28% in fiscal year 2019. Even hospitals higher quintiles experienced a small net down-classification in penalty status from 75.94% with the old method to 74.40% with the new method. Their median net penalty payment increased modestly from 0.32% in fiscal year 2018 to 0.35% in fiscal year 2019." Source: Medscape Central to this dispute are cries of foul from teaching hospitals charged treating the super beat-up poor people under federal "safety net" agenda.
Hospital Readmissions Reduction Program (HRRP)
A generic term aimed at measuring (reductions in) readmission rates within 30 days for discharge.
Hospital Referral Region (HRR)

A term sometimes used to reference regionally organized hospitals that work together with potential pricing discounts under ACO, and other managed care contracts.


A tern CMS wants to use to get hospitals with city-state mentalities to work with other not-for-profit (and for profit) hospitals to better serve their communities with better medical outcomes at lower (or more efficiently focused) use of available funding.

Hospital Service Area (HSA)
Hospital Value Based Purchasing (HVBP)
Hospital Value Based Purchasing (HVBP)
See: HITECH 2009 act, QPP, MACRA
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.

Implicit Bias (Cultural Competency)
A newer liability term or liability mitigation training used to sensitize doctors and/or hospitals to classes of people who have been historically discriminated against. I.e. Afro-Americans and / or women who some studies suggest are misdiagnosed, or not treated the same as white males, and whose statistics detail higher mortality or morbidity caused by the insured's care, or lack of it.
Implicit Biases (Blind spots)
A risk management term referring to a known population(s) higher adverse outcomes, and/or personal prejudices explaining adverse outcomes - etc.
Income Protection Agreement (IPA)
An elected permanent life insurance policy feature establishing an interest crediting rate over an elected/defined installment period(s). See: Income Protection Flex Agreement (not the same) Remember, Income for life features are by nature (separate from indexed crediting or lifetime policy guarantees) are materially higher than interest crediting guarantees, and contractually promised interest crediting rates. Talk to an expert.
Indemnification Agreement (Hold Harmless provision)
A common contract provision binding the parties to reimbursement from the offending party to the non-offending party not directly responsible for damages or a loss. See: Action Over, Subrgation
Several meanings. In context of classical or traditional insurance that for the most part is not available today buy at prices non one will pay premium costs, it means, to return an individual/company to the financial place they occupied before the loss event. This gets a bit complicated where coverages are accepted on a cost versus revenue bases. See: Direct Service
Independent Contractor
A definition that means many things. See: Bidens proposed rule aboloshing Trump's rule as related to not having to establish financial dependency on an employer to cause a contractor to become an employee, and whose employer is required to fund payroll taxes. "Executive Summary The FLSA requires covered employers to pay their nonexempt employees at least the Federal minimum wage for every hour worked and overtime pay for every hour worked over 40 in a workweek, and it mandates that employers keep certain records regarding their employees. A worker who performs services for an individual or entity (“person” as defined in the Act) as an independent contractor, however, is not that person's employee under the Act. Thus, the FLSA does not require such person to pay an independent contractor either the minimum wage or overtime pay, nor does it require that person to keep records regarding that independent contractor. The Act does not define the term “independent contractor,” but it defines “employer” as “any person acting directly or indirectly in the interest of an employer in relation to an employee,” 29 U.S.C. 203(d), “employee” as “any individual employed by an employer,” id. at 203(e) (subject to certain exceptions), and “employ” as “includ[ing] to suffer or permit to work,” id. at 203(g). Courts and the Department have long interpreted the “suffer or permit” standard to require an evaluation of the extent of the worker's economic dependence on the potential employer—i.e., the putative employer or alleged employer—and have developed a multifactor test to analyze whether a worker is an employee or an independent contractor under the FLSA. The ultimate inquiry is whether, as a matter of economic reality, the worker is dependent on a particular individual, business, or organization for work (and is thus an employee) or is in business for him- or herself (and is thus an independent contractor)."

Independent Dispute Resolution (IDR)
A regulated process required to determine "competitive fair market rates" comprising a Qualified Payment Amount (QPA) paid to providers for medical care. See: No Surprises Act (NSA). This can get very complicated with various COVID laws taking, or not taking precedent over Federal law and/or regulations under OSHA, and presidential executive orders. Multiple dates are involved with formally auditing when and what applies. "The IDR process requires that the IDR entity choose either the offer submitted by the provider, or the offer submitted by the payer. Each party will submit their offer within 10 days after the IDR entity is selected. The offers must include a dollar amount and percentage of the qualified payment amount (QPA)." Good Luck. Our advice is to act prudently since - remembering how expensive it is to litigate and win. See: Balance Billing, NSA,qualified%20payment%20amount%20(QPA).

Independent Marketing Organizations (IMO)
see: FMO, BGO
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.
Independent Review Organization (IRO)
See: IDRE, ERISA, Surprise Billing, CAPs, IDR, Balance Billing, etc. Trump Executive order requires hospitals to publish their best contracted rates in transparant fashion. This gets squirelly to figure out what the "real" rate charged is average, or what is accepted...

Indexed UL
A life insurance policy that credits interest on Cash Value at a percentage of a selected index. i.e. S&P, NASDQ, Russel 2000, etc.
Indexed Universal Life (IUL)
A life insurance policy that essentially packages Term life insurance with a Fixed indexed annuity. Like any Fixed annuity, premium deposits are not directly invested in the market by the policy holder, so if the market crashes, the policy holder loses no value. Where the market (i.e. S&P index) grows, the product contractually credits 0% (safety floor) to (currently) 10.5% cap. Carriers accomplish this by buying one year US Treasury notes, and gambling with the one year guaranteed interest by buying one year options betting the market will go up. IRS compliant policies allow "pension" loans (i.e. current charging a fixed rate of 4%)collateralized by cash value (accumulation value). Compliant loans are not taxed as income. Collateral used for loans remains in the policy holders Cash Value (Accumulation Value) and simultaneously earns interest crediting (i.e. 0% floor to 10.5% cap) - for life. Compliant loans require being paid off after death with tax free life insurance death benefit proceeds. Any remaining Death Benefit value goes to benificiaries. Most IUL contracts additionally credit (about 1%) BONUS from year 10 to death. These policys must stay in force for life or risk all loans being taxed as income. Primary benefit is protection of family, but "living benefits" are quite attractive to the policy owner. This is not tax advice. Provider Risk, LLC., recommends directing tax related questions to licensed CPA's or attorneys specializing in tax.
Individual and Family Plans (IFP)
What United (UHC) calls their marketplace offered plans. They may also use the same term for plans not offered on the marketplace but available directly from the carrier.
Individual Coverage HRA (ICHRA)
The Trump executive order allowing employers to reimburse employees with un-taxed payroll funds to pay for INDIVIDUAL (not Group) health insurance premiums paid directly by the employee to their carrier for medical insurance. "The ICHRA differs from other currently available HRAs in several ways: • Businesses of all sizes can offer the ICHRA. • Applicable Large Employers (ALEs) can meet the employer mandate with an ICHRA. • Businesses can offer both the ICHRA and a group health insurance policy, but not to the same group (or class) of employees. • Businesses can define benefit eligibility and offer different allowance amounts based on 11 employee classes. • There are no caps on the allowances made available through the ICHRA. • Employees have the option of collecting premium tax credits or participating in the ICHRA. With these features, the ICHRA appeals to businesses in unique ways not seen in the existing HRA landscape. Businesses without access to an HRA currently will be able to offer one for the first time in 2020." "In an effort to expand HRAs even further, President Donald Trump issued an executive order in 2017 directing the Departments of the Treasury, Labor, and Health and Human Services to review IRS Notice 2013-54 and find ways to further integrate individual health insurance with HRAs. The Departments responded with a final rule in June, 2019. The rule is a direct revision of the IRS Notice and states that, if certain rules are followed, HRAs may integrate with individual health insurance for businesses of any size. The result was the creation of the individual coverage health reimbursement arrangement, or ICHRA, which will be available starting January 1, 2020." " ICHRA affordability example In 2020, Derrick, an employee at Big Build Construction, has a household income of $45,000. His employer is offering an ICHRA. The lowest-cost silver plan in his area is $550. The calculation for affordability in this case is: $45,000 * .0978 = $4,401 $4,401 / 12 = $366.75 $550 - $366.75 = $183.22 In this scenario, the lowest allowance that can be considered affordable to the employee is $183.22. Wayne is another Big Build Construction Company employee who qualifies for premium tax credits. His total annual household income for 2020 is $30,000 a year. One-twelfth of his income is $2,500; multiplied by 9.78 percent, the figure is about $245. Because $245 is less than the company’s required HRA contribution of $300, Wayne’s ICHRA benefit cost is not considered affordable. (See: ARP that puts it now at 8.5%) Wayne can waive ICHRA participation and collect his premium tax credits instead." Just know that ACA applies to the affordability component and if an employee can access APTC. Complying with ACA law directing employer mandate (tax penalty for employers over 50 FTE) versus Trump Executive Order gets squirrelly. One way to think of this is it's Trump's trying to help employers reimburse low income people purchasing tax credited plans (on Marketplace plan the employee is eligible for because the employee's monthly premium contribution for their EMPLOYER plan exceeds 9.78% of monthly household income). ICHRA is for employers UNDER 50 employees, and can include part time employees. Source: People Keep White paper Oct 2019 Plan is available to 11 employee classes." Source: see link. This gets a bit confusing in that under original ACA, employees being offered coverage lose APTC eligibility, where monthly (Marketplace offered) plan cost exceeds 9.78% of AGI or MAGI. See: HRA, HFA, HSA, etc. See CMS Presentation link Employer-sponsored insurance is considered unaffordable for an employee, and the employee’s family members if they are also allowed to enroll in the coverage, if the amount the employee must pay for the lowest-cost self-only plan that meets the minimum value standard is more than a percentage of the worker’s projected annual household income. The percentage is 9.78% for plan years beginning in 2020. The percentage for plan years beginning in 2021 is not available as of the publication date of this training. A health plan meets the minimum value standard if both of the following apply: It is designed to pay at least 60% of the total cost of medical services for a standard population. Its benefits include substantial coverage of physician and inpatient hospital services. If the employee and his or her family members actually enroll in the employer-sponsored insurance, the employee and family members are not allowed APTC for their Marketplace coverage regardless of whether the employer plan is affordable or provides minimum value. " Source: Marketplace Exam "

Individual Mandate (Shared Responsibility)
A repealed provision of the (federal) ACA law penalizing individuals for not buying compliant coverage. Several other states have indicated that they have legislation adding an individual mandate and penalty for 2020 that will require reporting in 2021.
Individual Marketplace Authorized Functions (Marketplace Agent Authority with PII)
INDIVIDUAL MARKETPLACE AUTHORIZED FUNCTIONS Section II(a) of the Individual Marketplace Privacy and Security Agreement identifies the following authorized functions for which an agent or broker may create, collect, disclose, access, maintain, store, and use personally identifiable information in a Health Insurance Marketplace1 Individual Marketplace. 1. Assisting with applications for qualified health plan (QHP) eligibility 2. Supporting QHP selection and enrollment by assisting with plan selection and plan comparisons 3. Assisting with applications for the receipt of advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSRs), and selecting an APTC amount 4. Facilitating the collection of standardized attestations acknowledging the receipt of the APTC or CSRs determination, if applicable 5. Assisting with the application for and determination of certificates of exemption 6. Assisting with filing appeals of eligibility determinations in connection with the Marketplace 7. Transmitting information about the consumer’s, applicant’s, qualified individual’s or enrollee’s decisions regarding QHP enrollment and/or CSRs and APTC information to the Marketplace 8. Facilitating payment of the initial premium amount for the appropriate QHP 9. Facilitating an enrollee’s ability to disenroll from a QHP 10. Educating consumers, applicants, qualified individuals, or enrollees on insurance affordability programs, and if applicable, informing such individuals of eligibility for Medicaid or the Children’s Health Insurance Program 11. Assisting an enrollee’s ability to report changes in eligibility status to the Marketplace throughout the plan year, including changes that may impact eligibility (e.g., adding a dependent) 12. Correcting errors in the application for QHP enrollment 13. Informing or reminding enrollees when QHP coverage should be renewed or when enrollees may no longer be eligible to maintain their current QHP coverage because of age, or to inform enrollees of QHP coverage options at renewal 14. Providing appropriate information, materials, and programs to inform and educate consumers, applicants, qualified individuals, and enrollees about the use and management of their health information and services and options offered through the selected QHP and among the available QHP options 15. Contacting consumers, applicants, qualified individuals, and enrollees to assess their satisfaction or resolve complaints with services provided by the agent or broker in connection with the Marketplace or QHPs 16. Providing assistance in communicating with QHP issuers 1 When used in this document, the term “Health Insurance Marketplace” or “Marketplace” refers to Federally-facilitated Marketplaces (FFMs), including FFMs where states perform plan management functions and also refers to State-based Marketplaces on the Federal Platform (SBM-FPs). 17. Carrying out the agent’s or broker’s legal responsibilities related to QHP issuer functions in the Marketplace, as permitted or required by the agent’s or broker’s contractual relationships with QHP issuers 18. Other functions substantially similar to those enumerated above and such other functions that may be approved by the Centers for Medicare & Medicaid Services in writing from time to time Source: Marketplace Exam 2022
Individual Medical Questionair (IMQ)
A term used by Aetna for their (2 page) Level Funded Enrollment form.
Individual Medical Questionairs (IMQ)
A term Aetna uses for applications (voluntarily elected by the broker and or his client) to :underwrite "Level-Funded" plans for potential 10% GRX discount.
Individual Retirement Account (IRA)
There are many types of IRA's. 529 for college where income tax is paid on the funds going in, but not coming out, 401's and SEP for various business uses, Roth IRA for various needs that allow funds out without Income tax. IUL's also offer superior tax preferred benefits, and unlike IRA's come with interest crediting contractual promises and guarantees. Speak to an experienced agent and or your CPA or tax advisor. Yes, it makes a big difference in how much you get to spend versus how much you will have to pay Uncle Sam if you fail to plan for your retirement, or large college expense.

Inflation (Medical Cost Inflation)
"In July 2022, however, prices rose by 8.5% across the economy from the previous year, compared to 4.8% growth in prices for medical care. Overall price growth was at 8.5%, and core inflation (excluding food and energy) was at 5.9%. Many essential goods and services saw larger increases. Food prices grew by 10.9% and electricity costs grew by 15.2%. Many other household expenses, such as rent and clothing, have also seen larger price increases in the past year than medical care. By far the fastest-growing essential household expense has been gasoline – whose price has increased by 44% since July 2021. Prices for hospital services, both inpatient (3.9%) and outpatient (3.5%), as well as for nursing homes (4.5%), rose faster, while drugs and physicians' services had lower price increases (2.8% and 0.8%, respectively). Rising average employee wages and continued staff shortages in the wake of the pandemic may put upward pressure on operating costs." Source: Healthcare Finance - see link. In context to Medical pricing, its the percentage load underwriters use to estimate claims payments. 4%-7% is typical for large employers, but Individual Major Medical inflation rates can be massively higher, and tend to ignore subset age banded increases applied to some age banded ratings - i.e. years ago Blue Cross marketplace plan premium increased 45% in one year. See: CAGR, CPI, IRR, effective rates of returns, COLA. An inflation percentage is relative to a "market basket of goods" purchased. Social Security periodically increases benefits each year by COLA. CPI is probably the most widely used gage of real overall price increases. This is important for many things, especially retirees trying to earn more interest on their long term retirement accounts so they don't run out of money in old age. Ex. a 2% fed targeted inflation rate over a 10 year period means that 10 years from today, $1.00 buys only $.80 of same basket of goods purchased today. (That's 20% less buying power than today, and 40% less in year 20 - so not investing to stay even with inflation means real problems for those who fail to plan for "expected" and especially unexpected inflation).

Inflation Adjustment Rate (Growth rate)
Means many things. For Medicare commissions, it is the rate CMS uses to increase the rate. Inflation adjustment figures are commonly used when underwriters rate renewals, and factor into trend percentage increases.
Inflation Rider
A policy provision that increases the paid-out benefit by what the customer selects. Inflation riders cost more for higher percentages, and 3% is likely a solid election, but higher and lower options are usually available. This are common in LTC policies, but are found in a variety of insurance products. See: Return of Premiums, Continuation of Benefits, etc.
Initial Compensation
First year agency commission or payment. See: Renewal Commission.
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 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."

Inpatient Psychatritric Facility (IPF)

Inpatient Quality Reporting (IQR)
"Now Available: Updated 2019 CMS QRDA I Schematron for HQR The Centers for Medicare & Medicaid Services (CMS) has released an updated 2021 CMS Quality Reporting Document Architecture (QRDA) Category I Schematron for Hospital Quality Reporting (HQR). The updated Schematron provides technical instructions for reporting electronic clinical quality measures (eCQMs) for the calendar year 2019 reporting period for the: • Hospital Inpatient Quality Reporting (IQR) Program • Medicare and Medicaid Promoting Interoperability (PI) Programs for Eligible Hospitals and Critical Access Hospitals (CAHs)" Source: CMS See: KTCH, HH QRP, IRF, and rule CMS-1747-P)

Inpatient Rehabilitation Facility Quality Public Reporting (IRF QPB)
See: Preview Report Access link first. See: HH QRP, LTCH, IRF, and rule CMS-1747-P

Institute for Clinical and exonomic Review (ICER)
Medical informatics platform purporting to convey information on EBM and cost to its subscribers..
Institute’s Health Insurance Policy Simulation (HIPSM)
Urban Institute’s Health Insurance Policy Simulation Model.
Insur Tech
Latest jargeon describing on-line agent generated applications, and simetimes binding authority. Relates mostly to smaller simplified policy forms and coverages (usually less coverage, but not always). Its essense lay in carriers trying to lower costs of aquisition - moving to win policies on smaller lower risk perils and hazards without having to hire their own sales forces which is expensive. But, for complicated coverages, or additional coverages not offered for policy binding on-line, brokers must access other markets for best rates and available terms.
Insurance Certifications
See: CPCU, FLMI, AAI, ARe, CPIA, CLU, CSR, HIA, etc. Some take very little to get, and others take a typical two years of exam taking/passing... Not to be confused with MBA, FSA, MAAA, RN, MD, DO, ... formal post graduate degrees.
Insurance Literacy
A term used to convey insurance knowledge, particularly with the four primary coverage features common to all ACA QHP. (Deductible, Co insurance, Copays, and MOOP). There are several other important considerations that follow generic plan types. See: HMO, PPO, EPO, Health cost sharing plan, Discount plan, RBP plans, GAP, etc.
Insurance Professional Designations
Many: Commonly earned titles include: CPCU, FLMI, CLU, ARe, etc. See: Underwriting
Insurance Services Office (ISO)
Insurance Services Office: Provides many insurance services, forms, and standards. There are many insurance bureaus, such as the American Association of Insurance Services, etc. See: American Association of Insurance Services (AAIS)
Integrated Care
See: EBM, etc. Take all these with a grain of salt, and know that nothing sustainable happens without physician buy-in.

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.
Interactive Voice Response (IVR)
An automated voice system that allows individual patients to pay any part of their medical bill at any time. The term also relates to accessing EHR.
Interim Final Rule (IFR)
A term CMS uses to try and differentiate a Final Rule from one they are going to use until they publish the FR. Good Luck. In contexts to federal regulations, an abbreviated list of the most important rules pending Final-Rules promulgation by the assigned federal agency regulating the subject matter. Sometimes we never get the ratified and approved final rules...
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 )
Codes determine how care is classified and insured. Many who follow medical claim reimbursement standards know that the newer ICD-10 68,000 diagnosis codes and 72,000 procedure codes, up from the simpler ICD-9's 14,000 diagnosis codes and 3,800 procedure codes, make up-coding and up-billing more difficult. See: CMS HCC.
International Drug Pricing (CMS Rule for Doctors Office Drug Pricing)
See: EO and this rule "interim final rule" released 61 days before President Trump's last day in office. See: CRA. Medicare Drug Rebate Rule.

Interoperability and Patient Access
See: Link, and "current" Executive Order (10/17/17 allowing cross state line plan sales without active license in that state - at least in the beginning) we will have to see if Biden overturns it. Know most executives would not do something that would cause another state's ire. See: MEWA

Interroperability (Medicare Interoperability)
See MIPS, and EHR in context to merging both.

Involuntary termination
Term used in Group (employer) plans when an employee loses his job. Can get squirrely - includes constructive discharge and termination for cause, but not gross misconduct... See: ADA, AFLA, EPLI, etc.
IoT (Internet of Things)
An amorphous term coined to mean the connection of billions of smart devices through a network. In context to insurance, it means the inclusion of AI and its alogarithisms "predicting" outcomes by interpreting values monitored by various "smart" devices used to confirm or identify risk-factors used to underwrite (price and renew) many kinds of coverage. Ex. GL-BOP with BI, roofing, EPLI, and proximity to risk factors predicting losses. Key liability (privacy) issues - both personal and commercial involve express or implied agreement by an individual to their PI. Laws and opinion on what causes a violation are many.
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
ISO 45001
An OSHA international standard of employee safety. See OHSAS 18001, and ILO-OSH Guidelines

See: ACA Law


Joint Underwriting Association (JUA)
An association authorized to rate and bind insurance coverage, and that is not a rated entity, or Florida Insurance Guarantee Association insured. See: Citizens
Journal of the American Medical Association (JAMA)


Kaiser Family Foundation (KFF)
Great source for accurate information on complex medical financing subjects that matter.

Key Performance Indicators (KPI's)
Variables measuring primarily revenue streams of practicing physicians in context to payor contracting, trends, anaytics, and strategic/tactical planning. It can mean many things.


L&H (Life & Health)
Accident and Health. The term typically relates to agent or policy form license or authorization by each state.
L&H (Life & Health)
The term typically relating to agent or policy form license or authorization by each state.
Labor Law Exclusions (Action Over claims, Scaffolding Act in NY S240)
Generally, an exception to CGL common exclusions related to liability coverage over the "insured contract" as related to employee injuries on the job, and that are not insured by workers compensation. In other words, CGL insures "contractual liability".
Latent Variable Modeling (LVM)
See: CMS Hospital Compare. In short it is the ongoing attempt by CMS to accurately measure hospital performance by the quality metrics they select and somehow try to get accepted by stakeholders.
Learning and Action Network framework (Medicare LAN)
See Health Care Transformation Task Force (HCTTF) A CMS directed entity aligned to improve QPP. A multi-stakeholder driven public pritate partnership tasked with improving medical outcomes using EBM at lower cost. Published results do show VBM increasing usage as a percentage of total spending. See: MACRA, CMMI, APM, VBP, CMS.

Leased Paper
See: Fronted and Reinsured assignments
Lenders Loss Payable provision
A property and casulty policy provision allowed by the policy owner, authorizing insurance recoveries be paid directly to the lender, or lessor, or title insurance company, etc (and not to hte policy owner - insured). Very important to understand if there is a fire, and total loss, the property owner may not get paid what he need to repair the damage and bring the property back to rentable condition, etc. Talk to a qualified lawyer when agreeing to these.
Length of Stay (LOS)
A common quality measurement. See: Outlier
Letter of Credit (LOC)
Could also mean Line of Credit
Letter of Intent (LOI)
Level Funded Premium (LFP or Minimum Premium)
An underwritten ERISA qualified fully-priced and paid plan, that offers a premium rebate for favorable claims experience, typically triggering when actual claims (by month 14 of a 12 month policy) fall under 120% of the previous years trended claims histery. Typical premium surplus is split 50:50 with the carrier. Level Funded plans can price about 15%-20% less than comparably funded "Fully insured" plans. Claims comming in above 120% of last year's claims, and cause a loss are carried forward to offset succeeding year's potential rebates, if any. Bottom line is the employer is on the hook for only the fully-funded premium for their employees, and does not pay more than the assigned premium accepted to start the plan. They are very popular plans.
Level or Increasing
An elected (UL, Wholelife, IUL) life insurance policy feature operating the death benefit payout limit. Increasing means the death benefit increases during the term of the policy, and upon death, the beneficiary gets both the cash-value (aka Accumulation Value) and the death benefit. Increasing means the premium also increases as the person gets older, even in single premium policies. in an IUL, Level means the beneficiary gets just the death benefit. The features are designed to meet the insured's lifetime plan to protect their family (or business partner) with maximum death benefit at a cost meeting the lifetime plan. There are two primary rules governing IRS compliance to keep from MEC conversion, so be cautous. Cost of insurance can substantially decrease following the needs of the insureds with level, and go up with increasing. See: IUL. Also be aware that late in life when policy value is near or above the death benefit, the carrier does not charge insurance for the entire death benefit, only the difference between the Cash-Value and Death benefit. Other charges may apply, so work with an experienced agent and declare your primary needs so the policy matches its policy features (lifetime plan that can change with features allowed in a policy). In other words, the proper analytical method for a life insurance transactions involve a long term of typically 10-50 years, not one year. Understanding the four primary leverages that occure in a properly writtin life insurance policy, especially one designed to maximize pension payments (actual spending in retirement that does not tax growth as income when spent). See: No lapse guarantee, or Guaranteed minimum death benefit, or Guaranteed life time interest crediting, etc.
Liability Coverage
In context to insurance, it means different things in different policies. Three main types of Liability policies are E&O (professional liability = Errors and Omissions), D&O (professional liability Directors & Officers of a corporation with a fiduciary duty), and liability coverages and limits attached in package insurance policy forms like General Liability, Property, Homeowners, Auto, and Umbrella. Almost all liability polices detail coverage by insured peril and it's limit. Liability coverage almost always is limited to a location, or asset (house, car, boat, business) address. Some liability coverages travel with the person, or the asset, and some act like umbrella coverages increasing limits on both property and liability. In context to lawyers being involved in filed lawsuits, it means a responsibility for a stated (or estimated) damage amount, alleged against a defendant for some kind of negligence, tort, loss, damage or breach of contract. Integral to assessing liability attribution is defining the disputing party's relationship as a trusted advisor, order taker or something in between. The law (I am not a licensed lawyer, and am not providing advice) stipulates higher duty in many relationships, like Doctor-Patient, Attorney-Client, Guardian-Ward, Financial Planner-Client, etc. Typically, legal expenses are unlimited, and not part of the stated limit of the policy. See: Negligence, and fiduciary duty, causation, proximate cause, etc. We recommend speaking with licensed attorneys, and agents.
Licensed Only Agent (LOA)
A licensed agent or the person actually soliciting business. Its a term used in hierarchy's of appointments and commission assignments. A term mostly applicable to life insurance FMO's. See: BGA
Life Expectancy (LE)
The length of time or age 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/or selling life insurance policies. These estimations help entities purchasing life settlements budget expected premium cost through policy execution. See: Life Settlements, VBT. Normally the place you would most handily find the RMD tables is IRS Publication 590-B, "Distributions from Individual Retirement Arrangements (IRAs)."

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 from policy owners. 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. See STOLI, Prohibited Premium Financing schemes, Viatical, VBT

Limited English Proficient (LEP)
A conclution that may create eligibility for interpreters for Marketplace and CMS and Medicaid plan eligibility and enrollment.
Limited Medical Plan (MiniMed Plan, Scheduled Medical Plan)
See: Short Term Plan

Line of Athority (LOA)
Jargon used to define what types of insurance an agent is licensed to sell in a particular state. I.e L&H is Life and Health, and P&C is Property and Casualty
List Bill (Charge Master)
A fee-for-service invoice sent by a medical provider to an insured for services rendered. List Bills may be limited to the contracted rate, or may be whatever the provider decides to bill - subject to R&C.
Living Benefits (Accelarated Payments)
A term used by some life insurers featuring early death benefit payouts for terminally ill insureds. See: Viatical
Living Benefits (Terminal Illness Rider)
particla Death Benefit paid to an insured with a life ending diagnosis, prior to death. Typically total amounts payable in the last two years of (expected) life are available for various medical an palliative care. THese are not always straight forward, and can combine with LTC benefits in combined life-LTC policies. Policy eligibility provisions are pretty specific. See: Viaticals, LE, Life Settlements, etc.
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: Custodial Care,
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 Services & Support (LTSS)
See: Doal eligibles and measures directed at chornic care, and try not to get confused with what Medicare-Medicaid insures, and LTC policies insure.

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.
Loss Reserves
The actual or actuarially/regulatorily defined amount a carrier books as a liability in preparation of a pending claim.
Love is effortful, not effortless. There is no great love without great sacrifice. Radical inclusion of all of God's creation. Unconditional forgiveness. Human love is a work in progress. (A humble journey whose truth is relative to an individual's time.) I credit Richard Rohr for many of these conclusions. If you have not studied his book "Falling Upward", be prepared for "necessary suffering", and to be changed.
Lower Healthcare Costs Act
Federal bill centered on eliminating Surprise Billing, and federal prohibition against "federal (as opposed to exclusive health plan) negotiating pharmacy pricing discounts, and physicians gage order rule prohibiting Rx (generic or alternative) substitution. See: HELP Committee


MA Risk Score
Medicare Advantage Risk Score is a metric CMS assigns to individual MA, and Part D insured members (HMO/PPO Medicare insured with private carriers that may also have a Part D Rx plan) that affect the premiums for those insureds.
Maintenance of Certification (MOC)
See: American Board of Internal Medicine (ABIM) over its maintenance-of-certification (MOC) program. Recent Supreme court ruling for ABIM.
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.
Managed Care Organization (MCO)
An ambiguous term for many types of organizations managing medical, and / or financial care/risk &non-risk contracted and care, for all types of insurance and populations. (I.e Commercial, Medicare, Medicaid, Workers Comp, Auto PIP, STM, PEO, clinic, public/private Critical Care) and contracts, .
Managed Fee For Service (MFFS)
The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) is pleased to share the following updates: • Washington Managed Fee-for-Service: Final DY2 and Preliminary DY3 Medicare Savings Report • Training Opportunity: Palliative Care for Older Adults Dually Eligible for Medicare and Medicaid Washington Managed Fee-for-Service (MFFS): Final DY2 and Preliminary DY3 Medicare Savings Report On November 16th, CMS released the Washington final Demonstration Year 2 and preliminary Demonstration Year 3 Medicare savings report, containing Medicare savings results for the Washington Health Home managed fee-for-service demonstration under the Financial Alignment Initiative. The report is on the Innovation Center website:
Managing General Underwriter (MGU or Full Stack)
A Managing General Underwriter (MGU), sometimes called an MGA -- Managing General Agent, is an independent facility authorized by a carrier to rate, bind and/or issue policies. MGU's are contractually bound to represent the best interests of their sponsoring carrier. They typically share in contingency fees and overrides on profitable business. It is not uncommon for MGU's to be called MGA's (Managing General Agents) which is inaccurate because MGA's almost never have rating and binding authority, let alone claims responsibilities common under MGA contracts. The difference between a MGA and MGU is that most MGU's have some level of capital on deposit with a sponsoring carrier, or assume a level of deductible risk (see ASD type of structure). In short, MGU's have real incentive to maximize rates for the risk assumed. See: Contingency fees
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. Unlimited EHB are an example of compliant ACA benefits.
Mandatory Group Reporting

Mandatory Reporting
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).
Manuel for State Payment of Medicare Premiums (State Buy-in Manual)
On December 13, 2019, the Centers for Medicare & Medicaid Services (CMS) released a draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) to states and other stakeholders for review and comment. The draft manual updates information and instructions to states on federal policy, operations, and systems concerning the payment of Medicare Parts A and B premiums (or buy-in) for individuals dually eligible for Medicare and Medicaid. States pay Medicare Part B premiums each month for over 10 million individuals and Part A premium for over 700,000 individuals. This process promotes access to Medicare coverage for low-income older adults and people with disabilities, and it helps states ensure that Medicare pays primary to Medicaid for its dually eligible beneficiaries. Despite the importance of this process, federal guidance on buy-in is out of date. The draft manual reflects current statute, regulation, operations, and systems changes that have evolved over time. Additionally, the draft manual re-organizes content to make it easier for states to discern federal requirements and find information.

Manuscripted Coverage
A customized coverage rated to specifically desired coverage(s) and risk appetite. See: Private Label
Market-based Medicare Severity-Diagnosis Related Group weights
See: Supreme Court ruling forcing hospitals to publish the best prices they contract (or customarily accept as full payment) from their biggest insurance carriers....A CMS initiative to reduce Medicare reimbursement on procedures hospitals charge Commercially insured people less than Medicare currently reimburses. Changes are coming.
Marketplace (Federally facilitated exchange)
In context of medical insurance, marketplace means a federally facilitated exchange, or a state managed place where individuals and small groups can purchase medical insurance during OEP and SEP, and with APTC. See: ACA final Rules

Marketplace Enrollment
" Enrollment in health plans for 2021 through and state-run exchanges was about 5% higher than sign-ups during open enrollment for the 2020 plan year, but enrollment remains below the 2016 peak level, according to a CMS report. The proportion of enrollees who are new to the marketplace has declined to 21%, compared with 25% in the 2020 plan year and 39% for 2016." Source: Health Affairs ===== Individual and SHOP enrollments reported by CMS, HHS, etc.

Marketplace Learning Management System (MLMS - run by CMS)
CMS's agent training site used to complete CE's for marketplace certification of unlicensed Navigators and and licensed agents and brokers.

Marketplace Open Enrollment Notice (MOEN)
A notice sent to a Marketplace insured plan member that must be responded to prior to year end to maintain eligibility and or APTC.
Marketplace Open Enrollment Notice (MOEN)
A federal Marketplace notice of Open Enrollment.
Marketplace Open Enrollment Period Noticies (MOENs)
Federal notices to the public of Marketplace plans eligibility (for EHB and QHP plan(s)- without preexisting conditions exclusions).
Maryland All Payor Model (MAPM)
Take note: Medicare QPP model achieving results.

Master Services Agreement (MSA)
MSA can mean many things. Some carriers offering level funded plans call ASO contracts, MSA's. See: ASO, and Medical Savings Accounts
Matallic plans
A federal government term for Individual Marketplace or SHOP (employer plans) insuring a minimum level of benefits to a HHS defined actuarial value. For example, INDIVIDUAL Marketplace sold "Silver" level (70% Actuarial Value) plan(s) qualify for both APTC AND Cost Sharing. Employers QHP's require "Bronze" (or 60% Actuarial Value) plans to avoid potential penalty.
Material non-Public Information
"Material Non-Public Information Under the federal securities laws – and our Terms & Conditions – you are strictly prohibited from sharing MATERIAL NON-PUBLIC INFORMATION with any of our Clients Non-public information is information that a company has not disclosed to its shareholders or other potential investors Material Information – The federal courts have defined "material" information as information that "would have been viewed by the reasonable investor as having significantly altered the total mix of information" available and for which "there is a substantial likelihood that a reasonable investor would consider it important" in deciding whether to buy, sell or hold a security" Source: Guidepoint
Learning to like what you have to do anyway. Can you say "parenting teenagers"....
Maximum efficient Contract (MEC)
A life insurance term used to differentiate IRS compliant life insurance coverage benefits that are taxed versus Life insurance benefits (loans and death benefits) that are not taxed. IRS has two tests for determining compliant Life insurance meets statutory minimum standard. In short, IRS requires a minimum death benefit to premium deposit ratio for compliant coverage and tax free death benefits. We recommend legal opinion from licensed legal counsel if you are unsure your policy is, and will remain compliant during the entire policy period.
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 Non-network Reimbursement Program (MNRP)
Maximum Out Of Pocket (MOOP, or Out of Pocket Maximum (OOPM))
For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family. For the 2021 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,550 for an individual and $17,100 for a family. The maximum (annual) amount a single/family insured member must pay before their plan pays 100% of costs for eligible care - consisting of (eligible) Deductible(s), Copays, and Coinsurance payment patient liability. 2022 MOOP is $8700 Single and $17,400 per Family (of three or more). Not all medical insurance plans have a MOOP. Note: where care is received from out of network providers who "balance bill" the patient for the difference between the billed charge, and the allowable amount - balance billing amounts do not attribute to MOOP, and can be UNLIMITED - subject to state or federal laws that get enforced. Deductibles, Co Insurance, and Copay(s) amount(s) typically attribute to MOOP. Note: ineligible care from unapproved out of network providers or for ineligible care, including (uninsured) balance billed charges above the "contracted rate" or "Allowed amount" do not accrue to MOOP. See: RBP, Health cost share plans, Contracted rate, Balance Billing, and several kinds of ancillary medical plans.

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. Starting January 2019, providers who do not submit performance data get their Medicare reimbursements cut about 5%, and those that do get about a modest increase.
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 methodologies, inclusive of Next Generation ACO, and Comprehensive Primary Care Plus (CPC+) value to adjust reimbursement and potential bonus for meeting guidelines. See: QPP, Shared Services
Medi-share Plans
See: Medical plan sold whose plan document details it is not insurance. See: Health Cost Share, and Ministry Health plans (that may or may not be insurance)
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 12-15 categories of eligible people, and coverage. According to CMS, Medicaid insures 80 million in 2021, up from about 56 million in 2013, or a growth rate of 40%. Without Medicaid, many hospitals would go bankrupt. Typically, the federal government donates 50% of a state’s Medicaid budget. Under ACA, Medicaid eligibility was expanded from 100% to 138% of FPL (it changes by President) for eligibility in states electing to expand Medicaid eligibility. 13 states elected not to expand Medicaid eligibility under ACA (make available to people earning a little over 138% FPL). The Supreme Court allowed states to bail from the ACA law causing many hospital insolvencies. See: Home and Community-Based Services (HCBS)

Medicaid disproportionate share hospital (MDH)
Relates to a controversial CMS regulation apportioning Medicaid reimbursements to hospitals.
Medicaid Expansion
A voluntary state expansion of Medicaid eligibility offered under ACA by the Federal Government for three years. The provision allows poor people earning under 100% of FPL 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

Medicaid Expansion
Under the Patient Protection and Affordable Care Act, states may expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household MAGI at or below 138% of the FPL who are not otherwise eligible for and enrolled in mandatory Medicaid coverage, and are not entitled to or enrolled in Medicare Part A or B. This is known as "Medicaid expansion." However, some states have not expanded Medicaid eligibility. Regardless of whether a state expands its Medicaid eligibility, all state Medicaid programs must: Use MAGI as the income methodology for the majority of applicants (generally, all non-elderly, non-disabled populations); Not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI; and Streamline income-based rules, systems, and verification procedures. Source: Marketplace Agent Certification Exam

Medicaid For All
A ambiguous term typically used to describe Medicare eligible beneficiaries (as yet not) granted right to care by Medicaid participating providers, where Medicare participating providers are unavailable in rural areas. See: Medicare For All. According to CMS, Medicaid insures 80 million poor people in 2021, up from about 56 million in 2013, or a growth rate of 40%. WOW! Without Medicaid, many hospitals would go bankrupt. What has been happening for many years is poor uninsured people go to the hospital ER when they are sick. Because all hospitals are required to treat and stabilize people showing up, they do so by charging the maximum charge master rate, which is drastically more then what the hospital charges its contracted HMO's and PPO's, and overstates the charity care. The hosptials also rais the prices for commercially insured people in a process known as cost-shifting, causing medical inflation of commercially insured people to be 200%-about 400% of CPI. In almost all of the past 20 years, it has been at least 200% more, or double CPI. Wages have not kept up, and the middle class continuees to shrink over the past 25 years. FYI: My two person coverage costs about $20,000 per year, and comes with a $6,000 - $8,000 deductible. Messed up - you decide. If wife and me get sick together in the same calander yar, it costs me $20,000 + 2($6,000) = $32,000 EACH year ... and we ARE insured?!

Medicaid HCBS
Medicaid Home and Community Based Services. See: and prepare yourself for a difficult journey to understand eligibility, with Dual Eligibility (Medicare & Medicaid), and public health for the poor. See:, LTC, DI, public health administration and politics...
Medical Cost Inflation
A term usually reported as a percentage increases experienced in the past year on large group premiums, without adding in massively increasing deductible and out-of-pocket costs born by the insured. Historically, medical inflation outpaces CPI by 200% - 400%. In many years past, it has been more than 4 times (400%) CPI for Individual and small group premium increases. See: The Medicare link below. Milliman report. ===================== Milliman is a company specializing in advanced medical cost analysis and trend. Milliman is well known for establishing underwriting parameters. i.e (Milliman requires subscriptions to see their estimates): 2018 Average Medical Plan (premium) cost for family of four $28,000 (Plus deductible, copays and Maximum out of pocket costs) In 2018, my personal (Individual) insurance with Blue Cross (Silver plan) increased 45% in ONE year. Cost for my family of two in 2020 will be about $18,000 for a $8,000 deductible policy. In other words, if we have an accident with both people incurring full deductible, the plan does not pay 100% of medical costs until after we satisfy $16,000 deductible, plus $18,000 premium = $34,000.... and we are insured?! The reckoning is coming - See: Executive Orders affecting hospital reporting transparance pricing.

Medical Cost Sharing Plan
See: Health Cost Sharing plan
Medical Group Management Association (MGMA)
Medical Insurance Bureau (MIB)
A permanent medical record consisting of claims reported by insurers detailing health status of a potential insured. MIB is an underwriting tool used by carriers to decline or offer new insurance coverage to individuals. MIB is accessible only to entities securing proper HIPAA signed release.
Medical Loss Ratio (MLR)
The percentage of premium paid on claims, and traditionally defined as Total Claims paid/Total Premiums. ACA mandates premium rebates (on QHP plans marketplace plans) where the percentage of PAID claims are less than 80%/85% of Individual/Group (employer) and MA plans on collected premium. I am not sure if it applies to Medicare Supplimental products or most ancilliary services medical insurance products including Hospital indemnity, critical illness, Accident only, Cancer-Cardiac-transplant insurance products. Additional items (counted like claims) "may" by included in the "claims" number used like quality assurance, etc. MLR rebates (if PAID claims did not exceed 80% for INDIVIDUAL plan members, and 85% for GROUP (employer) plans applies to Marketplace plans. The law-regulation mandates a refund of excess premiums paid, back to the insured when claims paid is less than 80% for individuals, and 85% for Groups (groups 1-50 ee, or 1-100 ee depending on the market). Commissions and profit margin are not part of MLR, and neither are the tens of millions the federal government pays unlicensed Navigators enrolling people that used to get their insurance from agents earning abismal commissions (Its really not less expensive, and there is no service from Navigators that are unemployed 45 days after they work an Open Enrollment. Apparently, carrier's quality assurance expenses over a three year period do reduce "premium" in the MLR calculation. United Healthcare reported it paid $145M in 2021 rebates, which means they did not pay claims excess of 80%/85% of premiums (overcharged the customer - or insurance language, significantly applied an actuarial-fudge-factor favoring the carrier), and had to refund the difference. Lots of rules apply ... Trump inspired rule changes modified the calculation to allow carriers to add into the claims calculation various administrative services like "quality improvements" the affect a lower refund liability - without repealing ACA law. (source: United Healthcare Agent advisory) See Link for 2019 record payouts- meaning the premiums charged were much higher than needed for solvent plan operations at $2.7 Billion in 2020 v. $1.4B for 2019. "The Medical Loss Ratio (MLR) Early Warning Report key dates are now available. MLR 2021 payouts are for the 2020 MLR rebate reporting year using the 2019 average total number of employees (ATNE). MLR applies to fully insured plans only, not ERISA. MLR is based on legal entity, state and size of employer, and payouts are based on an aggregate of those factors – not on performance of a specific employer group or individual. For 2021 reporting, most states use 1–50 ATNE to determine small group. Only 4 states use 1– 100 ATNE for reporting – California, Colorado, New York and Vermont." Double check COVID federal EO's, and updated regs following ARP are followed in context to emergency temporary standards promulgated by federal agencies. Source: United Healthcare Agent Advisory 2021

Medical Savings Account (MSA)
A federally authorized account funded with pre-tax dollars for INDIVIDUALS (including Medicare beneficiaries) used to pay eligible medical expenses. Funds are typically used to pay eligible deductibles, co insurance and max out of pocket costs. MSA accounts allow for reimbursement of some costs of care that are not insured, and are outside of the major medical "insured" coverages. (I.e. AC expenses for asthmatic children. See HHS/IRS list of eligible uses of funds. See: HSA, ASO, 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

Medical Science Liasons (MSLs)
Jargeon used to try and capture the personal involved with merging MD expertise with IT, wireless, and state of the art technologies representing both the patient's treatments and its cost effect on it's institution(s) bottom line. Its serving two masters.
Medically Necessary
A legal term defined by ERISA, and modified by state statute where applicable. a.k.a. Medical care that is not experimental or prohibited by the FDA, that is appropriate for the diagnosis, treatment, cure or relief of health condition, illness, injury, disease, or its symptoms, within generally accepted standards of medical care in the professional community. Some definitions add that it does not include care solely for the convenience of the insured, or the insured's family. Examples of care that is not medically necessary might include keeping an elderly person in the hospital because the family does not want to deal with home rehabilitation because they failed to buy a long term care policy. Some cosmetic medical care is medically necessary.
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. ********************* What is MACRA? MACRA is an acronym for Medicare Access and CHIP Reauthorization Act, legislation signed into law in 2015. It is a law that states that anyone who is “newly eligible” for Medicare starting January 1, 2020, and beyond may not enroll in a Medicare Supplement Plan that covers the Part B deductible, such as plan C, F, or High Deductible F. (Source Humana Agent Advisory) ********************* 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. ================================= KEY TAKEAWAYS (Source Healthcare Leaders Dec 2018) More than 1,550 hospitals (over 55%) will share higher Medicare payments totaling about $1.9 billion in fiscal year 2019. The average net increase in payment adjustments is 0.61%, and the average net decrease is -0.39%. For 2019, average Total Performance Score across all participating hospitals increased to 38.1 from 37.4 in 2018 See: LAN, HCTTF

Medicare Advanced / Accellerated Payments (Advanced Payments)

Medicare Advantage (MA Plans)
HMO and PPO plans offered by commercial carriers, but (almost all) paid for by the gvernment (HHS) to people over 65 years of age. Unlike Original Medicare Part A (stand alone, Hospital only coverage), or Medicare Supplemental plans (A - N), MA plans mandate in-network provider access to reduce or eliminate out of pocket costs. Some PPO's allow some out of network care, but at risk of balance billing to the patient. These plans are not run by the government, they are (mostly) run by for profit private companies. Cost for MA plans ranges from $0 to about $25 per month, on top of Part B premium (cost about $95-$120 per month). MA plans do not typically require a MAPD plan (Rx) add-on at an additional cost of about $20 - $35/m. See: MAPD "Medicare Advantage premiums are $2 lower per month in 2022Part D prescription drug coverage is rising to $33 per month, compared to $31.47 in 2021. The average premium for Medicare Advantage plans will be lower in 2022 at $19 per month, compared to $21.22 in 2021, according to the Centers for Medicare and Medicaid Services. However, Part D coverage is rising to $33 per month, compared to $31.47 in 2021. The agency released the 2022 premiums, deductibles and other key information for Medicare Advantage and Part D prescription drug plans in advance of the annual Medicare open enrollment. Medicare open enrollment begins on October 15 and ends on December 7." Source Healthcare Finance 10/1/21
Medicare Advantage County-Level monthly capitation payment
A somewhat mysteriously calculated fixed monthly "premium" payment directly to carriers from the federal government to carriers offering Medicare Advantage (HMO/PPO) plans by county. "2020 county-level averages range from $755 per month, in Presidio, Texas, up to $1,609, in Nome, Alaska. The 2020 state-level averages ranged from $883 per month, in Hawaii, up to $1,168, in Alaska." Source:ThinkAdvisor - Oct 2019

Medicare Advantage Organization (MAOs)
Medicare Advantage Pharmacy Benefit (MAPB)
Pharmacy Plans attached to MA plans.
Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration (MAQI)

Medicare Advantage Risk Adjustment (MARAP)
See: 21st Century Cures Act
Medicare Advantage Value-based Insurance Design (VBID)
See: Medicare Part D
Medicare Advantage Value-Based Insurance Design (VBID)

Medicare and Medicare Coordination Office (MMCO)
Another CMS office tasked with coordinating Medicare and Medicaid initiatives.
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). ================ A special number Medicare uses to adjudicate claims that is not the HICN. See: HICNs. Just know there are exceptions, and good luck! (Source: CMS) SEE: NGHP, CMS, RREs
Medicare Cancer Payment Modle (Cancer Moonshot, Enhancing Oncology Model)
The Centers for Medicare & Medicaid See: QPP, VBP, etc A CMS program collecting and reporting selected quality metrics on many kinds of health care services from medical providers. I.e. Service’s (CMS) Innovation Center’s new, voluntary Enhancing Oncology Model (EOM) is intended to transform care for cancer patients, reduce spending, and improve quality of care. It is designed to test how best to place cancer patients at the center of the care team that provides high-value, equitable, evidence-based care. EOM aims to improve care coordination, quality, and health outcomes for patients while also holding oncology practices accountable for total costs of care to make cancer care more affordable and accessible for beneficiaries and Medicare, which are key priorities described in the CMS Innovation Center’s strategy refresh.

Medicare Compare
A web site showing some of the public comparative statistics for nursing homes, hospitals and other providers of care.

Medicare Coordination of Benefits

Medicare Coverage Gap Discount Program
A manufacturer discounting on brand name drugs to Part D member sho have reached the coverage gap (Donut Hole), and to are not receiving Medicare Extra Help. For Brand name drugs, the 70% discount provided does not include dispensing fee. Members pay 25% of the negotiated price and a portion of the dispensing fee for brand name drugs. 9Plan paid 55 does not count towards your MOOP. Some help is also available for Generic Drugs. Contact Customer care at you carrier. Beware: formularies and tier assignments can change suddenly and retroactively.
Medicare Critical Access hospital (CAHs)
See: Payment interoperability.

Medicare Diabetes Prevention Prog (MDPP)
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 Payment Percentage
See HHS qualification for federal grants to hospitals treating higher percentage of Medicare insured people. Currently:To qualify for a slice of the funding, safety-net hospitals must have average uncompensated care per bed of at least $25,000, profitability of 3 percent or less and a Medicare Disproportionate Payment Percentage of 20.2 percent or greater. (Source: Becker Hospital Review)
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 Double Dipper (Double Dibber)
A CMS term used to describe a Medicare Part A eligible person who purchased an Individual Marketplace plan, instead of purchasing Medicare Part B. CMS recently decided to "help" people avoid the late Part B penalty by allowing people to buy Part B, drop the Marketplace plan and waive (1% per month LIFETIME penalty - after age 65) penalty. CMS will not help people who owe APTC tax credits in arrears.
Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)
Health Outcomes After Bariatric Surgical Therapies in the Medicare Population Posted materials for meeting.

Medicare Executive Order
Pay attention to EO that contradict / violate ACA law, along with many regulations guiding FFS, PFFS, Shared Services risk based contracts and ACO demonstration projects, etc.

Medicare Extra-Help
A department to call to get help paying for drugs when the beneficiary is not already able to get Medicaid Dual Eligibility. It essentially looks at assets (not including your house, car or life insurance) to see if you qualify for extra financial assistance on high cost drugs.
Medicare Fee for Service Regulations (PFFS)

Medicare For All (M4ALL)
A contentious initiative supported by "single-payer" (national medical insurance) advocates that would allow INDIVIDUALS under age 65 to enroll in a plan allowing access to medical providers participating in the Medicare program, and reimbursing medical providers at a Medicare Allowable rate versus (much higher - about 120% - 240% of Medicare allowable) 100% of the Medicare (RBRVS, or DRG, etc.) schedule participating providers cannot balance bill (above). Most do not understand that "Original Medicare" insures only 150 plus about 20 more days per LIFETIME (not unlimited QHP in ACA qualified plans), so the benefits are not certain at this point in the discussion. Lots of smoke and mirrors from both parties, especially conservatives mischaracterizing it at a totally paid for entitlement by taxing people, versus a voluntary "Buy into Medicare" plan administered by commercial carriers (like Medicare Supplemental plans). Bottom line: If people under 65 can get a plan whose claims costs cause the premiums to be rated well below Marketplace priced plans, "participating" providers will have to function on less revenue from Medicare For All plan members. We can expect the AMA and AHA will act to protect their special interest group. There is no question premiums would be less expensive than plans paying providers a lot more - regardless of APTC and CSR. There is also little doubt it would have real effect on small town hospital closings, and viability of competing commercially offered plans. We would not bet on hospitals being able to indefinitely "cost-shift" higher commercial premiums to broke people, so it means getting lots better at reducing costs to keep the small town hospital solvent....

Medicare For All (Buy -In to Medicare)
A term used by many that typically means allowing everyone to buy insurance offering Medicare participating provider networks, with (ACA QHP benefit levels, not current Medicare Part A, B, C, D offerings), but whose benefits are insured to the MA amount, and not HMO/PPO/EPO, etc contracted rates. So far it pretty much focuses access/eligibility to such participating Medicare provider networks to people over 50, however Biden's new bill is attempting to lower Medicare eligibility to 60 from 65. Its just a bill, and whether it is totally paid for by the feds is not known, but have to doubt that premiums for 60 - 64 year old people are astronimically high. Mine (and wife) is about $20,000 a year with a $12,000 family deductible. (that means $32,000 out of pocket costs PER YEAR, and I am insured?! Medicare for all is not typically described as a total federal entitlement give away. People would pay (like now under ACA APTC) more or less depending on AGI/MAGI. See: Articles at There is no question it would cost people a lot less because the provider reimbursement rates would be a lot less, so we can expect AMA and AHA push back. Current research (accross the board for all medical charges comparison) detail Medicare authorized payments are about 240% less than commercially insured payments - and for the same procedures. Price for insurance is directly tied to expected claims, and the fee schedule used to pay claims so it can dramatically change premium pricing. It gets complicated... See: Articles, at

Medicare For All plan
A political plan supported mainly by democrats, but not yet available, to allow people under 65 years of age same or similar ACA qualified (unlimited EHB) insurance buy-in that uses existing Medicare participating providers.
Medicare LAN
See: LAN
Medicare MCMSA (Workers Comp Set Aside)

Medicare Modernization Act (MMA)
A term frequently used by The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) when updating: • Interoperability and Patient Access Proposed Rules. (related to dual eligible Medicare and Medicare beneficiaries.
Medicare OOPS / ASC
Medicare Hospital OPPS and ASC Payment System Final Rule for CY 2020 On November 1, CMS finalized policies that aim to increase choices, encourage medical innovation, empower patients, and eliminate waste, fraud, and abuse to protect seniors and taxpayers. The changes build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. In accordance with Medicare law, CMS is updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent. This update is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for Multi-Factor Productivity (MFP). Using the hospital market basket, CMS is finalizing an update to the ASC rates for CY 2020 equal to 2.6 percent. The update applies to ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for MFP. This change will also help to promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting. This directly affects providers who are and are not sending quality data to CMS. Source: CMS

Medicare Open Payments

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. The other key is physicians donating their time to inform people who did not go to medical school what type of information meets their goal.
Medicare Outpatient Surgical Care Rule (Out Patient Surgical Care Rule)
A rule by CMS, (with some kind of bearing to an EO) that requires some surgeries to be performed in certain settings to be eligible for CMS reimbursement.

Medicare PACE plans
A plan offering Part A & B benefits. These are "Programs of all-inclusive Care for Elderly (PACE) organization are special types of Medicare health plans, PACE plans can be offered by public or private companies and provide Part D and other benefits in addition to Part A and B benefits. They are also referred to as Demonstration plans, and/or some ACO plans, etc. Source: Medicare & You handbook 2020
Medicare Part A (Original Medicare (Hospital coverage only))
A federal entitlement available to people over 65, (or who are disabled, or who have ESRD, etc) who have paid 40 or more quarters of tax (FICA) into the system. Original Part A insures up to 150 days of acute-inpatient-hospital care (plus potentially 20 more inpatient hospital days) per LIFETIME (not per year), and that also insures eligible hospital-outpatient care, up to 100 days of eligible restorative SNF, Hospice and up to 100 days of SNF. Medicare Part A does not insure Long term (custodial-non restorative SNF) care. It insures acute-hospital-care (where the person is getting better). Part A is a pure entitlement which does not require a monthly premium (reduction from social security) by the eligible member who paid 40 quarters of Medicare taxes. Medicare part A does not pay for most out-patient drugs (except under Part D), or annual physical exams beyond one physical a year. Does not insure most dental care, routine foot care, eye care, hearing aids, personal comfort items or cosmetic surgery. Most importantly, it does not insure long Term Care (custodial care). Coverage out of country gets squirrelly to figure out.================= People who have not paid into the system can purchase Part A for $437/m, and can purchase Part B as well for about $100-$125/m depending on age and location. These rates are massively subsidized by the government.

Medicare Part B (Part B)
For 2022: Standard Medicare Part B premium to $170.10 a month, up $21.60, or 14.5 percent. It also increased Part B standard deductibles by $30, up 14.8 percent to $233 in 2022. Rates vary by zip code. A Federal medical insurance for people over 65 that pays rimarily for physician services. Medicare Part A pays for Hospital services. Recent changes to Medicare now offers extended benefits for "Dual Eligible" (Medicare and Medicaid eligible) lives and pays for things like food after a hospital stay, transportation to medica appointments some medications, some in home care that used to be considered LTC care, and in some cases, grocery funds for poor people who have not recently been in the hospital. Its complicated and involves dealing with Medicaid and Medicare simultaneously. Part B typically is paid as an automatic deduction from ones social security pension payment. Those that fail to elect to start the monthly deductions (at age 65) are penalized about 1% per month for every month they fail to elect coverage (and for life). Eligible persons wishing to elect a low cost Medicare Advantage (Medicare part C plans: HMO or PPO that insure Hospital, Physician, and typically include Rx coverage - Part D), must first enroll in part B, and pay the additional premium which reduces a person's social security monthly "pension" check. See: AARP explanation, Medicare Interoperability

Medicare Part C
Legislation enacted to offer HMO, PPOs, and MSOs to Medicare eligible people, and at $0 or very low premiums costs (Taken from the Social Security amount/m). The law also authorizes PSO's (Provider Services Organizations) designed to engage physicians into contracts under that compensate a fixed budget with goal of improving outcomes. See Medicare Shared Savings. MA plans typically come with a Part D (pharmacy) plan attached, and at no additional premium, unlike Medicare Supplemental plans (A-N) that mandate selection of a drug plan at an additional monthly cost of about $30 - $95 (in addition to the $250-350/m Supplemental plan premium, and Part B premiums). MA plans typically insure more things than Medigap plans, like some food, in-home care, some transportation, etc., that Original Medicare (Part A only stand alone), or Medicare Supplemental plans may not insure / reimburse. Selecting a MA plan (HMO/PPO) can mean big differences in monthly Pharmacy out of pocket costs. Find a qualified agent, or do the work to figure out Rx copay and network access differences between MA, and Medicare Supplemental plans.

Medicare Part D (MA-PD, Medicare Prescription Drugs coverage)
A stand alone Drug plan required to complete coverage for Medicare Supplemental insured people. These aplans are offered-managed by commercial carriers, but supervised by the Feds. There are no HMO/PPO networks in Medicare Supplimental plans, and each insured can use any willing provider who can and do balance bill the patient. Most drugs are insured to a fee scheduled amount, but it is always safe to ask what they are charging and confirm the Medicare Authorized reimbursement is accpeted as full payment by the carrier, so a surprise bill, or balance bill is not recieved unexpectedly. Formularies and Copay Tiers are different among the carriers. In some instances, MA-PD plans are also available at extra cost for MA PPO plans. Most Medicare Advantage plans insure pharmacy coverage, and do not require Part D separate election. and monthly premium obligation. See link for 2022 deductibles and Copay obligations. Know that there are significant differences in formularies, copays and what attributes to maximum out of pocket cost (liability) between plans. Find an experienced agent. Do the work to understand what you are buying. See: Credible Coverage Medicare Coverage Gap Discount Program.

Medicare Path Finder
A controversial web link that can be used to compare the cost of Medicare Advantage plans with the cost of combining what CMS calls ‘Original Medicare’ coverage (Medicare part A stand alone or with Part B, and/or D) with Medicare supplement insurance. The biggies to try and estimate are out of pocket costs related to Pharmacy (Part D), and copays. Remember, Pharmacy can change retroactively to a higher tier.
Medicare Payment Advisory Commission (MedPAC)
Medicare Physician Fee Schedule Final Rule (PFS Final Rule)
"Physician Fee Schedule Update On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS): • Provided a 3.75% increase in MPFS payments for CY 2021 • Suspended the 2% payment adjustment (sequestration) through March 31, 2021 • Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023 • Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024 CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage". Source: CMS See: PFS, MSP, MA-PD, Medicare Part B

Medicare Private Fee for Service plans (PFFS)
A Medicare entitlement plan option that "insures" care from non-contracted (non-participating) medical providers - up to the "Medicare Allowable" amount, and that allows balance billing to people choosing to go out of network and pay it. These are generally not available in most areas, but for small towns with no contracted (participating) medical providers. See: MSSP, ACO, etc
Medicare QMB
People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.

Medicare Secondary Payer (MSP)
Jargon used to highlight accurate subrogation of claims on dual eligible and multi-insured eligible people. See : Information and instructions for the Medicare Secondary Payer (MSP) Group Health Plan (GHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 MSP Mandatory Reporting GHP User Guide (GHP User Guide). Section 111 GHP Alerts Frequently, CMS will publish new guidance in the form of an alert on the GHP Alerts page. These alerts are incorporated into subsequent versions of the GHP User Guide and supersede information published in the GHP User Guide. To obtain the most up to date information and requirements related to Section 111 reporting, be sure to review not only the GHP User Guide, but also any pertinent alerts published after the current version of the GHP User Guide. Section 111 Coordination of Benefits Secure Website User Guide The Section 111 Coordination of Benefits Secure Website (COBSW) is used by GHP RREs to register for Section 111 reporting, monitor file submissions, and submit online queries of Medicare entitlement. The user guide for this Web portal can be viewed and downloaded after logging in to the Section 111 COBSW. The link to the Section 111 COBSW can be found in the Related Links section below. X12 270/271 Companion Guide Section 111 GHP RREs have the ability to transmit a query file to request information regarding Medicare status and Medicare Part A entitlement and Parts B and C enrollment of individuals covered by the GHP. This query file is submitted in the form of an ANSI X12 270/271 Entitlement Query transaction set. If you choose to use your own ANSI X12 translator to create the X12 270 files for the Section 111 Query Only File and process the X12 271 response, please refer to the companion document which is available in the Downloads section below. This is to be used in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 Implementation Guide. Please refer to the Query Only Input and Response File requirements in the GHP User Guide for more information.

Medicare Secondary Payer Act (MSP)
MSP regulation is recently fortified. See: Updates to the act See: Subrogation Know that Medicare lien resolutions both plaintiff and defendant are big business, and a negotiated processes of hospitals trying to get paid timely to an acceptable reimbursement. Also know that hospitals charge on average about 240% more for commercial patients than they do for Commercial patients. Lots of rules to follow. See: NGHP for subrogation, GHP, CRC, CRCP, 42 USC 1395yb

Medicare Secondary Payer Mandatory Liability Insurance (MMSEA)
Subrogation rules relative to Medicare beneficiaries COB of No-Fault (PIP), Workers Compensation, and INDIVIDUAL insurance. "Information and instructions for the Medicare Secondary Payer (MSP) Non-Group Health Plan (NGHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide). The NGHP User Guide is your primary source for Section 111 reporting requirements." Source: CMS.

Medicare Secondary Payer Recovery Portal (MSPRP)

Medicare Sequester
A program of continuing a delay in implementing a 2% reduction of Medicare Authorized reimbursements to providers who are not incompliance. See: QCDR, MIPS, QPP, etc. Congress must re-approve it, to not have a 2% reduction.
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 set FFS budget for that population. When it comes in less than FFS, then they split the savings with the feds. These contracts require medical providers to earn less than a FFS equivelent if they are unable to manage the care of the "capitated" population under the budget, and are typically managed over a three year term. See ACO contract. See: Medicare Shared Savings. See: ACO, MACRA, QPP, etc. "September 02, 2021 - The Medicare Shared Savings Program (MSSP) saved over $4 billion in 2020. Between the $1.9 billion in Medicare savings and $2.3 billion in accountable care organization (ACO) savings, this represents the program's best performance to date." Source: Revcycle Intellegence 9/2021

Medicare Site Neutral payments
Payments typically to hospitals for Medicare member care delivered off site, but billed at the higher hospital (on-site) facility rates, that (apparently) Medicare is going to retroactively pay hospitals.
Medicare Spending 2020
"...Medicare spending accounted for 20% of US health care expenditures in 2020 and 12% of the national budget, while Medicare benefit payments rose from $200 billion in 2000 to $769 billion in 2020, representing a 7.1% annual growth rate. Medicare Advantage is expected to account for 54% of Medicare spending by 2030, up from 46% last year, while Medicare enrollment is predicted to increase to 93 million in 2060 from 63 million in 2020." Source: Beckers Payer Issues 4/28/22

Medicare Summary Notices (eMSN's)
Medicare Supplemental Insurance (MediGap)
Federally stipulated plans A-N that are identical in coverage regardless of the Commercial carrier offering them. Medicare Supplemental plans are not run by the government, and are run by commercial carriers. Plans are quarantee issue to a person within 6 months of turning 65. MediGap plans do not have PPO or HMO networks per say, so insureds can go to any provider. Going to a non-"participating" provider means being exposed to balance billing liability. People over 65.5 in age, and that have a preexisting medical condition can be denied coverage, and required to seek MA plan enrollment. Most common plan is Plan F. Note: New regulations prohibit any plan from waiving Part B deductibles, on new plans in 2020. A typical person electing Medicare Supplemental coverage is also required to by both Medicare Part A (cost is about $130-$150/m) and, a Medicare Pharmacy plan (Cost is about $40-$50/month) Cost for Medicare Supplimenta plans differs by age, sex, and location and is about $250- $350/month. (Part B and Part D PBM is taken out of their social security mothly income payment). "In practice, the MACRA Medigap deductible provision means that many people who, in the past, would have bought Medigap Plan F policies now will have to buy Medigap Plan G policies. Medigap Plan G policies are like Medigap Plan F policies, except that they require the enrollee to pay the Medicare Part B deductible. Consumers were able to buy a high-deductible version of Medigap Plan F. Medigap Plan F High-Deductible coverage will become Medigap Plan G High-Deductible coverage. Users of Medigap Plan G High-Deductible coverage will have to pay the Medicare Part B deductible themselves, but the amount paid to satisfy the Medicare Part B deductible will now go toward satisfying the Medicare Part G deductible. The MACRA changes also affect sales of new Medigap Plan C policies. Medigap Plan C policies are similar to Medicare Plan F policies, except that they offer no coverage for “Medicare Part B excess charges,” or the extra amounts charged by providers who don’t participate in Medicare. Many people who would have bought Medigap Plan C policies will now have to buy Medigap Plan D policies." Source: Think Advisor 1/2/20 See: Balance Billing

Medicare Trump Executive Order (EO 13813 (Oct 3, 2019))
Executive Orders that may violate ACA law and patient protections, and that require very flexible administration of risk. Note effect on Medicare Supplemental reimbursements (or Original Medicare FFS) to hospitals and well known results. See Network Adequacy, PFFS, etc.

Medicare WCMSA
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is an agreement between Medicare and the Medicare beneficiary to take a portion of a Workers’ Compensation (WC) settlement and set those funds aside for all future work-injury-related medical expenses that are covered and would normally be paid by Medicare. The goal of creating a WCMSA is to set aside money from the settlement to cover those injury-related medical expenses for which Medicare may not make payment. Source: CMS

Medicare-Medicaid Coordination Office (MMCO)
See: Dual Eigibles
Medicare-Medicaid Coordination Office (MMCO)
Good luck.
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.
Mental Health / Substance Use Disorder (MH/SUD)
Mental Health Parity Addition Equity Act (MHPAEA 2008, Mental Health Parity)
See: Mental Health Parity and Addiction Equity Act of 2008, NQTL , CAA 202, NQTLs,Non-Quantitative Treatment Limitations Good luck

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. 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 ( i.e. Shared Services contracts) 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: CAHPS, QPP, APM

Metalic Plans
A CMS term used to describe four Marketplace plans types meeting Actuarial Value guidelines for coverage. I.e Bronze, Silver, Gold and Platenum whose benefits insure MLR at prescribed Actuarial Value customer out of pocket costs. Bronze pays the least, but the premium is lower too. See: Actuarial Value
Midwife (Doula)
Milliman Medical Index (MMI)
Milliman is a medical actuarial company estimating medical costs inflation of many things. i.e. Premiums, medical provider costs, etc. Milliman also publishes a subscription only underwriting manual used to rate premiums.
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 Aggregate Deductible
Typically means, the lowest possible Aggregate (stop loss) Deductible applicable to the Contract Period or fraction thereof. See: ASD, etc.
Minimum Essential Benefits (MEB)
The actuarial value percentage a QHP plan must pay of claims as defined by HHS MLR. See: QHP
Minimum Essential Coverage
See: QHP, PPACA law
Minimum Participation Rate (MPR)
The minimum percentage of eligible (FTE) employees counted and/or enrolling in major medical group insurance - typically defined as 75% of the group size. See Contribution requirements.=====In context to SHOP plans, MPR is 70%. Rates can differ by state.
Minimum Premium
A term used to describe the lowest premium amount a carrier feels justifies underwriting, administrative, profitability and risk charges or "loads". This can also mean a kind of level-funded medical plan pricing structure with or without profit sharing or "surplus" shararing. See: MVP and know the differences between fully-insured, self insured, ACA compliant EHB, etc.
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.
Ministry Health Plan (Medi-Share Plans)
An RBS medical product that is not (usually) insurance. A non-compliant QHP that is typically not insurance in most states. State law(s) determines if it is insurance. (See: PSO, COOP, risk bearing entities, Health Cost Share plans, RBS plans, etc.) Some of the early marketing efforts had people calling and detailing eligibility was contingent upon being a follower of Christ. Premium cost is typically 50%-60% less than ACA QHP, but is neither major medical insurance, nor discount plan.  Some states have specific classifications for "shared medical discounting association plans". Preexisting medical conditions are almost always excluded, along with limited benefits in key areas of EHB (i.e. surgical services, hospital charges, ER, Rx). These plans typically REIMBURSE the member up to a maximum limit RBP - typically a percentage of the Medicare Allowable that is typically well below the billed (non-discounted PPO contracted rate at about 240% of MA amount) "self pay, or Bad Debt" amount charged by many providers who do not accepting RBP.  Religious affiliation may not be a requirement but is usuall part of the marketing process for "ministry" plan sales.  See: Balance billing, RBP, Medicare Authorized charge, STM, Risk Bearing Entities, etc. There is no universally accepted definition for these plans. Successfully vetting sometimes ambiguous state law compliance can take a lawyer, politician. and insurance expert. Lower pricing for these plans comes with strings attached, and may not warrant effective ACA QHP (and APTC, etc) plan substitute. See: Healthcare Sharing (cost sharing) plans/associations.=================
Ministry Health Plan (Healthcare Cost sharing plans, Faith Based Pl)
An individual or group major medical plan that may not be insurance, or Discount plan, and is in fact a RBP "association" "reimbursement" plan. Assignment of benefits can cause unexpected "insurance" compliance issues. Be cautious. These plans operate in "sometimes" nebulous (or unenforced ACA prohibitions against) non-ACA compliant QHP coverage, rules and regulations. Several states have specific law affecting these less expensive plans. See: ACA QHP, EHB, Preventive Care, Actuarial Value, PreX prohibition, underwriting, community rating, etc. See: (companies): Trinity Healthshare, STM, Health Insurance Innovations, PIVOT, MEDEK, Reahlm health, One Source, etc.
MIPS Extreme and Uncontrollable Application (MIPS EUA QPP)
QPP guidelines can change each performance year.

Mission Toot hClause
A Dental Plan provision excluding dental implant insurance where the targeted site already has a missing tooth. Dental plan require studying limits, exclutions and waiting periods. Most dental INSURANCE (not discount plans) mandates a 1 year waiting period for extensive dental procedures like root canals, crowns and implants (where insured).
A numerical value calculated by NCCI to rate classes of employee risk for workers compensation premiums. The higher the number, the higher the premiums/risk. Values excess o 1.0 are considered greater risk, and are charged higher premiums. See: Distressed Risk.
Modified Duty Options
A term used when an injured worker returns to work at lesser ability function while in recovery, and typically accompaning an adjustment to his workers compensation dissibility income beneifit. The goal is to get the worker back to work and productive.
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.
Monoline Policy
A policy with essentially one coverage like liability, or just Commercial Auto, or just property. See: CPP
Monthly Income Protection
See: Term life insurance product option that pays death benefits in the form of a Monthly Income Protection benefits stream. Final Expense (for funeral costs) can be added as well for additional premium. This is not a annuity like product that guarantees a fixed percentage (See GMIB sometimes called an "income Roll- up percentage credited when the annuity owner elects forced annuitization) of the annuity total each year that the beneficiary uses as income that cannot be outlived. Life insurance policies can also be endorsed with LTC provision for extra premium too. Rules and premium charges governing these kinds of offerings from converted Term policies to Whole Life (or UL) policies vary amoung carriers.
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. Stop Loss reimbursements typically follow the lowest contracted rate competently paid by the administrator of the claim.
Most Favored Nations Clause (MFN (see report))
A contractual provision declaring the lowest amount paid, scheduled, or contracted for billed charges is accepted as full payment. In context to hospital bills, about twenty states have attempted to limit providers influence though banning these clauses. Source: "State Policies on Provider market Power Feb 2020" See: CON, price fixing, antitrust, reprice

Most Favored Nations Clause (MFN (see report))
A contractual provision declaring the lowest amount paid, scheduled, or contracted for billed charges is accepted as full payment. In context to hospital bills, about twenty states have attempted to limit providers influence though banning these clauses. Source: "State Policies on Provider market Power Feb 2020" See: CON, price fixing, antitrust, reprice

Motor Truck Cargo (MTC program)
A commercial (cargo) trucking insurance package plan.This coverage insures against the risks of direct physical loss to covered property while in transit, loading or unloading, and while at a terminal or dock awaiting final distribution. There are many types and special attention needs to be paid to ports and transportation through and in between covered service areas. See: BI
MSSP Track 1

Shared Risk CMS provider contract option that essentially allows medical providers to assume 4-8% of the contract (total Medicare A+B) budget savings on medicare contracts.

MSSP Track 3

See MSSP Track 1.    See MACRA

Multi Level Marketing (MLM)
See: FMO
Multi-factor Authentication (MFA)
A term that can mean many things, but mostly refers to at least two identity matching processes to confirm a log in, or access to account access, or PII. **** A term or system of follow-up by the insured to mitigate potential fraud. i.e. calling the customer back on a prearranged phone number to confirm the order, policy change, or funds transfer, texting a password change code, etc. It can be a kind of warranty expressed in the policy conditions, exclusions and definitions or sometimes as part of the application form. These can be very contentious. See theories of proximate cause. See first party, secondary party losses. Cee: CMS MFA multi systems access.

Multi-Factor Authorization (MFA)
A security process of sending ID identifiers to multiple devices. I.e. texting a security code to input into a log in site before accessing the log in credintials.
Multip State Plan (MSP)
See: Presidential Orders, and / or certain types of plans offered in specific states in compliance with ACA, state law, and federal law... Its get complicated...
Multiple Chronic Conditions (MCC)
Multiple Employer Plan (MEP)
See: MEWA, Open MEP, closed MEP, Common Interests, ARP (essentially a MEP)
Multiple Employer Welfare Association (MEWA)
A MEWA is a Multiple Employer Welfare Association. It is a federally protected class of health plan organized to provide health insurance to multiple employers not organized under the same federal tax ID. It is regulated by DOL, and by it's Employee Benefits Security Administration (EBSA) - under ERISA legislation that allows employers to take financial (medical) risk on their own employees in context to applied stop loss coverages, aggregate and/or specific. ERISA applies to any self funded plan such as General Liability and/or self funded workers compensation. ERISA provides various exemptions from state insurance regulation. Practically speaking, most states despise MEWA’s (and MEPs), and will challenge them regardless of ERISA federal superseding exemption from state insurance solvency and licensing regulations. The grey area is where some states prohibit plans without Certificates of Authority, and federal law(s) allow them accross state boarders. Of the protected classes ERISA legislation governs: (Associations, Trusts, Self funded Employers and Unions), MEWAs are rare, and so are MEPs. (See: Trum Executive Order allowing MEPs accross state lines which is nothing innovative) The over-reaching purpose of self funding any of these organizations is to reduce insurance costs by assuming a higher deductible (risk), and hoping for average medical claims being lower than the (trended) "fully-insured" (higher priced) plan. Two primary types of stop loss are purchased by the Plan Sponsor (employer) to mitigate unexpected catastrophic claims. Self funded MEWAs can offer multiple employers a group medical plan structure to command greater buying power, and even risk management functions worthy of serious consideration. But, where each "member employer" is small in number of employees, MEWA's may not be capitalized (up front) to sustain unexpected (specific and aggregated) losses by their "association" - which is one reason states dislike undercapitalized MEWA’s. Participating employers may not fully appriciate group's evolving riskk(s), so experienced brokerage-consulting is advisable, if not essential. ERISA details high levels of potential liability for Plan Sponsors, Employers, etc. Additional financial risk-taking is part of any self funded plan. A Fully Insured Health Plan MEWA may, or may not be federally required to possess a state issued Certificate of Authority of stipulated "transfer" (or direct reinsurance pass through) and/or transparency. Most states mandate it. There are a couple of key reinsurance/stop loss provisions that satisfy State DOI requirements for Certificates of Authority. There is long history of states aggressively moving to eliminate MEWA's not meeting state solvency and transparency standards compliance, regardless of federal ERISA supersession. Material legal assistance is required to set these up and maintain them successfully within state guidelines, despite ERISA exemption. Prudent management of any ERISA self funded plan mandates purchase of stop loss, and / or fund predictable first and second dollar risk positions. Structuring reinsurance (or stop loss) placement takes real experience, and carrier appetite to insure sustainable committment and tenure. ERISA plans enjoy greater flexibility of benefits to employees in context to SPD. Presidential Executive Orders, and DOL agency non-enforcement of ACA law agenda cloud compliance consideration(s). We strongly recommend licensed-seasoned stop loss and legal advice to anyone considering MEWA, or AHP plan offerings. Most recently, DOL is considering letting (authorized) carriers offer MEP's to small employers. Few carriers will offer competing plans that compete with existing fully insured (low deductible) plans. Almost all major carriers offer "Level-Funded, or Minimum premium plans" targeting small and mid sized groups, and offer "contingent" bonus for lower than expected medical claims experience over a 12-15 month period. These plans typically have very low deductibles that typically fail to make cost savings versus maximum premium savings versus risk assumption trade-off financially attractive. This blog is offered as a courtesy, and is not tax, legal, or accounting advice.

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.
Musculoskeletal Disorders (MSD's)
A term typically used in context to a workers compensation claim or injury, and that are reported to be about 1/6th of all US health care spending... "The annual cost of musculoskeletal disorders (including health care costs and lost worker productivity) is around $600 billion, which is greater than heart disease ($309 billion), cancer ($243 billion) and diabetes ($188 billion)." Source Risk & Insurance article "This Employer Reduced MSD's by 86%. 7/27/22


N0-Fault (PIP)
A term typically related to statutorily mandated auto insurance that pays the medical or property damage expenses caused by a car accident without assigning fault. It does not insure collision, comprehensive damages, or liability. PIP limits are statutorily assigned at $10,000 per person and $20,000 per accident.
National Association of ACOs (NAACOS)
National Association of Independent Life Brokerage Agencies (NAILBA)
National Association of Insurance and Financial Advisors (NAIFA)
One of many associations for insurance and financial professionals.
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 workers compensation employee Class Codes, and rules, and that set individual employer (class codes) MOD factor that determines cost of workers compensation rates for employer. NCCI recently reported that hospital mergers (oligopolies) result in average price increases of 6-18%. See below "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 use 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) "By NCCI Insights July 11, 2018 KEY TAKEAWAYS Healthcare consolidation improves integration of care and reduces duplication of clinical services. Hospital mergers can lead to operating cost reductions for acquired hospitals of 15%−30%. Reductions in hospital operating costs do not translate into price decreases. Research to date shows that hospital mergers increase the average price of hospital services by 6%−18%. For Medicare, hospital concentration increases costs by increasing the quantity of care rather than the price of care. In addition to mergers, hospitals are also buying up provider practices. Between 2015 and 2016, hospitals acquired 5,000 physician practices. For workers compensation, hospital consolidation is likely to affect both the quantity and price of medical services. Forthcoming NCCI research will investigate the effect of hospital consolidation on prices and utilization of medical services in workers compensation. The Impact of Hospital Consolidation on Medical Costs The year 2017 was a record one for merger and acquisition activity among hospitals and health systems, and this momentum is staying strong in 2018. This Drill Down describes the wave of hospital consolidation since 2010, identifies observed effects of hospital consolidation on utilization and prices of healthcare services, and discusses NCCI’s research in progress on the impact of hospital consolidation in workers compensation insurance. " Source: NCCI
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 Drug Codes (NDC)
Pharmacy billing codes
National Emphasis Program (NEP)

National Flood Insurance Policy (NFIP)
National Healthcare Policy
The link is for CMS's Medicaid and Medicare, but it leads what becomes policy for commercial carrier reimbursements and managed care ... See: QPP, VBR

National Insurance Producer Registry (NIPR)
The Federal agency that assigns a six digit ID national number for each licensed insurance agency.
National Practioner Data Bank (NPDB)
Medical provider data bank tracking histories of medical provider performance. Exactly how this interfaces with MACRA is not known. See: Healthcare integrity Protection Data Bank.
National Producer Insurance Registry (NIPR)
The federal agency that assigns already licensed agents (in their domiciled state) a 6 digit number called the National Producer Number.
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
NavigateNOW (UnitedHealthcare NavigateNOW)
United's Level Funded agent/employer on-line administrative portal. "Introducing NavigateNOW Introducing UnitedHealthcare NavigateNOW, a level funded health plan offering for new business (5-300) in select Florida counties with June 1, case effective dates. NavigateNOW is a new virtual first health plan that offers a single, digital entry point to medical, behavioral, and pharmaceutical services that begin virtually and move to in-person when necessary. You can begin to quote NavigateNOW plans today. About NavigateNOW NavigateNOW was created to be a part of your clients’ overall health plan offerings and must be paired with a standard UnitedHealthcare Level Funded health plan. • Designed for convenience, and affordability, NavigateNOW offers quicker access to care with online scheduling and same day appointments. On average, NavigateNOW is 15% lower cost than a UnitedHealthcare Level Funded Choice Plus plan1. • With NavigateNOW, care begins with the member’s virtual primary care provider (PCP) and connects to other care providers, such as behavioral health specialists, at the touch of a button. The virtual PCP is supported by a personal Care Team that helps coordinate other services that may be needed, including in-person care with local providers that are in UnitedHealthcare’s broad Navigate Network. The Virtual Care Team is comprised of clinical and non-clinical staff, can be accessed 24/7, and provides white glove service to member’s care needs. • All NavigateNOW plans have $0 copays for primary care visits, behavioral health visits, virtual visits for urgent care, and Tier 1 prescriptions" Source United Healthcare agent advisory
Navigation Services
See: RBP in context to contracts held directly by carriers, hospitals, employers versus by venders offering their networks. I.e. Claims handling services, pricing models (DRG, case rate, FFS, bundled payment, gain-sharing agreements, risk based, capitation, VBP, quality metrics, provider access, outcomes, EBM, etc) See: Healthcare Advocate
Navigator (Certified Application Counselers, Assistors)
A CMS term for an unlicensed person who helps a person enroll in a Marketplace offered health plan, and who is typically employed for 45 days of the year (during OEP), and unable to be called directly by any of the people they enroll. These temporary employees will not divulge their location, last name, or call back number where they can be reached. No one seems to know if an Assistor is certified with an exam passing (like agents are required) to handle PII, and all the complicated highly regulated confidentiality and security agreements (and exams) mandated by the same entity making mandated for licensed agents. === Good luck! Organizations (private for profit companies) that are approved by and receive grants from the Marketplace have certified Navigators who, among other things, assist consumers in applying for and enrolling in health coverage through the Marketplace." Navigators are prohibited from commissioning on health plans sales, but we can tell if they commission on the Dental plan sale? "Health insurance and stop loss insurance issuers and their subsidiaries are expressly prohibited from being Navigators." Source: Marketplace Exam See: 45 CFR 155.227, Non Exchange Entity, Agents, Brokers, web-Brokers, and OEID - Other Entity Identifier as Enumeration System identifies them in 45 CFR 162.508. (and call your lawyer to explain it)
Navigator Notice of Funding Opportunity (NOFO)
$80 Million funding to help distribute Marketplace individual and SHOP plans. See: Navigator, and know that most are unemployed after 45 days of Open Enrollment, and none will give their last name, the supervisors last name, or a direct contract number for any accountability.
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 Marketplace Plans
Federal and or State defined minimum standard for QHP eligibility. 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 that is sufficient in 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 provider whose contract is being discontinued 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 Standards for network adequacy and essential community providers may differ in SBM-FP states. Source Marketplace Exams

Never Events
Jargon used by hospitals and physicians describing avoidable events like amputating the wrong arm, or removing the wrong eye, and /or unreasonable hospital acquired infection "rates", etc. The stuff no one wants to own or be responsible for...
New Engliand Journal of Medicine (NEJM)
Like JAMA, a leading journal of science based medical review and effect.
Next Generation ACO (NGACO)
The Next Generation ACO Model created by CMS consists of 44 NEXT GENERATION ACO's. Total ACO's (Jan 2019) is 561. ACO's are CMS's attempt to get medical providers to take financial risk for fair budget deficits caring for Medicare members. 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 a percentage of the "Shared Savings" budget. The program started with "Pioneer ACOs". Next Generation ACO (44 ACO's) accept "Shared Risk" contracts for Medicare members, and share 50% of the savings, - with some also sharing up to 100% of losses (deficit from the shared services budget). Regular ACO's share roughly 40% of the savings and under the January 2019 CMS "Pathways to Success" (directed at rural practices) mandate about 40%-100% (shared services budget) risk be accepted within one, two or three years.
Next-Generation Risk Adjustment Methodology that includes a zero-sum coding intensity adjustment to ensure there are no increases in payments triggered solely by coding intensity.

No Surprises Act Final Rules
An act that prohibits additional charges from out of network (non contracted) providers to the patient for services rendered in the patient's in network (contracted) facility. Common provider conflicts typically occur with ER physicians, radiolotists, ambulance companies, pathology (labs from the ER). One component that portends difficulties to plans, and Plan Sponsors is that the act does not specifically limit an unreasonable charge to a common standard like (a percentage of) the Medical Allowable amount to R&C, or even the commonly accepted amount paid to providers in a specific zip code.

Non Abusive Business Practices
See: Final Rules Value Based contracting in context to Stark and CMS safe harbour.
Non Exchange Entity
See 45 CFR 155.26(b), including but not limited to Navigators, Agents, Brokers, and Web-brokers. See: IMO, FMO, etc.
Non Group Health Plan (NGHP)
See: MSP for subrogation, MMSEA rules. "Information and instructions for the Medicare Secondary Payer (MSP) Non-Group Health Plan (NGHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide). The NGHP User Guide is your primary source for Section 111 reporting requirements." Source : CMS, MSP, RRE

Non Public Personal Information (NPPI)
See: HIPPA, and PI
Non Qualified Limitations (NQTL)
See: Mental Heatlh Parity. Relates to mental health benefits and procurement of services not be different then QHP mandated ACA benefits.
Non Quantitative Treatment Limitation analysis (NQTLs)
Federal structure to determine if mental health parity is met. Plan Sponsors have to show their work when proving they accurately and properly reduced coverage using non-numerical limits on the scope or duration of benefits for treatment of mental health beginning 2/1/21, and presumably other insured benefits. See: CAA, MHOAE, Mental Health Parity Act. See: SIIA
Non Renewal
In context to insurance policies, it is notice from the carrier of not offering a renewal offer. Lots of rules apply.
Non-Effectuated Enrollee
A Marketplace enrolled customer who has not paid the premium by deadline. Molina uses the term.
Non-Group Health Plan (NGHP)
See: Medicare BCRC, RAR, CMS, MBI, RREs See: CMS - Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Recovery Town Hall Questions and Answers and Commercial Repayment Center (CRC) Group Health Plan (GHP) Recovery Town Hall Questions and Answers Overview

Non-Quantifiable Treatment Limitations Reporting (NQTL)
See: CAA 2021, MHPAEA 2008, and new reporting requirements especially for MHPAEA.
Non-Quantitative Treatment Limitations (NQTLs) (NQTLs)
See: regulations
A legal term defining the amount of time an entity has to notify an assigned recipient of such notice. In context to ARP, it means an employer must notify their x employee of expiring federal premim payment assistance for covering COBRA (medical benefits extention for up to 18 months) within 60 days of that person becoming eligible for such support, and or when premium assistance will expire. For health plans, their notice of expiring federal payments of the x employees "notice of expiring benefits" (COBRA medical benefits federal subsodie) must be at least 60 days from the date benefits end. These rules are different for QSEHRA, FSA, Medicare eligibility, or if the x employee is eligible for another group medical plan, etc. Find an experienced agent. ending September 2021, eligible Medicaid, and Marketplace people are NOT eligible for COBRA subsodie, whereas people eligible for Medicare, traditional Group coverage (employer plan) or Group coverage through a spouses plan are eligible.
Nursing Home Quality Measures (NHQM)
See related measures 16 Quality Measures


Occam's Razor
The principle of minimizing assumptions when explaining cause of effect. Or, The principle guiding the simplest explanation with least amount of assumptions is the best explanation of cause and effect. See Hanlon's Razor, and Ad Abcertum
Occupationtional Safety and Health Administration (OSHA)
A federal agency charged with overseeing safe employee working conditions. Very important for employers to manage these regulations and avoid penalties. 2021 OSHA mandates testing and or vaccinations for employers with over 100 employees, now that the FDA approved the vaccine, and to protect the greater population from C19 death. Biden characterizes as an epidemic of the unvaccinated.... Supreme court overturned the mandate, and OSHA responded. "Regardless of the ultimate outcome of these proceedings, OSHA will do everything in its existing authority to hole business accountable for protecting workers, including under the COVID-19 National Emphasis Program and General Duty Clause." Means, be prepared to defend themselves on any harm inflicted on employees deemed negligent by current and future administrations, so probably safe to practice prudence. See: ERISA fiduciary duty of plan sponsors and cross potential application of meeting even one of the standards.

A coverage for losses incurred within the policy period, and reported during or after the policy period. Occurance coverage can be substantially more expensive than Claims Made coverage. Claims Made coverage insures claims incurred and reported within the policy period. Occurrence can mean different things, in different policies. I.e. Professional Liability versus Builders Risk policies. See: Claims Made coverage
Occurrence Limit of Liability (OLLE)
"Occurrence Limit of Liability SS (OLLE) Scheduled Limits SS Blanket coverage for first-party property insurance risks has become increasingly difficult to secure and often is not available regardless of price. SS Please note that your quote may not provide coverage on a blanket basis and, based on current market conditions, a blanket coverage option might not be available. Any reference(s) to an Occurrence Limit of Liability Endorsement (OLLE), margin clause, maximum amount payable, and/or scheduled limits indicate that blanket coverage is not provided. Instead, the amount of recovery afforded by the policy is limited in some respect to the amount(s) set forth on the Statement of Values (SOV) provided to the insurer. This potentially can materially reduce the insured’s recovery in the event of a loss as compared to blanket coverage. Additionally, the policy language for these clauses may vary by insurer and some insurers limit the amount recoverable for extensions of coverage, additional coverages, and additional covered property to the values as shown on the SOV (statement of values)." Source: Scottsdale GL - Property policy. See: Occurrence, Claims Made policy forms, and various provision affecting bound coverages.
A mandated ACA (including ERISA plans) fee ($2.54 2020) extended through 2029 used by HHS to figure out efficacy of treatment.
Of Cycle Termination
A term some carriers use on (group) Level Funded plan terminations meaning a minimum of 30 days notice is required to cancel the plan outside of Open Enrollment.
Off Set
The amount a carrier can reduce a paid claim - calculated by the amount of premiums by and insured. The claim is "off-set" (reduced) by the premiums due.
Office of Burden Reduction & Health Informatics (OBRHI)
CMS rules designed to lift some of the burden from medical providers treating Medicare patients. May also apply to Tricare and or Medicaid members. "Final rule gives providers access to patient treatment histories, and streamlines prior authorization to improve patient experience and alleviate burden for health care providers Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care. “Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.” The “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly. Today’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking. Prior Authorization Burden Reduction Payers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner. The final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically. The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems. The final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024. In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike. The rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly. Today’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care. The final rule is available to review today at:" Source: CMS See: Final rule.
Office of Insurance Regulation (OIR)
What Florida calls the Department of Financial Services, which administers insurance regulations. Florida Auditors come from the OIR.
Office of Minority Health (OMH)
A CMS agency designated to primarily help people over 65 understand insruance, access and timely care.

Office of the National Coordinator (ONC)
See: MACRA, CMS, QPP, CMMI, and good luck!
Office of the National Coordinator for Health Information Technology (ONC)
A federal office whose purpose is to refine data collection and disbursement into more effective public information delivery. See: CMMI
Office of the National Coordinator of Health IT (ONC)
Federal Office charged with making (mostly medical data) information available and meaningful to consumers. See HIPPA, MACRA, VBP, RBP, etc.
Omnibus Claus
Liability insured in a BAP policy insuring against losses caused by "the conduct of an insured—includes any person or organization not otherwise included or excluded by the first two categories of insureds, to the extent this third category of insureds is vicariously or statutorily liable for another insured’s conduct." Source CE exam CGL material 2021
On line Service Center (OSC)
See: FMO, TPA, etc
On-site Clinics
A concept effectuated several ways by some carrier like Blue Cross, but mostly meaning by Employers with an on site nurse or even a doctor. The goal is to reduce medical fragmentation by earlier intervention and treatment of conditions that avoid hospital admissions, Classic programs include: preventive and acute care, chronic disease management, and on-site medication dispensing.
Onboarding (Account Installation)
A loose term for enrolling people in a policy, or efficiently orienting a client with required reporting, and premium payments. Its also a term used to convey established (or absent) account installment requirements or events fostering account retention and management. Larger policies involving premium/claims reconciliations and/or interdepartmental reporting typically have more well defined installation procedures.
Onsite Mitigation Project Management (OPM)
A property insurance term used to describe then carriers (themselves) or by subcontrated specialist put a loss mitigation specialist (i.e. ServPro) on site to remediate the loss, or determine scale and risk management. The goal is to lower overal costs, and get the insured back to business faster after a major property loss.
Open Access
A term that typically means being able to see a specialist physician without referral from a primary care physician. It can also be a term used to describe insuance coverage of non contracted medical providers. Plans requiring referral from a primary care provider to access specialty care are called Gatekeeper plans. Open Access refers to plans that typically do not require PCP referral for SCP appointment scheduling. OA also refer to plans having no PPO network, and insure charges from licensed providers delivering accident/sickness care. See: R&C or Referenced based pricing. It's important to ask the balance billing questions before receiving care to avoid unpleasant and unexpected large balance billing issues. See STM plans, Balance billing, RBP, etc.
Open Enrollment Final Rule

Open Enrollment Period (OEP)
See: ARPA, and Biden special EO or directives that modify OEP Enrollment periods for Federal Marketplace plans available to INDIVIDUALs and SMALL GROUPS (SHOP), Employer Open Enrollment periods, Medicare Open Enrollment periods for Medicare Advantage and/or Medicare Supplemental plans. Marketplace OE is typically November 1st through December 15th, but many times get extended with various rules, and exceptions. Medicare OEP are not the same. SHOP OAP may be the same as Marketplace individual OAP. Employer Open enrollment periods are not the same. Employer Open Enrollment means that employees can elect to become enrolled/insured, (and/or elect additional voluntary benefits) within a specified 30 day period prior to renewing plan start (and old plan expiration as applicable See: Virgin Groups) Lots of rules governing guarantee issue coverages apply. Employer new plans do not have a open enrollment period. One life Employer groups have a separate annual 30 day OEP period, but rates for those proprietors are very high do to adverse selection (but, coverae is guarantee issue). See: Special Enrollment periods
Open MEP
AN open multiple employer plan typically refers to a 401 (retirement) plan offered among multiple employers that typically have a common interest and/or business purpose function. Latest efforts are to get DOL to eliminate existing requirements allowing companies that want to manage and profit from the administration of them a bigger market.
Open Payments (Federal) ( Dollars for Docs)
A term used in reference to ACA reporting mandate (where enforced by HHS) of payments to medical providers for using or advocating use of brand name drugs and medical devices. According to ProPublica, from 2014-2018, drug and medical device companies paid providers over $2 BILLION. Source: ProPublica

Open Risks Policy
In context of Property (land, buildings, Contents, etc.) it refers to a high coverage policy were general practices (and in states that have specific laws directing property policies, especially Homeowners policies) and standards cause any hazard or peril not specifically Excluded or limited to be insured. Most AOP (All other Perils coverages are Open Risks Policies. For example, in Florida windstorm is many times insured under separate HO3 coverage/policy, while AOP applies to losses that are no caused by Wind/Hail/Hurricanes. See: Your state's laws.
Opiod Treatment Providers (OPT)
The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) is pleased to announce the following update: • Training Opportunity: Supporting Individuals with Intellectual and Developmental Disabilities (I/DD) as they Age • Draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) for Public Comment • Tip Sheet on State Coverage of Medicare Part B Deductible for Dually Eligible Patients • Third Annual Report of the Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform Training Opportunity: Supporting Individuals with Intellectual and Developmental Disabilities (I/DD) as they Age Date/Time: Wednesday, December 18, 2019, 12:30 PM to 1:45 PM (EST) This interactive webinar will discuss strategies for providing care to dually eligible individuals with I/DD across the lifespan. Participants will learn about the physical, cognitive, and behavioral changes typical of the aging process, and how these changes may manifest for someone with I/DD. Speakers will share key supports families, health plans, providers and individuals with I/DD may need to manage these types of changes across the life span, as well as describe an integrated approach for responding to the needs of individuals with I/DD as they age Register at: Intended Audience: This webinar is intended for a wide range of stakeholders – health plan leaders, primary care providers, social workers, care coordinators, case managers, caregivers, and organizations that provide services for dually eligible beneficiaries with I/DD. Education Credits: Please see the registration link above for detailed information on continuing education opportunities with this training. Draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) for Public Comment On December 13, 2019, the Centers for Medicare & Medicaid Services (CMS) released a draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) to states and other stakeholders for review and comment. The draft manual updates information and instructions to states on federal policy, operations, and systems concerning the payment of Medicare Parts A and B premiums (or buy-in) for individuals dually eligible for Medicare and Medicaid. States pay Medicare Part B premiums each month for over 10 million individuals and Part A premium for over 700,000 individuals. This process promotes access to Medicare coverage for low-income older adults and people with disabilities, and it helps states ensure that Medicare pays primary to Medicaid for its dually eligible beneficiaries. Despite the importance of this process, federal guidance on buy-in is out of date. The draft manual reflects current statute, regulation, operations, and systems changes that have evolved over time. Additionally, the draft manual re-organizes content to make it easier for states to discern federal requirements and find information. The draft manual is available at: We are welcoming comments through 5:00 p.m. EST on February 29, 2020. Read the New Tip Sheet on State Coverage of Medicare Part B Deductible for Dually Eligible Patients The Medicare Part B annual deductible applies to opioid use disorder treatment services. For the majority of individuals dually eligible for Medicaid and Medicare, state Medicaid agencies are liable for the Medicare Part B deductible, subject to certain limits. The new Tip Sheet for Opioid Treatment Program (OTP) Providers Serving Dually Eligible Individuals: State Coverage of the Medicare Part B Deductible gives an introduction to the Part B deductible and how OTPs can get Medicaid payment for this deductible when treating dually eligible individuals. It also gives information about enrolling in Medicare and Medicaid, the Medicare claims crossover process, and how to find additional information.

Organization for COmmunity Assisted Health Plans (ACAP)
An organization striving to level descrepencies in healthcare access to various underserved populations.

Orphaned Drug (Specialty Drug)
"Drug makers have built a lucrative business around drugs developed to treat rare diseases, according to an AHIP study that found prices for orphan drugs are 25 times higher than prices for traditional drugs. Average annual orphan drug prices increased from $7,136 in 1997 to $186,758 in 2017, 88% of them cost more than $10,000 per patient each year, and drug makers are increasingly focused on rare diseases." AHIP update September 2019) Specialty Drug is a super expensive "Brand" name drug that is either not insured, or insured in a 4th or 5th tier at very high out of pocket costs to the insured. This area of insurance can be highly contentious.
Other Entity Identifier (OEID)
See: Navigator
Out of Network (OON)
A term used for medical claims billed from non-contracted (HMO/PPO/ EPO/etc.), network providers, subject to a higher deductible, co insurance, and maximum out-of- pocket patient claims liability. ACA does not limit OON patient liability. Very contentious issue(s).
Out of Pocket (costs) (OOP)
Out of pocket typically refers to direct customer paid costs at time of service consisting of: Deductibles, Co insurance, Copays each plan defines as insured (eligible). See: MOOP Balance Billing Note: Link relates to Group OOP, not Individual OOP. 2022 MOOP is $8,700 (single) and $17,400 Family

Out Patient Professional Services (Medicare reimbursement for OPPS)
A term used to represent the contentious area of HHS 2019 decision to lower off-campus out patient services on Medicare patients. AHA lost, then won, then lost on appeal and is asking the supreem court to decide it.
Outbreak Period
In context to federal extensions of periods in response to Covid 19. See: Open Enrollment, Special Enrollment, COBRA enrollment, premium extensions. Make sure SPD matches up for active risk management. Not same for benefit payments.
Outcomes Based Agreements (OBA's)
A term typically used to denote a medical condition falling outside of the standard DRG (reimbursement) because of co-morbidities, and that affords increased reimbursement. DRG have "modifiers" or codes that allow for more reimbursements on sicker patients. Outliers refer to all types of populations and "insurance" conditions.

Outpatient Prospective Payment System (OOPS)
See: Price Transparancy. One of two Trump HHS rules forcing hospitals to divulge secret rates they charge different insurers or patients. A "separate" "final rule" termed, 2020 OOPS & Ambulatory Surgical Center (ASC) Price Transparency Requirement for Hospital to Make Standard Charges Public Final Rule confirmed that HHS will move forward to publish publicly facing ("machine readable" - whatever that means?) "best prices" they contract with their insurers. Be sure this will cause major league problems for hospitals who routinely charge 200%-100% more for the same procedure to a person over 65 as a person under 65. Even more difficult is calculating accurate MOOP, which is a requirement of one of the rules. Hospitals will need to comply by 1/1/21. Source: Revcycle Intelligence. See Shared Savings, and MLR, and bring aspirin.

Outpatient Quality Reporting (OQR)
See: Hospital Quality Reporting, Prospective Payment
Over the Counter (OTC)
A term typically referencing Rx available without prescription. More recently, relates to reduction of ER visits caused by over the counter care benefits available by Urgent care, and various "company" sponsored nursing services designed to triage simple and complex (high/low cost) medical events.
Overloan Provision
Prevents an outstanding policy loan from terminating life insurance policy, even if the accumulation value is insufficient to cover policy charges. There is no charge for this agreement until exercised. Remember, IRS compliant Life insurance policies allow for loans against AV ( not cash value) that are not taxed as income. Most people fail to appreciate how paying 25%-35% of investment gains radically effective returns in the 10-40 years of investment term (and paying the about 1% financial management fee). Its big! Do the numbers, and look at carrying income tax liability (i.e. 25%), and market-crash risk in old age - against contractually promised interest crediting (i.e. from 0% - 17% blended index). See: IUL
A term generally considered to be a type of claims denial (amount).


Paid Time Off (PTO)
Paid Up Additions (PUA)
A permanent life (whole life, or UL) insurance policy premium deposit account used to pay a lump sum (premium deposit) into, but apply premiums from it into a life insurance policy, in compliance with (two) IRS compliance tests, thereby avoiding a life insurance policy (loan distributions) converting to a (income taxable) MEC. PUA accounts pay guaranteed fixed-interest on remaining funds as they get applied each month into the policy. Some carriers use different terms like, Paid up insurance, or Account A (holding account) and Account B (Policy cash value or accumulation value). Super leverage is available when distributing pension "Loans" using cash value as collateral, but without reducing cash value (used as collateral to any loan) that then gets credited contractually promised interest 0% to the cap, and with the IRS compliant loan offering tax preferred advantage. (If it converts to MEC, Growth gets taxed as income in the year it is spent.) Note: Cash value is not reduced by loans or loan interest. We advise double checking facts with an experienced agent, and accountant specializing in tax. See: GMP rule, Account A olicy crediting explanations, etc. Similar to fixed annuities, PUI is held by the carrier outside of the policy until such time as it is applied into the policy following two IRS MEC tests. Carriers use these set-ups to simplify life insurance premium payments for clients who want to make one large up-front premium payment, and keep the tax preferred features, including planned pension loan distributions for maximum leverage (growth), but without stock market crash risk. We recommend speaking with an experienced agent.
Pallative Care (Costodial or Hospice care)
Its estimated that 4% of the Medicare population (age over 65) accounts for 25% of the entire Mecicare spending budget.  Many advocates for reducing these costs recommend end of life planning BEFORE people are at the end of life.  Other estimates put the estimate of LIFETIME costs of medical care being 80% incurred in the last weeks or months of life. Herein lies a delicate balance of merging a multidiciplanary approach to "end-of-life" counseling patients to seek, or not seek heroic (expensive) medical care measures (like resussitation of a person whose brain is no longer functioning, or living wills, etc.), where physicial/mental recovery is unlikely, and further care causes even more pain and suffering to themselves, and their familys.    Waiting until the patient is too sick to render competent decision to refuse care without a sighed living Will typically means that hospitals will MANDATE all heroic medical care - even contrary to family members demanding care be terminated.  See: Living wills, and Advance Directives. Be responsible for making these decisions, or force the burden upon your children at an extreme time of sadness. Do the work.    (From Article) "As stakeholders call for a dedicated Medicare benefit for the growing field of community-based palliative care, one government-led payment model is going strong in California through Medi-Cal, the state’s Medicaid program. Effective Jan. 2018, the state’s Senate Bill 1004 (SB 1004), requires Medi-Cal managed care plans to cover palliative care for patients suffering from cancer, end-stage liver disease, chronic obstructive pulmonary disease, or congestive heart failure. Patients may continue curative treatments while receiving palliative care." According to the article, only California Medicaid covers hospice care. Source: Hospice News - Dec 2019

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.
Paremetric Insurance
A term describing types of catastrophic coverage triggered by complex causes of loss. See: Proximate causes of loss. These polices make it easier to claim insured losses caused by wide ranging causes (earthquake, floods, your critical commodity supply ship sinking, etc) that may not be directly defined in a policy. See BI in GL, etc.
Participating (Contracted)
A term generally referred to as a contracted medical provider who has elected to accept as full payment what the contract says, and not what they may decide to charge at the time of service. See; Balance Billing, RBP.
Participating Provider (In network provider)
Contracted Provider, PPO/HMO network provider of medical services, supplies or hospital care. See: OON Members receiving care from contracted providers are protected from unlimited out of pocket costs, whereas care from non-contracted providers affords no limit to OOP under ACA. (where the feds enforce it...)
Participating Provider
A term first used to define a Medicare contracted physician or hospital who accepts as full payment the Medicare Authorized amount. It now includes any contracted medical provider who accepts the contracted rate.
A group medical insurance term expressing the minimum percentage (50% - 70%) of qualifed employees required to quality for a QHP. Different participation rates apply to different kinds of group (employer) plans. Individual and group plan rules are not the same. See: underwriting quidelines See: Simultaneous Contribution rules. See: SHOP. It can be confusing, especially with what qualifies for QHP. Talk to an experienced agent,
Participation (MPR or minimum participation rate)
A term that means several things: 1. A contracted medical provider considered "in-network", 2. A Medicare contracted provider 3. The minimum percentage (i.e. 75%) of employees who must elect major medical coverage to qualify for a "group" major medical plan. This gets a bit complicated. See: Contribution FFM has a MPR calculator to help with Marketplace offered SHOP plans
Pathways to Success
See: Next Generation ACO
Patient Activation Measure (PAM)
A term used to describe a method of gathering more individual medical history to augment better care.
Patient Assistance Program (PAP)
Term used to describe a direct from manufacturer copay card that actually makes the patient choose the more expensive drug. See: Specialty Drug
Patient Centered Medical Home (PCMH)
A term used to describe a primary care physician lead team approach that coordinates Specialist care to achieve preferred EBM outcome. See: CMO, Episode Based Care (EBC), and Clinical Integrated Networks (CINs).
Patient Centered Outcomes Research (PCQOR)
Patient Centered Outcomes Research The Patient-Centered Outcomes Research Institute (PCORI) fee is $2.39 per covered life for 2018. Self-funded employers are responsible for paying the fee.

Patient Protection and Affordable Care Act (ACA / Affordable Care Act / Obama Care)
The Patient Protection Affordable Care Act, or the Affordable Care Act/ACA/PPACA, or Obama Care is the law of the land. The ACA (Affordable Care Act) is a 800+ 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: QHP (Qualified Health Plans meeting minimum essential Health benefits) 10 unlimited Essential Healthcare Benefits (EHB, tax credits for individuals earning between 100% - 400% of Federal Poverty Level (FPL) (up to and now beyond 9.83% FPL under Binden), and Cost Sharing for people earning between 100%-250% FPL. Cost sharing reductions  (CSR) lower deductibles and max-out-of-pocket member costs, thereby limiting total annual Individual or SHOP enrollee's health spend from (about) 2% - 8.5% AGI/MAGI, and for "INDIVIDUALS" earning under 400%+ FPL.   HR1 (Tax Reform law) was passed December 2017, and eliminates the Individual ACA law penalty mandate (2.5% tax penalty), effective plan year 2019.  ACA law is not repealed, but for the Individual penalties for not being insured with AHP coverage. Medicaid eligibility is expanded to 138% of FPL. Small employers (see: ALE - under 50 ee) (for profit gets 50% tax credit, and Not for Profits get 35% tax credit). Marketplace offered SHOP plan availability is mostly unavailable (not offered by commercial carriers) in most states. As a rule the SHOP program has failed (still none offered in Florida), and few plans are even offered anywhere by carriers, but for a small number of states.  (There is very long history of carriers doing everything legal to not write groups under 4 lives - like paying commissions of $0 to $3.50/ee (FL) to the agents, etc, and/or not hiring staff to process applications by deadline.) See; ACA final Rules, MLR, APTC, OEP, SEP, CSR, QHP, SHOP, reinsurance, ACA final rules, etc. See: article Trumping Healthcare Reform

Patient Reported Outcome Performance Measure (PRO-PM)
Fargeon used to describe a risk bearing provider group contract with an authorized insurer. See: IDS
Paycheck Protection Program (PPP)
A COVID federal loan program to small businesses whose liability gets forgiven under certain quidelines.

Payor Provider Relations Coordinator (PRC)
A value based reimbursement (personnel assignment) title, who is responsible for population based and individual based data analysis, and whose goal is to reduce ED visits, and lower costs. They may be part of the patient contact team to bring in unstable chronic co-morbitity cases sooner to avoid expensive hospital care. The PRC deelops best practices and provider implementation and use protocols. In short, it means bringing care to the patient, not waiting for the patient to come in with the very expensive problem. No, dont shoot the messenger - I did not say house calls - but, we all know that community health centers, and company-nurse programs save major money.
PDM (Periodic Data Matching )
See Advance Payment Tax Credit
A term that can mean many things. In context to Covid19 401 plan disbursements, it means DOL has approved penalty free 401 disbursements in private-equity funds and investments heretofore considered more risky than public ETF's etc.
PEO Guidelines (NAIC 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 maximums stated in the policy, and / or "statutorily" guided.
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 Employee Per Month (PEPM)
Per Employee Per Year (PEPY)
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.
Performance Year (PY)
A term CMMI uses in Direct Contracting indicating surplus or deficit from year 1, or "PY1", year 2, or "PY2", etc These contracting option include non risk, and risk based where "Participants" (providers) choosing capitation (etc), participate in surplus or deficit year end reconciliation against a FFS services charged in excess to the capitation. Its complicated. See: Direct Contracting
Performance Year (PY)
Periodic Data Matching (PDM)
See: Authorized Marketplace federal access to PII re APTC. HIPPA, etc.
Persistency Bonus (Reimbursement of Expenses Bonus)
A IUL feature that credits back all or almost all of any loan interest charge for funds "loaned to yourself". Typical credits are less in the first 10 years than succeeding years. I.e. If the Loan interest charge is 4% fixed, then the annual credit is about 3% - 3.25%. Different carriers have different loan interest fixed charges. The feature allows policy owners to take IRS compliant loans (to themselves on all the growth over their lifetimes), that are not taxed as income, while continuing to earn interest on the same values used as collateral to the loans. Unlike 401 loans, Cash Value is participates (earns interest) the same with these funds that never leave the account. 401 loans are placed in very low interest accounts for the remainder of the owners life. This leverage comparison is apples to oranges with IUL being clearly superior and without exposing the insured to market crash risk. This is not tax advice.
Personal Auto Policy (PAP)
Personal Injury
In context to CGL: “Personal injury” refers to a variety of offenses against a person other than a physical injury, such as invasion of privacy, slander, libel, trespass, and false imprisonment. May also involve "Advertising injury". See: Property Injury.
Personal Injury Protection (No Fault - PIP)
In some states, No-Fault insurance is required for purposes of auto claims less than $10,000. Travelers policy states: " UNINSURED MOTORI STS AND PERSONAL I NJURY PROTECTION COVERAGE IMPORTANT - PLEASE READ CAREFULLY YOUR OPTIONS REGARDING PERSONAL INJURY PROTECTION ARE DESCRIBED BELOW Personal Injury Protection (PIP) must be provided for any motor vehicle subject to the Florida Motor Vehicle No­ Fault Law. We will pay, in accordance with the Florida Motor Vehicle No-Fault Law, as amended, to or for the benefit of the injured person as follows: (a) 80% of medical expenses, if an insured receives initial services and care within 14 days after the motor vehicle accident, and (b) 60% of work loss and (c) replacement services ex­ penses, and (d) death benefits of $5,000 per each insured. The total limit available for medical expenses, work loss, and replacement services expense is $10,000. We will pay up to $10,000 for medical expenses that have been determined to be an Emergency Medical Condition and up to $2,500 for medical expenses that have been determined to be a Non-Emergency Medical Condition in accordance with the Florida Motor Vehicle No-Fault Law. Please refer to your Travelers policy and endorsement(s) for a detailed explanation of PIP coverage. There are several premium-saving Personal Injury Protection options available to you as the person(s) identified in the Named Insured section of the Declarations. A premium reduction will result from these elections. The named insured may elect a deductible and exclude coverage for loss of gross income and loss of earning capacity ("lost wages" or "work loss benefits"). A premium reduction will result from these elections. A named in­ sured can select a deductible of $250, $500, or $1,000. When making your decision on whether to choose a de­ ductible and for what amount, consider your ability to pay a portion of your medical expense and/or whether your health insurance carrier will meet the costs of these expenses. You also have the option to exclude benefits for lost wages due to an auto accident. If the insured or dependent resident relatives are unemployed or retired, you may want to select this exclusion.You are advised not to elect the lost wage exclusion if the named insured or dependent resident relatives are employed, since lost wages will not be payable in the event of an accident. You may choose to have these options (deductible and/or exclusion of work loss benefits) apply to the "named insured alone" or to the "named insured and all dependent resident relatives". In making this election, a resident spouse is treated as a named insured and not a dependent resident relative. THIS NOTICE DOES NOT ALTER, AMEND OR CHANGE THE COVERAGES AFFORDED BY YOUR POLICY. The coverages currently provided by your policy are indicated in the Declarations provided with this No­tice.If you would like to make any changes to your Personal Injury Protection coverages, please do not hesitate to call your agent or representative." Source: 2021 Auto Travelers policy See: Uninsured Motorists, Comprehensive, and Collusion coverage.
Personal Injury Protection (Auto) (PIP, No Fault insurance, PPI)
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 at higher limits where damages are severe or permanent, and/or excess of the $10,000 per person limit. No-Fault insurance is designed to reduce court congestion on low dollar claims. Statutory rules apply to medical billing. In MI its PPI, Personal Protection Insurance - that has recently been changed to allow people to elect other options less than unlimited coverage.
Personal Protective Equipment (PPE)
Personal Representative
A term defined by HIPAA related to handling PHI with prudent confidentiality defined under the law.
Personal Time Off (PTO)
Personally Identifiable Information (PII)
As Defined by CMS for Federal Marketplace Agent annual exam study material: Key consideration is if the information can be linked to identify and individual. ============================ PII is defined to have the meaning contained in Office of Management and Budget (OMB) Memoranda M-17-12 (January 3, 2017) and refers to information that can be used to distinguish or trace an individual's identity, either alone or when combined with other information that is linked or linkable to a specific individual. Section II(b) of the Individual Marketplace Privacy and Security Agreement and the Small Business Health Options Program (SHOP) Privacy and Security Agreement specifies the types of PII that an individual may encounter in performing the role of an agent or broker in the Individual Marketplace or SHOP. • 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 CSRs eligibility indicator, start and end dates • Applicant CSRs level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSRs 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 address • 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 and name • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Address Employee Applicant Spoken and Written Language Preference Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Employer Business Name If American Indian/Alaska Native: Name and Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name and ID Number Dental Plan Name and ID Number Other Sources of Coverage Accepting or Waiving Coverage Dependent information, if applicable, including • Dependent Name • Dependent Date of Birth • Dependent Social Security Number • Dependent Relationship to Employee • Dependent Sex • Dependent Spoken and Written Language Preference • Dependent Race and Ethnicity • If American Indian/Alaska Native: Name and Location of Tribe • Dependent Tobacco Use Indicator and Last Date of Tobacco Use • If individual is living outside of home; name of individual, address, phone, e-mail address • Dependent Other Sources of Coverage • Dependent Accepting or Waiving Coverage • Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth See: HIPPA, Marketplace Agent Exams

Pharmacy Benefit Manager (PBM)
A Pharmacy Benefit Manager is a company specializing in the administration of commercial, Medicare, Medicaid and/or Workers Compensation pharmacy costs and utilization administration. A PBM may also be a specialized entity for a specific high cost drug such as factor agents for hemophiliacs, cancer infusion, dietary feeding, and an array of infusion therapies. Lots has been made over the effectiveness or legitamacy of PBM services, but experienced consultants know their are many ways to lower the costs by moving from a brand name drug to an equivelent generic, or by more efficiently distributing-administering (batched) dosages super high cost Rx. Pharmacy has for over 10 years been the fastest growing component of the healthcare dollar inflation - especially for coumpounded and/or specialty drugs. ACA unlimited EHB includs Rx, and is directly responsible for some pharmacy charges to be higher then we have seen in 25 years, and potentially capable of bankrupting self funded employers who have not effectively worded SPD's to limit potential liability. It is not a straight forward issue, but we have seen significant litigation surrounding levels of Rx charges that border on fantacy, abuse, and cost shifting driving premiums to even more unaffordable levels. ==========="Prices in the United States are higher than those in all comparison countries U.S. prices were 256 percent of those in the 32 comparison countries combined. In comparisons with individual countries, U.S. prices ranged from 170 percent of prices in Mexico to 779 percent of prices in Turkey. The gap between U.S. prices and prices in other countries was larger for brand-name originator drugs. U.S. prices were 84 percent of prices in all non-U.S. countries for unbranded generics. U.S. prices were 190 percent of prices in other countries after adjusting U.S. prices downward to account for rebates and other discounts." Source RAND Research See: Stark and various safe harbour rules, Biosimilars

Pharmacy Inflation
We will see if the Feds actually do negociate better prices for Medicare and Medicaid beneficiaries, let alone Tricare military dependents...

Pharmacy Inflation
"About 150 pharmaceutical manufacturers had increased prices on 866 drugs by an average of 6.6% as of Jan. 20, nearly matching the US economy's 7% rate of inflation, according to data from Rx Savings Solutions. Top-selling medications including AbbVie's anti-inflammatory treatment Humira, Eli Lilly and Co.'s diabetes therapy Trulicity, and Pfizer and Bristol Myers Squibb's anticoagulant Eliquis were among the products that saw price hikes." Source: Beckers Hospital Review link.

Pharmacy Superspender
A patient incurring pharmacy and medical drug therapy expenses of $250,000 or more annually. For many years, the fastest growing part of the health care cost dollar has been pharmacy spending, and especially for "Specialty Drugs". Many plans will simply exclude them, regardless of plan language.
Phsical Damage
A term used in many types of policies. In contingent GL BI policies, physical damage caused by a covered peril is oftentimes required to trigger BI coverage. Technology is changing how this is done.
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 Compensation 2017
Source: Medscape

Medscape report

Physician Fee Schedule (PFS, or CY 2023 Physician Fee Schedule)
Term used by CMS when discussing proposed Medicare Part B QPP related matters, and/or medical physician fee schedule final rules related to their conversion factor. "CY 2023 PFS Ratesetting and Conversion Factor CMS is finalizing a series of standard technical proposals involving practice expense, including the implementation of the second year of the clinical labor pricing update. We also included a comment solicitation seeking public input as we develop a more consistent, predictable approach to incorporating new data in setting PFS rates. Per statutory requirements, we are also updating the data that we use to develop the geographic practice cost indices (GPCIs) and malpractice RVUs. With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 of 0%, and the expiration of the 3% supplemental increase to PFS payments for CY 2022, the final CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61."

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

PII Employee Information
Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Address Employee Applicant Spoken and Written Language Preference Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Employer Business Name If American Indian/Alaska Native: Name and Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name and ID Number Dental Plan Name and ID Number Other Sources of Coverage Accepting or Waiving Coverage Dependent information, if applicable, including Dependent Name Dependent Date of Birth Dependent Social Security Number Dependent Relationship to Employee Dependent Sex Dependent Spoken and Written Language Preference Dependent Race and Ethnicity If American Indian/Alaska Native: Name and Location of Tribe Dependent Tobacco Use Indicator and Last Date of Tobacco Use If individual is living outside of home; name of individual, address, phone, e-mail address Dependent Other Sources of Coverage Dependent Accepting or Waiving Coverage Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth
PII Employer Information
Employer Name/"Doing Business As” Employer Federal Tax ID Number Employer Address Business Type Employer Attestation to SHOP Eligibility Requirements Employer Contact Information Employer Contact Name and Title Employer Contact Mailing Address (if different than employer address) Employer Contact Phone Numbers (and type) Employer Contact Spoken and Written Language Preference Employer Contact Email Address Employer Contact Fax Number Secondary Contact Name (optional) Secondary Contact Phone number (and type) Secondary Contact Fax Number Secondary Contact Email Address Secondary Contact Authorizations Employer Coverage Offered Employer-selected AV Levels (Bronze, Silver, Gold, or Platinum) Benchmark Plan Offer of Dependent Coverage Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID Employer Contribution Information: Benchmark Plan ID number-Medical Plan Benchmark Plan ID number-Dental Plan Percentage towards Employee-Medical Coverage Percentage towards Employee Dental Coverage Percentage towards Dependent Medical Coverage Percentage towards Dependent Dental Coverage Employer Offering-Single QHP or Single Metal Level or Single Issuer Employer Offering-Single Stand-alone Dental Plan (SADP) or multiple SADPs Offer of Stand-alone Dental Coverage Desired Effective Date of Coverage Employee Selection Due Date Waiting Period for New Hires to Enroll Employee List, including Employee Name Employee Date of Birth Employee Age Employee Social Security Number Employee Email Address Employee Employment Status Employee’s Other Coverage Number of Dependents Dependent information, including Dependent Name Dependent Date of Birth Dependent Age Dependent Social Security Number Dependent Email Address Dependent’s Other Coverage Payment Method options, including Electronic Funds Transfer Information (Checking Account Number, Routing Number) Credit Card information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date) Checking Information Employer Attestation to Consolidated Omnibus Budget Reconciliation Act (COBRA)/Medicare Compliance Questions
Pilot Provider
See: Value Based Reimbursement, PRC
Plan Appointed Claim Evaluator (PACE)
A typically certified or very experienced professional hired by the plan who can service multiple functions in context to traditional plan management, and price/costs review of billed charges and stop loss application recovery(s).
Plan Star Documents (PRDs)
See Plan Star Ratings
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.
Policies In Force (PIF)
Jargon used by some TPAs to describe their client's eligible claims (from policies in force at time of claim adjudication).
Policy Cancelation
A term that can mean different things in different situations. See: Policy Rescission, Policy Termination.
Policy Rescission
A carrier action completely canceling an existing policy, as if it existed. See: Policy Cancelation, Policy Termination.
Policy Termination
A carrier action stopping coverage at a date prescribed by the carrier.
Polychonic care (comorbidiies)
The latest term being given to EBM in context to effectively caring for people with multiple serious diseases. "...serving polychronic patients means considering social determinants and health equity. It means making real efforts to improve patient engagement and prioritizing care with the right information. Find out how you can enable fundamental changes in the health care system. Reinvent processes, priorities and systems to treat the whole person and help change the trajectory of health care costs." Source: Optum See: CMS Interoperability
Pooled Employer Plans (PEPs)
See: Secure Act, MEWA

Pooled Plan Provider (3(38) Fiduciary)
A DOL fiduciary appointed for oversight of MEP, ARP's etc. See: Secure Act, PEO's Pooled MEP's, etc.
Poor Man's Self FUnded (Level Funded Medical plan)
An fully funded (premium paid monthly) ERISA eligible plan that essentially looks the same to employees, but that has materially lower stop loss $30,000 not $50,000+) deductibles. These come in many sizes and shapes, with Premium rebating features paid out in months 14-18 on a 12 month policy period cycle. They are not all the same.
Pop up Clinics
Term used to define a pandemic related clinic that usually becomes an eligible expense under an insurance policy.
Populate (Pre-populate)
An on line or real time computer automated function inserting information into a field on an insurance form, or computer query to a user. A user is the person using the computer.
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.
Possessed Insurance
A policy owned by a leasing company on aviation assets, and other types of assets. See: Contingent insurance.
Post Acute Care (PAC)
CMS term used in context to billing coding. See: Web based training - three courses, Understanding Prior Functioning and Prior Device Use, GG0131 Self Care items, and GG170 Mobility items.
Post Acute Network (PAC)
Jargon used to describe the facilites used and or managed after patient discharge. See: Long term care, Pallative care, hospice, etc.
Post Acute Providers (PAC)
CMS term used to describe QRP to the QIES-ASAP quality reporting measures related to after hospital discharge data (and multiple system problems related to uploading performance data from PAC).
Potentially Avoidable Utilization (PAU)
See: Maryland Health Care Commission
Practice Improvement and Measures Management Support (PIMMS)
Pre-Obamacare Health Plan Rule (Grandfathered Plan rule)
A rule allowing some employers to keep grandfathered plans (pre ACA plans) that some say allow those employers to shift more costs to employees, and perhaps lower some coverage-benefits.

Preauthorization (PA)
What physicians and hospitals have to verify at the insurance company to assure they get paid. Can also refer to a Physicians Assistant degree
Predictive Analytics
See: Disease Management, TQI, TQM, EBM, etc. Can mean many things, but tends to focus on Rx profiling, or diagnosis (or specific procedures like lower back scans) triggers that set in action medical interventions to lower the bill, and/or to focus specialized regimes of care for better outcomes. These programs are more or less common/ sophisticated by insurance types (not all carriers are the same) like workers comp or traditional major medical.
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)

Premium Dollar Breakdown
Few methods provide more information than a simple commercial premium dollar breakdown. "Medication and medical services accounted for 81.6 cents of the health care premium dollar. 21.5 cents are used to pay for prescription drugs. 19 cents are used to pay for in-patient hospital costs, while 19.8 cents are used to pay for out-patient hospital costs. 12.1 cents are used to pay for doctors’ visits. 4.6 cents are used to pay for federal, state, and local taxes. 2.4 cents are used to pay for the prevention of fraud, waste, and abuse. Only 3 cents of every health care dollar go toward health insurance provider profits." Source AHIP

Premium Tax Credit (PTC)
See: APTC. Relates to tax return reconciliation of actual income versus estimated income an APTC paid in the previous year - and determines if a person has to repay an overpayment of the APTC if they made more income than estimated in the previous year.
Premium Tax Credit (PTC)
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.
Prescription Drug Monitoring Program (PDMP)
See: Maryland Health Care Commission.
Prescription drug Monitoring Programs (PDMP)
Means many things
A term typically used by Human Resources to describe a reduction in employee productivity as measured by their distraction from many voluntary and involuntary causes. The point is that management is wise to recognize "some" personal, physical, and emotional causes of distraction that can dramatically increase or decrease (team) productivity which directly translates to earnings. The most inspired companies recognize employees are their business. Many have written about it.
Presumption Law
A liability suite filed presuming the injury was caused by an insured hazard. I am not a lawyer. I.e. Someone dies from COVID, and their family files a workers comp claim that the injury was caused by a work related event (without any direct proof of infection being any different from being infected from another source or event). See: Proximate cause, and call a lawyer to figure it out in you state.
Prevention Care (Wellness care)
Different carriers call it by different terms. In general, it means ACA defined preventative services INSURED without any out-of-pocket costs to the insured. newer services may include HIB prevention, and expanded women's health prevention - expanded coding for lactation counseling, breast cancer prevention medications, and postpartum depression counseling. See: Coverage Determination Guidelines (DCG) These are typically detailed by carriers in their policies, etc. See: ACA QHP

Prevention Quality Indicator (PQI)
See Maryland Health Care Commission
Preventive Health Management (PHM)
A term used o describe concurrent "large group" medical plan case management, and incentive payment to patients achieving improved medical outcomes (and typically lower comorbidity costs) in context to 5 chronic (expensive) conditions: BMI, Blood Pressure, Blood Glucose, Cholesterol and tobacco use.
Price Transparancy (Healthcare Transparancy)
Means many things: A federal rule mandating hospitals publish their best (HMO/PPO/EPO) contracted prices publically, that takes affect 1/1/2021. Or, Jargon not agreed upon that is typically used to describe some type of publicly facing "hospital best prices charged list". Sherman and Clayton antitrust prohibits price fixing, but public healthcare "policy" (benign negligence) "practically insulates" (most) hospitals from prosecution - thus the public law to show people what it costs. President Trump's HHS issued memos directing CMS requirement of making hospitals divulge secret prices. See: Trump EO. Hospitals are fighting it, and want to keep cost-shifted (to people buying commercial insurance versus Medicare insurance) higher charged prices secret from those that have to pay them. See: RBP The rule also requires accurate MOOP estimation. The problem is that the cost of insurance is past the tipping point with millions more uninsured in just the last few years - under President Trump's destabilizing: CSR withhold (going to the Supreme court, and losing), Medicaid work requirements (injuncted by a federal judge), federal Marketplace reinsurance program uncertainty (millions less insured during Trump's tenure), immigrant health insurance visa requirements (injuncted by a federal judge), etc, measures. Very contentious issue. Hospitals better figure out a way to live on 150% of Medicare allowable (instead of 150%-240% average, but it can be 1000% more charged to commercially insured patients than is charged for the same service delivered to a Medicare insured person) because that cost-shifting-cash-cow is getting too old to milk. "Under one rule resisted for months by a broad swath of the health-care industry, hospitals must for the first time reveal the discounted rates they negotiate privately with insurers for a list of 300 services patients can schedule in advance, including X-rays and cesarean deliveries. That is slated to go into effect in January, 2021. See: RAND Employer Hospital Price Transparancy Project See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing bing applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter. “CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.”

Price Transparancy
Means many things, especially if speaking with lawyers involved with ERISA and applicable potential fiduciary, and/or the Trump EO that Biden did not revoke. In context to national healthcare policy, see Presidential Executive Orders, and deadlines imposed on hospitals mandating disclosure of confidential "best price" contracted rates for procedures and services. See: CMS Price Transparancy.See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing bing applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter. “CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.”

Primary Care First Models -CMS
Primary care First is a CMS model designed to interface primary care acute care, chronic care and hospice (palliative care) organized by CMS. Know that getting control of Palliative (end of life care) is a major step in controlling costs, and improvine health outcomes for patients willing to make decisions about "herioc" medical care in the last weeks of life. "Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the underlying principles of the existing CPC+ model design: prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes." Source CMS

Primary Insurance Amount (PIA)
The amount Social Security pays an eligible insured (who has paid into the system long enougn) when that person starts the payments. See: Social Security, and Medicare eligibility. As a general rule, it is a good idea to never start the payments before FRA, and delaying payments beyond FRA means increasing each payment about 8% each year, and to death. Makes a lot of sense to not start it if you can survive without out it past full retirement age. For example, a person born in July 1959 FRA is 66 and 10 months. Wating to start until 67 asn 10 months means getting 8% more for the rest of life.
Principal Based Reserving (PBR)
No, not the beer! A calculation some carriers may use to reserve revenue for future expected claims. See: State Compliance and licensure guidelines by state, and authorized product filing.
Principle-Based Reserving (PBR)
The 2017 Principle-Based Reserving (PBR) — a new way of calculating (life insurance, etc) reserves to pay future claims. See: CSO
Prior Authorization
A term used in most (commercial) HMO, and some PPEO or EPO health plans denoting a primary care physician's referral to a specialist prior to seeing the specialist for an insurable event. Medicare and Medicaid rules are not the same. See: Gatekeeper HMO

An indivuals right to control the use or disclosure of personal information. Source: Federal Marketplace Exam 2022
Privacy Impact Assessment (PIA)
Privacy Notice
PUBLIC FACING NOTICE: In compliance of Federal Marketplace Privacy Notice Statement we declare for our clients and customers: We are authorized to collect personally identifiable information (PII) from you by many carriers we are appointed (Humana, Aetna, Cigna, United, and sundry MGA agreements affirming appointed powers to represent various P&C coverage too with many carriers). Any PII we collect is used only for the purposes of soliciting, binding (where authorized), managing, renewing or replacing policy coverage(s) we service in our clients best interests. We will never sell your information. Where we are required to disclose any PII under prevailing state stature/regulation, federal statute, or court order, we will contact counsel to determine if we are violating any HIPPA laws, etc. If you choose not to provide us with the PII requested, or not to respond to certain questions ore requests for information from your insurance carriers, your coverage may be cancelled, rescinded, pending carrier response caused by your decision to not supply requested PII. We will always work in our clients bests interests, and follow all available security laws applicable to licensed insurance agents and agency policy administration.
Privacy Notice: Provider Risk, LLC.
PUBLICALLY FACING PRIVACY NOTICE: Provider Risk, LLC. collects Personally Identifiable Information (PII), and distributes it only to entities authorized and licensed Carriers, Agents or Brokers offering insurance coverage services. All customers have right to forbid transaction of PII at any time. By sending us, or telling us personally Identifiable Information - you grant us the right to distribute it to carriers requiring it for potential policy bid, program enrollment, or policy servicing issues. Call Stephen George at 305-546-2073, or HealthSherpa if you have any questions, or concerns about how your PII is managed in your best interests.
Private Annuitant (PA)
A private annuity is an unsecured promise of one person (the Obligor) to make a fixed payment to another person (the annuitant) for life in return for the transfer of property from the annuitant to the obligor. Source: Benefits Pro Nov 2021
Private Fee For Service (PFFS)
See: Medicare PFFS
Private Label (Fronted and Reinsured assignment)
A sophisticated program of leasing an already licensed (usually A rated) carrier paper in a particular state (or many states) to field an "authorized" and/or "eligible" insurance product. See: Risk Bearing entities. These can take many forms of risk transfer, capital surplus, SIR, and claims liability, etc. These are a negotiated placement subject to ongoing negotiation. See: Finite and Facultative reinsurance.
Professional Employer Organizations ( PEO, Employee Leasing)
A corporation that derives its income from providing traditional Human Resource services (i.e., Group benefits, HR payroll tax filings, payroll, ancillary benefits, and typically discounted workers compensation coverage) to client employers 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 "similar" classes of industry. The "similar classes" method my comply with state MEWA requirements. Less expensive liability and health insurance are typically attributes of "leasing" one's own employees, if offset by the payroll fees PEO's charge. PEO's have a long colorful history of workers compensation employee class rating methodology and challenge. PEOs are not one size fits all, and come with colder approach to employee recruitment. PEOs do not all have top rated on-line capabilities. EPLI issues get squirrelly. Short story is that PEOs make economic sense where the workers compensation cost savings justify added payroll/HR processing charges, payroll filing benefits, and (in some cases) cross state workers compensation rating/administration, and fees. We recommend conservative approach, and rated paper if possible. See: MEWA and know if the PEO gets their MOD challenged by appropriate authority, then everyone in the same Comp rating gets hit, and the hit might be retroactive. Same goes for catastrophic claims (risk pooling) events of one member affecting the group. See: re-establishing MOD.
Profit Sharing (Profit Commission, Premium Refund)
A term used typically conveying a "premium rebate" contingent upon favorable (claims less than targeted loss ratio) claims history. These only happen under clearly defined contractual contingencies. Done well, profit sharing creates strategic advantage and co-dependent benefit. There are many kinds of profit sharing arrangements that can span into areas of contingency fees, and incentive programs, See: Dividend plan.
Program Business
Slang for many kinds domestically and offshore offered of insurance, or reinsurance supported risk transfer structures/facilities that can take the form of reinsured, fully insured, partially self-funded, and fully self-funded offerings and administration.
Program for Evaluating Payment Patterns Electronic Reports (PEPPERs)
See: Medicare relating to short term acute care hospitals.

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.

Prohibited Transaction Exemption (PTE 84-24)
See: Fiduciary Rule (DOL) effective 1/22/22 " Are You an ERISA Fiduciary? The DOL Fiduciary Rule updates expanded the interpretation of the existing 5-part test to determine when an individual is an ERISA fiduciary: 1. You render advice about plan assets (401(k), 403(b), IRA, etc.); 2. On a regular basis; 3. Pursuant to a mutual agreement; 4. The advice serves as a primary basis for investment decisions; and 5. The advice is individualized. The DOL’s new interpretation makes fiduciary status more likely, especially for rollover recommendations. The new interpretation includes: 1. Providing a rollover recommendation meets the “render advice” prong (#1 above); 2. Statements disclaiming a mutual agreement do not control; 3. Statements forbidding reliance will not control; and 4. All facts and circumstances will be considered, and marketing materials that indicate that you are a trusted adviser or want an ongoing relationship with clients will be viewed as more likely to meet the 5-part test. If a producer is an ERISA fiduciary, he/she cannot receive compensation related to that investment advice unless he/she complies with the requirements of a PTE. Notably, an existing PTE – PTE 84-24 – is available for producer use to receive compensation for investment advice. The general conditions of PTE 84-24 include: 1. That a recommendation is made in the ordinary cause of business and is as favorable as an arm’s length transaction with an unrelated party would be; 2. The combined total of all fees, commissions, etc. received by the producer must not be in excess of “reasonable compensation”; and 3. The producer may not have certain relationships with the plan or IRA including acting as a trustee, or administrator to the plan or employer. PTE 84-24 also requires that a producer disclose: 1. The nature of any affiliation or relationship with the insurance company whose contract is being recommended, and any limitations on the products that can be recommended; 2. The sales commission, expressed as a percentage of gross annual premium payments; and 3. Any charges, fees, discounts, penalties or adjustments under the annuity contract." Source: Lafayette Life Agency Advisory
Proof of Vaccination Status
acceptable proof delivered to Employers ((over 100 employees): 1. The record from a physician or Pharmacy, 2. US CDS Covid-19 card detailing the date of vaccine recieved, 3. a medical record copy of the vacciniation, 4. state or tribal immunization information document, 6. any other official documents detailing type of vaccine delivered, dates of administration and name of entity delivering the vaccine. See: OSHA for changes if any.
Property & Casualty (P&C)
Property and Casualty: The term typically relating to agent or policy form license or authorization by each state. See: L&H
ProPublica Treatment Tracker
A report made available by CMS of transactional frequencies between fee-for-service Medicare Providers.
Prospective Payment
A term usually referring to a complex system of rules from CMS that pay hospitals. We used to call the inpatient-outpatient part that hospital recieve monthly the PIP. See: Out patient Prospective Payment Rules.

Protected Health Information (PHI)
A HIPPA term used to denote confidential medical information. see: PII
Protecting Access to Medicare Act (PAMA)
See: QPP, APM, MIPS, MACRA, AUC Practice and reporting standards directed by CMS and related to Medicare eligible treatments.
Provider Excess Loss (Provider Stop Loss)
A coverage that does have federally issued mandates, but that typically does not always follow the guidelines. Coverages are typically issues by Physician and Hospital (specific")separated deductibles and rated premiums. Aggregate coverages are typically rare, but are not more common because of recent ACO initiatives sponsored by CMS. See Physician incentive plan guidelines and ACO shared savings contracting.
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 for what Medicare defines as outliers.

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 Emergency (PHE)
See: COVID and the many Medicaid offered eligibilities to assure public right to care, expecially during a pandemic. See: APTC

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 movement gaining strength to create a voluntary government health plan "buy-in" that competes directly with commercially offered major medical plans, and that would be available to both individuals and small businesses. It is not free national health insurance to all, or any plan to eliminate Medicare, Medicaid, the VA or Tricare, or the large group market. It would not likely be available to larger employers. Central to the debate is how much less any plan using Medicare maximum allowable charges to rate the premium is way less than non-RBP rated plans, that currently charge much more. Physicians and hospitals are fighting it. Any plan whose underwritten claims are (I.e. 50% - 1,000%+) less costly, will price premiums that (render non-RBP plans) beat competing plans. plans. In other words, most people would pick a less expensive QHP with a bigger PPO network, over a plan priced to pay doctors and hospitals a lot more than Medicare allows - and not being exposed to unlimited OON MOOP, surprise billings, balance billings, etc. Be clear that doing it is almost turn key (network and network pricing is already accepted and established, and so is ACA QHP, and even Medicaid claims process units, reinsurance, CSR, CMMI, LAN, ACO hybrid, FFM, Community health center interface, AARP support, etc) where the pollical will to keep people insured, and so hospitals don't go bankrupt treating poor/uninsured people. Its coming simply because the premium costs have escalated beyond what millions of American can no longer afford, and the Feds (and states) will have to keep hospitals from going bankrupt.
Public Use Files (PUFs)
Jargon CMS uses to describe publically available information from statre and federal authorities.
Purchaser Collaborative
A nuanced term that can mean many things, but that usually means a network of medical providers willing to bill their services in a "bundled payment", not usually taking any down side financial risk. Currently, it is more an idea of getting buyers and providers on the same page to effect higher quality care at lower costs supported by real EBM. The patient is not typically part of the conversation.


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.

QPP Library

Qualifed Disabled & Working Insividuals (QDWI)
A category of Medicare beneficiary getting help paying for Part A premiums where the individual did not pay tax or work 40 qualifying quarters to get Part A benefits. (i.e. $345)
Qualifed Employer
See: 45 CFR 155.20
Qualifed Payment Amount (QPA)
This is not QPP. See: Balance Billing, MSP, NSA, etc, and know that COVID makes it complicated.
Qualified Employee
See: 45 CFR 155.20
Qualified Health Plan (QHP)
A medical plan meeting ACA EHB for individual and Group coverage. See: ACA final rules. See: 45 CFR 155.20
Qualified Independent Provider (QIP)
A term used by CMS related to Part A covered services and being eligible or participating as a Medicare provider, or supplier.
Qualified Longevity Annuity Contract (QLAC)
An anntuity used that typically offers an income for life ("Pension" like) benefit.
Qualified Medicare Beneficiary (QMB)
Qualified Payment Amount (QPA)
The median in-network (contracted rate) amount PAID for a given medical SERVICE in a region (zip code). This gets complicated because of the many rules and current litigation in process. See: IDR in context to Interim Final Rule HHS will enforce, but some courts (like TX) are litigating it... See: Balance Billing, No Surprises Act. "During the IDR process, an arbiter is directed to consider all information submitted by the physician and insurer, including the median in-network rate, complexity of the case, previously contracted rates, and market power of the physician and insurance company, among other things." Source: health Leaders March 2022
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. Its gets complicated. Employees electing to buy an Individual Marketplace plan with help from the APTC, must reduce (or pay back at year end) the APTC by the amount an employer contributes to ICHRA. Call a CPA.

Qualifying Life Event
See: SEP in context to eligibility to enroll in Marketplace plans.
Qualifying Longevity Annuity Contract (QLAC)
A fancy name for an annuity offering lifetime income payments (that are taxed as INCOME at distribution(s). See: Non qualifying deferred annuities. Annuities can have multiple interest rates running in the same annuity when an income for life feature is elected. In general, all annuities except Variable annuities offer MINIMUM interest guarantees (sometimes called roll ups). Fixed and Fixed-Indext annuities guarantee principal safety and interest rate guarantees. (i.e. Fixed 10 years at 2.5%, and Fixed-Indexed "range" at 85 BP up to say 3%). Variable annuities (value) follow their index selection growth, or decline (can crash when the index crashes and lose both principal and interest in that period). DIfferent companies offer different "Income-for-life" options that always guarantee more than the minimum interest guarantees offered. (I.e. up to 8%), so think of it as one, or two colums running simultaneously in the same annuity, and whose values all start with the same premium deposit (plus bonus if offered). (Pure Fixed means one colume, Fixed-Indexed means two columes detailing a range of about 85 basis points up to 3% and the minimum guaranteed interest credit, and Variable is typically two columes detailing Indexed interest credit growh or loss, and the Income-for Life credit (i.e. 8%). To get the 8% guaranteed interest, the annuitant must accept "forced-annuitization", which means the owner gets a guaranteed 8%, but cannot liquidate (cash in the Face) should there be an emergency need for funds - once the payments begin (typically at the end of the annuity term). Many carriers will offer (forced) annuitization election at annuity maturity (i.e. end of 10 years). The primary benefit of an income for life benefit lay in not outliving ones money, but it comes with a tradeoff. Lastly, the actual income distribution payment to the annuitant each year is a fixed (for life) percentage (of the total Face + accumulated interest) and is always less than 8% following the schedule accepted by the insured. (I.e. at age 70, maximum payment would tyically be 5%, age 80 at 6%, etc). Read the annuity to see for yourself.
Quality and Resource Use Reports (QRUR)
Quality Care
A contested definition mostly determined by a patient's perceived restoration of health and function enjoyed prior to disease onset and treatment. See: EBM, RPM, VBR and the many constant attempts by many players to quantify it and ignoring the patient's opinion as to if the patient felt their health was returned to the same or better state prior to A&H event. See: EBM, QPP, MACRA, CQMC, etc. More recently inspired thinking includes not just financial and medical outcomes, but also what is termed an experiential quality as deemed valuable by the patient, and the patient's long-term engagement and commitment to maintaining healthy chronic care management activities and their associated lower cost outcomes. See: VBR, RBP, QPP.

Quality Clinical Data Registries (QCDR)

Quality Data Model (QDM)
The Centers for Medicare & Medicaid Services has published the Quality Data Model (QDM) standard, version 5.4. The standard has been updated to align with the emerging standard, Health Level Seven International (HL7) Fast Healthcare Interoperability Resources (FHIR) and add increased explicit capabilities. Support for these features and modifications will be implemented in the production version of the Measure Authoring Tool (MAT) to be released in Fall 2018 (MAT v5.6). Measures produced using QDM v5.4 are anticipated for implementation in calendar year 2020, whereas QDM v5.3 is for calendar year 2019.

Quality Data Reporting Architecture III (QRDA reporting)

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 Medical Care
The least expensive legally defensible care supported by EBM. See: CAHPS, QPP, APM ============================= Most of us believe in free markets and capitalism. When profit margins (or Retained Earning for not-for-profit entities) are percieved to be threatened, be not surprised when the AHA and AMA attempt to crush them, regardless of batient benefit. So, it ends up being the classic argument (and hypocrisy) of big government versus small government, and what institutions declare they dislike despite aggressive acceptance of payment by federal and state programs dealing with the poor, uninsured, or unvaccinated populations. Any society that considers itself civilized is judged by how it treats vulnerable children, the poor elderly, and mentally incompetent. I did not think that one up, but it follows sound principles of love, and its shared purpose being the glue that holds society together.
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 ============================= • Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: To receive assistance more quickly, consider calling during non-peak hours—before 10 a.m. and after 2 p.m. Eastern Time (ET). o Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant. ========================= See: MACRA, MIPS, QPP, PQRS, HCTTF

Quality reporting
Can mean many things, especially with VBR, QPP. See: HEDIS
Quality Reporting Program (QRP)
Means many things to many carriers, and populations, and programs. For CMS, HHS and IRS mandated medical cost, and detail reporting aka Patient Centered Outcomes Research (PCORI). , it is 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. This tax may not still be mandated, but we are not sure? The ACA act was not repealed (except the individual tax penalty mandate), but many provisions are not being enforced. 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.
Quantitative Easing (QE)
A term used usually to describe the Fed's behavior in making money less expensive by dropping the fed funds rate. It can be used to describe underwriter agenda to lower premium rates based on better than expected losses.
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 software program designed to defeat cyber-security measures, comit a crime, and whose methods include making the attacked entities' data unavailable until an extorted payment is made. More and more D&O/E&O/GL policies are now including specific language limiting or excluding coverage for Ransomware attacks. See: Cyber Liability policies
Rap Fund (Florida Property Reinsurance Layer)
A slang term used by Florida to discuss its reinsurance efforts to support a struggling Florida property wind storm reinsurance program said to comprise a first layer of reinsurance purchased by the state (not the policy holder) projected to cause a 2-3% reduction in homeowners premiums. Details are are not settled.

Rasomware-as-a Service (Raas, or Affiliate Program)
A "Dark Web" offered software ("service or subscription") whose goal is to defeat cybersecurity defenses and commit a crime.
Rate of Retuen (ROR)
See: AOR, and CAGR
Rated (Carrier strength)
A term used to convey well accepted bond rating companies financial strength of a specific carrier. In context to insurance/reinsurance companies, it means the reputation for paying claims on time as would be expected by substantial capital and/or surplus reserves conservatively funded to pay expected claims. There are several well regarded rating agencies. For insurance company ratings AM Best is considered the top with S&P, MOODIES and FITCH also important where multi agency ratings are available on a specific company. For most of these companies, a carrier rated A+ must be at least 10 years old, and not have excessive complaints filed against them for non payment or untimely payment of claims.

http://See: AM BEST, or S&P

Rated or Ratings (FSR - Financial Sequrity Ratings)
A term used to convey a compan'y financial strength and / or reputation for paying claims timely. i.e. Standard and Poors, Moodies, AM Best, Fitch, etc. Ex: AM best specifically includes reputation for paying claims promptly, whereas other agencies my not keep track of customer complaints at the state level. Be cautious. Demotech and D&B ratings are not typically accepted by underwriting. Demotech offers Agents an E&O coverage (extension) that triggers if an insolvent carrier is actually liquidated. Be cautious.
Re-establishing MOD
The process of NCCI establishing a new employer MOD (typically higher). See: PEO, and know that leaving a PEO is a time consuming and sometimes expensive process.
Re-Hire versus New-Hire
A carrier specific technical definition used to describe an employee's group-insurance eligibility and enrollment process. Re-Hire appplies to x-employees offered major medical enrollment within 12 months, and New Hire applies to new (or re-hired employees) enrolling after one year from lay off or terminiation. Not all carriers follow the same rule. See: Eligibility
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

Rebuttable Presumption
In context of Covid 19, federal position that some employees did in fact contract C 19 at work, and would be eligible for workers compensation insured losses. (as apposed to requiring a burden of proof that work related injury in fact did occur at work)
A state authorized risk bearing entity that is typically not assessable to it's capitalizing 'association" membership.
Referenced Based Pricing (RBP)
A term used to define medical reimbursement in Plans insuring, or "reimbursing" members up to an "established" fee schedule. Lots of rules apply, depending on the population insured, contracts in place, and the plan. RBP plans may not be insurance. See: Risk Bearing entities, STM, Ministry health share plans, Health Cost Sharing plans, Limited Medical plans, scheduled medical, medical discount plans, ACA compliant QHP. Medical billing disputes litigated in many states are increasing. Prompt payment: ERISA (each state) policy language and medical provider "not-for-profit" organizational type, etc - obligations help guide the process.  This from a major carrier published December 2019... "All Savers® Alternate Funding will no longer access the Shared Savings Program (SSP), effective Jan. 1, 2020, for all new and existing business. Note: This change was implemented on Sept. 1, 2019, in Florida, Georgia, Illinois, Missouri, North Carolina, South Carolina and Texas. Claims from out-of-network providers will be paid using Extended Non-Network Reimbursement Program (ENRP) or Maximum Non-network Reimbursement Program (MNRP). Processing claims at ENRP or MNRP rates rather than discounted Shared Savings Program rates will help decrease the All Savers out-of-network spend, provide a greater financial incentive for members to use network providers and further align All Savers with fully insured reimbursement policies. Key points: Were members notified of the program changes? Yes, members with 5 or more out-of-network visits in the last 6 months of shared savings providers have been notified. Were ID cards reissued to members who no longer have access to SSP? Yes, all members in the impacted states received updated ID cards without the Multiplan logo. Does the change to SSP access constitute a change (reduction) in benefits? No, this does not constitute a reduction in benefits. We are still covering out-of-network (OON) services according to the member benefit plans, but if a member continues to utilize OON providers, they may have additional financial responsibility. Can members be balance billed? Yes, when non-network claims are paid at the ENRP or MNRP rate, the provider can balance bill the member for the difference between billed charges and the ENRP or MNRP rate." This from Benefits Pro 2/14/20, in context to pharmacy. "The cost savings the tactic provides are not only significant, but also grow over time for both plan sponsor and employee—a finding that was borne out by previous research published in the New England Journal of Medicine in 2017 that used the same employee population. The addition of the second study added another two and a half years of data and brought the total research period to five years. While the 2017 study had found that use of reference pricing resulted in drug spending for employers that was nearly 20 percent lower, it also resulted in a 10 percent increase in cost-sharing for patients. However, the new study found that cost-sharing fell by more than 20 percent as both physicians and patients adjusted to the use of reference pricing. By five years after implementation, according to ActiveRADAR,..." Source: Benefits Pro Feb 2020 Some of the success stories include agreed discounts on the following that caused lower medical expenses to plans, and therefore lower renewal premiums. I.e. • Knee replacements; • Hip replacements; • Cataract surgery; • Colonoscopies; and • Imaging etc.

Registered Health Information Technicians (RHITs) (RHITS)
Registered Independent Advisor (RIA)
A licensed financial professional who sells/services securities. See: RSC
Registration Completion list (RCL)
CMS published list of certified Marketplace agents/brokers/navigators.
Regulation Best Interest (Reg BI)
A DOL regulation affecting licensed securities brokers providing advice on retirement account roll-overs - requiring certain types of disclosures (declaration of compensation, conflicts of interest and any disciplinary actions on the broker dealer or financial advisor) on investments. Reg BI mandates greater disclosure than standard "suitability". See form CRS filing, See: BIC See: Form CRS Relationship Summary, the Standard of Conduct for Investment Advisers, and a new Interpretation of “Solely Incidental.” "Reg BI also requires the following: Disclosure obligation: Broker-dealers must disclose material facts about the relationship and recommendations, including specific disclosures about the capacity in which the broker is acting, fees, the type and scope of services provided, conflicts, limitations on services and products, and whether the broker-dealer provides "investment monitoring" services Care obligation: The broker-dealer must establish, maintain and enforce written policies and procedures reasonably designed to identify and at a minimum disclose or eliminate avoidable conflicts of interest. The obligation, which is an enhancement from the proposal, specifically requires policies and procedures to: Mitigate conflicts that create an incentive for the firm’s financial professionals to place their interest or the interests of the firm ahead of the retail customer’s interest; Prevent material limitations on offerings, such as limited product menu offering only proprietary products, from causing the firm or its financial professionals to place his or her interest or interests of the firm ahead of the retail customer’s interest; and Eliminate sales contests, sales quotas, bonuses and non-cash compensation that are based on the sale of specific securities or specific types of securities within a limited period of time. Compliance obligation: In an enhancement from the proposal, broker-dealers must establish, maintain and enforce policies and procedures reasonably designed to achieve compliance with Regulation Best Interest." Source: Think Advisor June 2019 CEO Ron Kruszeswki states, "It’s very important to note that Reg BI applies the same fiduciary principles to the brokerage model: a duty of loyalty — a duty to act in the best interest of the customer, to not place a broker’s interest ahead of the customer. Likewise, Reg BI has a duty of care — to act with diligence, care and skill in making an investment recommendation." June 2019 Stifel CEO Praises CEC Reg Bi, Blasts House Vote as Partisan" ThinkAdvisor June 2019
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 types of medical reinsurance are HMO reinsurance, Employer Stop Loss, Provider Excess loss, Workers Compensation reinsurance, and CHAMPUS/Tricare reinsurance. Reinsurance applies to insuring an authorized insurance plan, or re-insurance. The ACA authorized (by regulation) coverage insured between $45,000 to $250,000, and is in its own class. There are thousands of kinds of reinsurance. See Aggregate and Specific insurance. ===================== 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. =======

Relative Value Unit (RVU)
See: RBRVS, CMS final rule PFS (physicia Fee schedule). I.e. for 2022 conversion factor reduced from $34.89 to $33.59, eliminate geographic restrictions in telehealth visits for behavioral health services, some audio-only telehealth is allowable, and increase payments for administering vaccines for influenza, pneumonia and other common diseases. See: special COVID rules

Remote Patient Monitoring (RPM)
An ambiguous term referencing eligible reimbursement of Medicare and perhaps some commercial carriers. See: Telemedicine, and a myriad of wireless heath data transmission/collection devices and services.
Remote Patient Monitoring (RPM)
See: Brittle well, a term used to describe chronically ill members. The trend is to automate chronic care management to engage the patient in their own wellness, and much lower costs from avoiding massive hospital bills to manage critical care. Key requirements include engagement from physicians, and especially patients in their own care (high risk stratum managment and intervention). Many types of incentives are used to engage the patient. Commonly targeted diseases include: Diabeties, Hypertention, obesity, cardiac care, back pain, asthma, etc. See: Telemetry (the old term for some devices that manage mobile patients)
Representations and Warrentees Insurance (RWI)
Insurance used in M&A
A generic term used to convey a billed medical charge being itemized (typically discounted) to a RBP schedule. See: RBP, QPP, cost shifting, MACRA, etc. Re: RAND Study of $33.8 Billion of charges studied _ "Key Findings: In 2018, employers and private insurers paid 247% of Medicare. This difference increased from 224% of Medicare in 2016 and 230% in 2017. From 2016 to 2018, the overall relative price for hospitals increased from 224 to 247%, a compounded annual rate of increase of 5.1%. High-value hospitals exist; low prices + high safety. There is no clear link between price and quality or safety." Rand Nationwide Evaluation of Health Care Prices Paid by Private Health Plans. Most recent research has the average commercial pricing at 240% more than the Medicare authorized amount. Repricing is relative to the population and location of services rendered. i.e. COmmercial Medicare, Medicaid, workers Compensation, PIP, Tricare, ACO special contracts, bundled payments, value based pricing, etc. See: Rand report link

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 (ACA compliant - i.e. unlimited) catastrophic (Major Medical) plans. Several "new breed" plan are available including "referenced based pricing", and "faith-based" plans that insured only a maximum fee schedule reimbursement, and may expose the insured to a "balance-billing" liability. Some are promoted as a plan, but that is NOT insurance. Many are 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, corridor risk. Read ACA Law, and figure out for yourself what is being ignored and what is being enforced.

Latest bill

Request For Application (RFA)
Term CMMI uses to announce next demonstration initiative to lower costs and improve quality.
Request For Proposal (RFP)
Required Minimum Distribution (RMD)
A federal law mandating a person reaching 70.5 years of age spend (withdraw and pay tax on) a minimum of 5% of the total IRA/401 amount. See: Roth IRA's and most IUL's that don't have it. See IRS guidelines and talk to your CPA. Talk to an agent about IUL while you are under 55 or have 10+ years of Life Expectancy.
Reservation of Rights (ROR letter)
A letter typically from and insurance carrier agreeing to something, but reserving their right to amend what they have agreed to...
Resources for Integrated Care (RIC)
See: MMCO which is a CMS related.
Responsible Official
See: HIPPA, ACA law, and good luck.
Responsible Reporting Entities (RREs)

Responsible Reporting Entity (RRP)
See: QPP i.e. "CMS will be hosting a second webinar on to discuss the impact of the SUPPORT for Patients and Communities Act on Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 reporting for GHP Responsible Reporting Entities (RREs). The intention of this webinar is to further clarify who should report as an RRE and provide additional information on how to appropriately submit primary prescription drug coverage information. Complete webinar information is available in the Downloads section of the Mandatory Insurer Reporting for Group Health Plans (GHP)" Source CMS (your government in action.)

Retiree Drug Subsodie (RDS)
A tax subsidy program available to fully insured and self funded employers. Audits are required that offset costs savings.
Retirement Account 401(k), ect
*Source Benefits Pro - 10/18 Participants in 401(k) and other defined contribution retirement accounts will see their annual contribution cap raised from $18,500 to $19,000 in 2019, according to the Internal Revenue Service. The catch-up contribution limit on defined contribution plans remains unchanged at $6,000. Savers with IRAs will see the annual contribution cap raised from $5,500 to $6,000 — the first time the cap on IRA deferrals has been raised since 2013. The annual catch-up contribution for savers age 50 and over will remain at $1,000. COLA increases will also be applied to the deduction phase-out scale for IRA owners who are also covered by a workplace retirement plan: for single filers the scale will be $64,000 to $74,000, up $1,000 for joint filers where the spouse contributing to an IRA is also covered by a workplace plan, the phase-out slot increase to $103,000 to $123,000 for an IRA contributor whose spouse is covered by a plan, the income phase out is $193,000 to $2003,000 Single contributors to Roth IRAs will see the income phase out range increase to $122,000 to $137,000, up $2,000 from last year. For married couples filing jointly the range will increase to $193,000 to $203,000, up $4,000 from last year. More low and moderate-income families may be able to claim the Saver’s Credit on their tax returns for contributions to retirement savings plans. The threshold increases $1,000 for married couples, to $64,000; $48,000 for head of households, up $750; and $32,000 for singles and single filers, up $500 from last year. The deferred compensation limit in defined contribution plans for pre-tax and after-tax dollars will increase $1,000, to $56,000. And the maximum defined benefit annual pension will increase $5,000, to $225,000.

Retirement plan for public schools and NFP employers (403(b))
Similar to 401(k) plans, that employers can match employee contributions with pre-tax dollars.

Retirement Plans (employer sponsored) (Golden Handcuffs)
Employers can initiate Defined Benefit and Defined Contribution plans that "vest" to the employee over period of time, thereby retaining valuable key employees. IRS regulations mandate a minimum of 5 years funding, however the intent is permanent sponsorship being funded indefinitely. … Defined Benefit Plans use life and annuity products, with the life products allowing efficient "borrowing" against "cash value", in addition to the life insurance benefit. … Defined Contribution plans offer cash that can be invested in risk bearing marketable securities, (managed by properly licensed brokers), and that vest over a period of time. Funding of these benefits is pre-tax. Many regulations affect such transactions. … "Retirement Plan Types Defined Benefit Plans Defined Benefit Plan A Defined Benefit Plan is a retirement plan that provides guaranteed retirement benefits to the owners and employees of a company, provided annual premium contributions have been funded. The plan may be funded with, but not limited to, life insurance and annuity contracts. Fully Insured Defined Benefit Plan A 412(e)(3) Fully Insured Defined Benefit Plan is a retirement plan that provides guaranteed retirement benefits to the owners and employees of a company, provided annual premium contributions have been funded. The plan is funded solely with life insurance and annuities, or annuity-only contracts, offering minimum guaranteed interest rates. Cash Balance Plan A Cash Balance Plan is a defined benefit plan that provides benefits to participants in the form of hypothetical account balances normally stated as a dollar amount or a percentage of compensation. Each year, eligible participants receive their benefit in the form of a pay credit and an interest credit that is added to their hypothetical account. However, the plan is still funded like a traditional defined benefit plan with funds going into a pooled account. Defined Contribution Plans Profit Sharing Plan A Profit Sharing Plan is a defined contribution plan in which the employer makes discretionary contributions. A key advantage is flexibility in determining the annual contribution. The maximum annual employer deduction for contribution is 25% of eligible compensation. There is also a maximum individual contribution limit. The individual limits are adjusted annually for cost-of-living increases. 401(k) Profit Sharing Plan A 401(k) Profit Sharing Plan allows employees to defer a portion of their income (tax deferred) to the plan while also allowing the employer to fund a matching and/or discretionary contribution. Lafayette Life Retirement Services Pension Guide > 5/ 16 The salary deferrals are always 100% vested. They are limited to the lesser of 100% of the employee’s compensation or the current year’s dollar limit. Participants age 50 or older may make an additional “catch-up” deferral. These thresholds are adjusted annually for cost-of-living increases. A matching contribution by the employer may be included based on the salary deferrals. The matching allocation formula varies according to the employer’s funding objectives and may be discretionary. Highly compensated employees’ deferrals may be limited, and retirement benefits are impacted by investment returns. 401(k) Plans also must satisfy nondiscrimination testing requirements. Safe Harbor 401(k) Profit Sharing Plan The Safe Harbor 401(k) Profit Sharing Plan is designed to eliminate the nondiscrimination testing imposed by traditional 401(k) Plans and allow every participant, including the owners, to defer up to the maximum limits. In order to maintain the “safe harbor” status, the employer must make a 100% vested “safe harbor” contribution with one of the following two options: a 3% of compensation contribution to all eligible employees; or a matching formula equal to 100% of salary deferrals up to 3% of compensation and 50% of salary deferrals between 3% and 5% of compensation. Retirement benefits are impacted by investment returns." Source: Lafayette Life insurance company 2019: We recommend experienced agency for these products and services. … This is not tax advice.
Retrocessional Reinsurance (Retro)
Coverage bound by insurance companies insuring insurance companies following the 1st rule of managing catastrophic risk - "spread it out", or "don't take all of it".
Return of Premium (ROP)
Many Meanings. In life insurance it can mean, return of all premiums PLUS the death benefit, or a reduced death benefit payout in the first 1-3 years of the policy. For other policies: An insurance policy provision allowing for all or part of premiums being refunded where the policy coverage was never accessed by the insured (or rescinded by the carrier). These are not uncommon in Long Term Care policies whose policy ROP features detail the percentage return over an extended number of years, i.e. 20% ROR in year 10, not 100%. Different carriers offer different terms. Read the policy carefully. ACA regulations mandate ROR or Premium rebating (for overcharged individual policy holder as a class), where MLR is less than 80% for Individually insured's and 85% for Group insureds. Many exceptions on the healthcare insurance products side.... See: Premium Rebates, MLR on marketplace plans, Policy rescission, policy termination, policy replacement, policy cancelation. i.e. on Life insurance Final Expense (funeral costs policies guarantee issue to high age customers), and other policies: • Graded Death Benefit • 1st year: ROP + 5% (full death benefit paid immediately for accidental death) • 2nd year: 50% of Face Amount • 3rd year: 100% of the Face Amount
Return to Office (RTO)
Jargeon used to try and articulate employee aquisition and retention, and that my apply to EPLI issues.
Revenue Cycle Management (RCM)
Reverse Payment
A tactic used by brand name drug manufacturers to delay competitive generic versions coming to market. This gets complicated, and may run afoul of some rules.
The probability of gain or loss associated with a choice or investment. Contrary to Merriam Webster's definition (an obvious pessimist!) ... it implies both gain or loss. Risk, like beauty, is in the eye of the beholder. Unpredictable risk (to a policy holder) is generally considered SIR excess of $50,000. Appropriate SIR is a function of risk appetite, liquid assets (defined by its jurisdiction), underwriter opinion, available instant / long term credit and/or finite treaty, etc. In context to stop loss / reinsurance premium performance (rating), its what the underwriter is willing to accept to transfer the risk (at various SIR, limits, terms). All underwriting units have their sweet spot.
Risk Adjustment - ACA

Risk Adjustment Data Validation (RADV)
A CMS audit to discover over-reported (or fraudulently) reported medical severity scores by hospitals resulting in overpayments from CMS, and to recover overpayments by CMS on MA beneficiaries.
Risk Adjustment Factor (RAF)
Each HCC is weighted by RAF to reflect relative weight (to DRG), age, gender, comorbidities, etc. Its a work in process whose goal is part of the transformation by CMS to structure reimbursements (and shared savings derived by beating the assigned budget for care) to better outcomes at lower cost. The transition is from Hospitals managing "beds not heads", to "heads not beds" (filled with FFS patients). See: DRG Outlier
Risk Adjustment Rule
See: EO

Risk Based Capital (RBC)
A term used by carriers, or captives describing the amount of money available to pay claims. The point being that the insurer intentionally budgets for losses above minimum capital reserves (amount) to plan for appropriate cushion against unexpected losses. The term can mean many things, and its calculation can be directed by the entities domicile. See: Surplus Reserves, Capital Reserves, Finite Reinsurance, etc.
Risk Bearing Entities
As a general description of "options" available to companies seeking to assume their personal risk, or group's risk(s): Admitted carrier, Non-Admitted carrier (Surplus Lines), Cover Holder, Risk Retention Group (RRG), Reciprocal, Captives, Captive cell(s), VEBA, MEWA, ERISA plan, PSO, AHP, ACO, HMO, PPO, IPA, COOP, off-shore X, Fronted & Reinsured Assignments, etc. Selection of risk bearing structure starts with liability considerations, and insolvency accountability against its corporate and / or capital contributing participants. Fronted and reinsured assignments can be substantially better alternative to managing risk at much lower costs than captives. We recommend experienced legal, accounting and brokerage agency when considering the risks and costs of fielding one's own product, and/or risk transfer. See: ERISA obligations
Risk Corridor (ACA risk corridor)
In context to ACA law and reinsurance payments already made to participating major medical Marketplace carriers over several years of Obama administration - it means federal payments to carriers who paid much higher claims amounts (by lowering deductibles and MOOP of their insureds) for INDIVIDUAL and SMALL GROUP (SHOP) members whose income fell between 100% - 250% FPL. The deductible and MOOP limit reductions are the CSR federal help to the poor (along with APTC). … ACA law did not spedify federal reinsurance set rates, or detail specific payments to carriers. The reinsurance was to have come from a 2.5% - 3% premium tax that purchased a $45,000- $250,000 stop loss recovery "safety net". Additional restriction on carriers, above the already stringent MLR (80%-85%) mandated any "profits" greater than 3% would be forfeited to the fund to pay carriers getting hit with adverse selection. … So far several Federal Courts have agreed with the Trump administration that the government does not owe carriers what the law does not explicitly stipulate (ignoring about seven years of HHS payments) payable. Carriers are looking to the Supreme Court to settle it. Current estimates of the payments are over $12 BILLION, and significantly expose many large carriers (especially Blue Cross alleging $5 BILLLION owed), to insolvency. Also very exposed are hospitals exposed to large uninsured populations. … Chief Judge Sharon Prost filed the majority opinion on Moda Health’s claim that HHS is contractually obligated to reimburse risk corridor payments in full. The judges stated that there was no official contractual agreement between HHS and health insurers for the timing of risk corridor payments, which makes Moda’s claim to the payments invalid. “Although section 1342 [of the ACA] obligated the government to pay participants in the exchanges the full amount indicated by the formula for risk corridor payments, we hold that Congress suspended the government’s obligation in each year of the program through clear intent manifested in appropriations riders,” Prost said. “We also hold that the circumstances of this legislation and subsequent regulation did not create a contract promising the full amount of risk corridors payments.” The judges also contended that the risk corridor payments were not budget-neutral, and that risk corridor payments were not obligatory, since the government did not provide budgetary authority to HHS to administer the payments. (Source: Healthpayerintellegence 6/18) Carriers like Blue Cross who are allegedly is owed over $5 BILLION argue, federal "performance" payment history clearly show congress' intended to fund it, without it being specifically detailed in the ACA law over many years (its called regulation). DOJ contends congress is not obligated to pay what the "law" (DOJ loosely honors on other very important items like preexisting medical conditions plan sales being illegal) stipulated, and that congress separately intended to fund each year (if HHS felt like it "this" year). Result: Destabilized individual, small group and even large group health care Marketplace with millions more people uninsured. Many carriers - Cigna, United, Coventry, Aetna, Humana) carriers abandoned the individual and small group market offerings. Result: REAL insolvency risks to any carrier carrying debt for (Deductible and MOOP higher) claims they already paid, and long term insolvency risks especially to small hospitals, and even large hospital oligopolies (because people abandon insurance, incur giant bills when they show up in the ER). Risk Corridor is very different (Stop Loss and or Professional coverages offered by CMMI under Direct Contracting with 0% to 90% "shared savings" potential bonus on Medicare lives. Its complicated.
Risk Level Data Report (RLD)
Slang for a detailed Bourderough Report showing individual (properties or assignments) by premiums, limits and TIV. I.e. property policies detail Coverage A, B, C, D and bulding characterists.
Risk Pooling
A term typically used to describe a grouping of risk involving an manuscripted coverage. Many types of risk pooling exist on the private and public fronts like HO3, General Liability, Workers Compensation, MEWA, Trusts, OBGYN Professional Liability, PEO, various surplus lines initiatives (on-shore & Off-shore), etc.
Risk Rating 2.0 (Flood Insurance FEMA designation)
RISK RATING 2.0: EQUITY IN ACTION | PHASE II - RENEWALS FEMA is changing the way it views flood risk and prices flood insurance, making it easier for insurance agents to write and sell flood insurance policies. The National Flood Insurance Program's new rating methodology, Risk Rating 20, will deliver rates that are easier to understand and better reflect a property's unique flood risk. Rates will now be developed on a structure-by-structure basis, offering your clients a more individualized picture of their risk. The NFIP has moved into Phase II of Risk Rating 2.0: Equity in Action with the focus on transitioning existing policies. Beginning April 1, 2022, all policies will be priced under Risk Rating 2.0: Equity in Action at their next renewal.
Risk Retention Grop (RRG)
A state authorized risk bearing entity that, depending on the advising attorney advice, is not assessable to hits capitalizing membership or holding company. Assessable liability may change depending on RRG meeting minimum and ongoing capital surplus state requirements. Its complicated, so rely on licensed legal advice.
Risk Scoring (ACO Reach Model)
A method of paying ACO's for their care delivered to ACO members whose risk score is calculated, and that can cause the reimbursement to increase 3%. See: DRG, CMS, updated Risk Scoring component, Risk Scoring abuse
Risk Transfer (Risk cede)
An amorphous term describing risk cede of a defined peril or hazard. Risk can be ignored, funded, or transferred. An insurance policy transfers the majority of a defined risk in context to covered perils, limits, and the policy terms. Various self funded options provide for transferring a defined risk (by a deductible, claims reimbursement bases, etc), and is typically designed to trigger above where the insured in not comfortable, or unable to solvently assuming all the risk. Two old addages say it best - How do you manage catastrohhic risk, "Spread it out", and/or "Dont take it all." Remember that when pricing (brokering) risk for best rates, it is more what the underwriter believes is risky, than the entity's opinion seeking to transfer the risk. We recommend experienced brokerage with trusted relationships. In general context, risk transfer relates to population size and location, changes to that population or the plan design, SIR, claims handling experience, reserving practices, IBNR claims, loss prevention (risk manament) and mitigation, etc. It essentially boils down to the seven components of premium, and assigning credibility weights.
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.
Rule of 72
A rule allowing people under 59 1/2 to take money out of their 401's without the 10% penalty It is called a Section 72(t) distribution. In a 72(t) withdrawal, the distributions must be "substantially equal" payments based upon your life expectancy. Once the distributions begin, they must continue for a period of five years or until you reach age 59½, whichever is longest.

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 Clinic (RHC)
Rural Health Clinics (RHC)
See Federally-Qualified Health Centers
Rural-Urban Continuum Codes (RUCC)
See: Maryland Health Care Commission
RVS Update Committee (RUC)


Safe Harbour
In context to health care delivery, insurance and administration - Safe Harbor means a state or federally scheduled exception from an existing law prohibiting payments to or from self referring entities. See: Stark. "Anti-Kickback Safe Harbors (Portfolio Excerpt) (Excerpted from HLBS 1500 Federal Anti-Kickback Law, by Precious M. Gittens, Fresenius Medical Care North America, and Joseph LaMagna, Partner, Hooper, Lundy & Bookman, P.C., San Diego, Calif.) Value-Based Arrangements The following three safe harbors protect exchanges between or among participants in a value-based arrangement, to foster better coordinated and managed patient care.1 Although the safe harbors differ in level of financial risk assumed by the eligible parties, they share a commonality when it comes to which entities are ineligible for protection. Ineligible entities include: (i) pharmaceutical manufacturers, wholesalers, and distributors; (ii) PBMs; (iii) laboratory companies; (iv) pharmacies that primarily compound drugs or primarily dispense compounded drugs; (v) manufacturers of devices or medical supplies; (vi) entities or individuals that manufacture, sell, or rent DMEPOS (other than a pharmacy or a physician, provider, or other entity that primarily furnishes services, all of whom remain eligible); and (vii) medical device distributors or wholesalers that are not otherwise manufacturers of devices or medical supplies.2 a. Care coordination arrangements (1) General requirements The first value-based arrangements safe harbor, the care coordination arrangements safe harbor, was developed to facilitate value-based care and improved care coordination for patients by providers and others that may be assuming little or no substantial downside financial risk. It protects in-kind remuneration exchanged between a VBE and qualifying VBE participant or between qualifying VBE participants pursuant to a value-based arrangement that satisfies certain requirements. The terms of the value-based arrangement must be put into writing and signed by both parties prior to, or simultaneously with the commencement of the arrangement.3 Protected remuneration must predominantly be used to engage in value-based activities that are directly connected 1 These safe harbors were created by a final rule published Dec. 2, 2020. See 85 Fed. Reg. 77,684 § III.B.1. (effective Jan. 19, 2021). 2 The care coordination arrangements safe harbor includes a separate pathway, with specific conditions, that protects digital technology arrangements (as defined at paragraph §1001.952(ee)(14)) involving manufacturers of devices or medical supplies and DMEPOS. 42 C.F.R. § 1001.952(ee)(13); 85 Fed. Reg. 77,684 § III.B.1. (Dec. 2, 2020, effective Jan. 19, 2021). 3 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.3. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee). 4 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(9). 5 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(10). to the coordination and management of care for the target patient population. Further, protected arrangements cannot: • induce VBE participants to furnish medically unnecessary care or reduce medically necessary care; • limit medical decision-making or patient freedom of choice; or • take into account the volume or value of business outside of the value-based arrangement. All recipients must pay 15 percent of the offeror’s cost or 15 percent of the fair market value of the remuneration. (2) Monitoring and assessment The VBE, a VBE participant in the value-based arrangement acting on the VBE’s behalf, or the VBE’s accountable body or responsible person reasonably must monitor and assess the following no less frequently than annually or at least once during the term of the value-based arrangement for arrangements with terms of less than one year: (i) the coordination and management of care for the target patient population in the value-based arrangement; (ii) any deficiencies in the delivery of quality care under the value-based arrangement; and (iii) progress toward achieving the legitimate outcome or process measure(s) in the value-based arrangement.4 If the VBE’s accountable body or responsible person determines, based on the monitoring and assessment, that the value-based arrangement has resulted in material deficiencies in quality of care or is unlikely to further the coordination and management of care for the target patient population, the parties must within 60 days either terminate the arrangement or develop and implement a corrective action plan to remedy the deficiencies within 120 days.5 b. Value-based arrangements with substantial downside financial risk The second value-based arrangements safe harbor protects both monetary and in-kind remuneration exchanged between referring entities. "Anti-Kickback Safe Harbors (Portfolio Excerpt) (Excerpted from HLBS 1500 Federal Anti-Kickback Law, by Precious M. Gittens, Fresenius Medical Care North America, and Joseph LaMagna, Partner, Hooper, Lundy & Bookman, P.C., San Diego, Calif.) Value-Based Arrangements The following three safe harbors protect exchanges between or among participants in a value-based arrangement, to foster better coordinated and managed patient care.1 Although the safe harbors differ in level of financial risk assumed by the eligible parties, they share a commonality when it comes to which entities are ineligible for protection. Ineligible entities include: (i) pharmaceutical manufacturers, wholesalers, and distributors; (ii) PBMs; (iii) laboratory companies; (iv) pharmacies that primarily compound drugs or primarily dispense compounded drugs; (v) manufacturers of devices or medical supplies; (vi) entities or individuals that manufacture, sell, or rent DMEPOS (other than a pharmacy or a physician, provider, or other entity that primarily furnishes services, all of whom remain eligible); and (vii) medical device distributors or wholesalers that are not otherwise manufacturers of devices or medical supplies.2 a. Care coordination arrangements (1) General requirements The first value-based arrangements safe harbor, the care coordination arrangements safe harbor, was developed to facilitate value-based care and improved care coordination for patients by providers and others that may be assuming little or no substantial downside financial risk. It protects in-kind remuneration exchanged between a VBE and qualifying VBE participant or between qualifying VBE participants pursuant to a value-based arrangement that satisfies certain requirements. The terms of the value-based arrangement must be put into writing and signed by both parties prior to, or simultaneously with the commencement of the arrangement.3 Protected remuneration must predominantly be used to engage in value-based activities that are directly connected 1 These safe harbors were created by a final rule published Dec. 2, 2020. See 85 Fed. Reg. 77,684 § III.B.1. (effective Jan. 19, 2021). 2 The care coordination arrangements safe harbor includes a separate pathway, with specific conditions, that protects digital technology arrangements (as defined at paragraph §1001.952(ee)(14)) involving manufacturers of devices or medical supplies and DMEPOS. 42 C.F.R. § 1001.952(ee)(13); 85 Fed. Reg. 77,684 § III.B.1. (Dec. 2, 2020, effective Jan. 19, 2021). 3 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.3. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee). 4 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(9). 5 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(10). to the coordination and management of care for the target patient population. Further, protected arrangements cannot: • induce VBE participants to furnish medically unnecessary care or reduce medically necessary care; • limit medical decision-making or patient freedom of choice; or • take into account the volume or value of business outside of the value-based arrangement. All recipients must pay 15 percent of the offeror’s cost or 15 percent of the fair market value of the remuneration. (2) Monitoring and assessment The VBE, a VBE participant in the value-based arrangement acting on the VBE’s behalf, or the VBE’s accountable body or responsible person reasonably must monitor and assess the following no less frequently than annually or at least once during the term of the value-based arrangement for arrangements with terms of less than one year: (i) the coordination and management of care for the target patient population in the value-based arrangement; (ii) any deficiencies in the delivery of quality care under the value-based arrangement; and (iii) progress toward achieving the legitimate outcome or process measure(s) in the value-based arrangement.4 If the VBE’s accountable body or responsible person determines, based on the monitoring and assessment, that the value-based arrangement has resulted in material deficiencies in quality of care or is unlikely to further the coordination and management of care for the target patient population, the parties must within 60 days either terminate the arrangement or develop and implement a corrective action plan to remedy the deficiencies within 120 days.5 b. Value-based arrangements with substantial downside financial risk The second value-based arrangements safe harbor protects both monetary and in-kind remuneration exchanged between 2021 Outlook on Health Law 24 a VBE, that assumes substantial downside financial risk,6 and a payor under one of three methodologies . A qualifying VBE participant must meaningfully share the financial risk. The terms of the value-based arrangement must be put into writing and signed by both parties prior to, or simultaneously with the commencement of the arrangement.7 Protected remuneration must predominantly be used to engage in value-based activities that are directly connected to the items and services for which the VBE has assumed (or has entered into a written contract or value-based arrangement to assume within the next six months) substantial downside financial risk. In line with the other two value-based arrangement safe harbors, protected arrangements cannot: • take into account the volume or value of, or condition the remuneration on, referrals of patients outside of the target patient population or business not covered under the value-based arrangement; • limit the VBE participant’s ability to make decisions in the best interests of its patients; or • induce the VBE or VBE participants to reduce or limit medically necessary items or services furnished to any patient. c. Value-based arrangements with full financial risk The third value-based arrangements safe harbor protects both monetary and in-kind remuneration exchanged between a VBE and a VBE participant pursuant to a value-based arrangement where the VBE has assumed, or is contractually obligated to assume full financial risk8 for a term of at least one-year.9 Protected remuneration must predominantly be used to engage in one or more of the VBE’s value-based purposes. In line with the other two value-based arrangement safe harbors, protected arrangements cannot: • take into account the volume or value of, or condition the remuneration on, referrals of patients outside of the target patient population or business not covered under the value-based arrangement; • limit the VBE participant’s ability to make decisions in the best interests of its patients; or • induce the VBE or VBE participants to reduce or limit medically necessary items or services furnished to any patient. 6 A VBE can assume risk from the payor through an arrangement that meets the definition of “value-based arrangement,” or a VBE can assume risk from a payor through a written contract that places the VBE at substantial downside financial risk. 7 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.4. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ff). 8 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.5. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg)(2). 9 The value-based arrangement must be set forth in writing, signed by the parties, and specify all material terms, including the value-based activities and the term. 85 Fed. Reg. 77,684 § III.B.5.f. (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg). 10 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.6. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg)(2). 11 Safe harbor protection extended to a VBE participant that provides patient engagement tools or supports through a third party that qualifies as an “eligible agent,” as defined in §1001.952(hh)(9). Arrangements under this safe harbor are also protected under the Beneficiary Inducements CMP. 42 C.F.R § 1003.110(10); 85 Fed. Reg. 77,684 § III.B.6.d. (Dec. 2, 2020, effective Jan. 19, 2021). Patient Engagement and Support The patient engagement and support safe harbor, 42 C.F.R. § 1001.952(hh), protects patient engagement tools and supports—in-kind items, goods, and services564— furnished directly by VBE participants to patients in a target patient population of a value-based arrangement to which the VBE participant is a party.10 Patient engagement tools or support cannot be funded or contributed by a VBE participant that is not a party to the applicable value-based arrangement or by an entity listed at §1001.952(hh)(1)(i) through (viii).11 The aggregate retail value of patient engagement tools and supports furnished to a patient by a VBE participant on an annual basis cannot exceed $500. Any protected tool or support must have a “direct connection” to the coordination and management of care of the target patient population and must not result in medically unnecessary or inappropriate items or services reimbursed in whole or in part by a Federal health care program. The tools and supports must advance one or more of the following goals: • Adherence to a treatment regimen determined by the patient’s licensed health care professional. • Adherence to a drug regimen determined by the patient’s licensed health care professional. • Adherence to a follow-up care plan established by the patient’s licensed health care professional. • Prevention or management of a disease or condition as directed by the patient’s licensed health care professional. • Ensure patient safety. The following entities are not eligible for protection under this safe harbor: (i) pharmaceutical manufacturers, wholesalers, and distributors; (ii) PBMs; (iii) laboratory companies; (iv) pharmacies that primarily compound drugs or primarily dispense compounded drugs; (v) manufacturers of devices or medical supplies (except with respect to digital health technology, as described below); 2021 Outlook on Health Law 25 (vi) entities or individuals that sell or rent DMEPOS (other than a pharmacy, a medical device or supply manufacturer that also sells or rents DMEPOS, or a physician, provider, or other entity that primarily furnishes services, all of whom remain eligible); (vii) medical device distributors or wholesalers that are not otherwise manufacturers of devices or medical supplies; and (viii) medical device manufacturers, distributors, or wholesalers with ownership or investment interests held by physicians. CMS-Sponsored Models a. General requirements The safe harbor created at 42 CFR § 1001.952(ii) protects certain financial arrangements and patient incentives related to the Medicare Shared Savings Program under section 1899 of the Act and models established and tested by CMS under section 1115A of the Act. The CMS-sponsored model patient incentive must have a direct connection to the patient’s health care, unless the participation documentation specifies a different standard.12 b. Duration of protection (1) For a CMS-sponsored model governed by participation documentation other than the legal instrument setting forth the terms and conditions of a grant or a cooperative agreement, the exchange of remuneration between CMSsponsored model parties that occurs on or after the first day on which services under the CMS-sponsored model begin and no later than 6 months after the final payment determination made by CMS under the model. (2) For a CMS-sponsored model governed by the legal instrument setting forth the terms and conditions of a grant or cooperative agreement, the exchange of remuneration between CMS-sponsored model parties that occurs on or after the first day of the period of performance (as defined at 45 CFR § 75.2) or such other date specified in the participation documentation and no later than 6 months after closeout occurs pursuant to 45 CFR § 75.381. (3) For a CMS-sponsored model patient incentive, an incentive given on or after the first day on which patient care services may be furnished under the CMS-sponsored model as specified by CMS in the participation documentation and no later than the last day on which patient care services may be furnished under the CMS-sponsored model, unless a different timeframe is established in the participation documentation. A patient may retain any incentives furnished in compliance with paragraph (ii)(2) of this section. 12 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.7. (effective Jan. 19, 2021). Cybersecurity Technology and Services 42 CFR § 1001.952(jj) created a safe harbor to address the growing threat of cyberattacks impacting the health care ecosystem and protect nonmonetary donations of certain cybersecurity technology and related services necessary and used predominantly to implement, maintain, or reestablish effective cybersecurity.568 This safe harbor will not protect the following donations: • donations where donors directly take into account the volume or value of referrals or other business generated between the parties when determining the eligibility of a potential recipient for the technology or services, or the amount or nature of the technology or services to be donated; • donations where donors condition donations of technology or services, or the amount or nature of the technology or services to be donated, on future referrals; and • donations where the recipient or the recipient’s practice (or any affiliated individual or entity) makes the receipt of technology or services, or the amount or nature of the technology or services, a condition of doing business with the donor." Source: Bloomberg 2021 Outlook on Health Law

Safety Net Provider
A CMS term for primary care physician availability or access to care in underserved areas of poor people. See: Value Based Care.

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 )
While the PPACA allowed each State to operate its own State Exchange, currently 11 States and the District of Columbia operate their own Exchanges, five States utilize the SBE–FP model, and FFEs operate in the remaining 34 States. CMS seeks to support innovation by States operating State Exchanges by providing opportunities ....
Jargon used to describe a medical prescription for drugs. See AWP See DTC.
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.
Secondary Annuity Market (Factored Structored Settlements)
As with just about all assets, life insurance and annuity products, there are primary, secondary and tertiary markets offering lump sum payouts in return for the asset. How it gets taxed by the buying entity makes a big difference.
Section 125 Plans (FSA, 125 Plans)
Medical benefit plans employers can establish to pay for eligible insurances with pretax funds, and thereby save on payroll taxes. Funds can also be applied to things like parking expenses, so talk to a CPA. 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. New options are also available, and change the calculation of what is affordable (i.e. 9.61% of Employees AGI/MAGI) that now INCLUDES cost insuring the employee's family, and not just the cost of the employee. See: ICHRA, QSEHRA's. Talk to a CPA, and good luck figuring out exactly how much the employee's famuily gets (in addition to the employees total compensation benefits package) in a tax cedit to the employer to insure his family.

In context to the S&P 500 Index (Standard and Poors): A term describing one of eleven industries representing 500 stocks included in the index. See: SPY
Secure Act
An law that lowers the requirements for non-similar business entities to offer retirement plans. See: MEPS, ARPS, PEPS, PEOs, MEWA. ======================Related to lowering the requirements needed to reimburse employees directly with "pretax" earnings for individual health insurance purchased when the employer does not insure employees with a group plan paid for my the employer. "Beginning in 2021, small-business clients will have more retirement benefit options. The Secure Act removed the commonality of interest requirement that previously limited multiple employer plans (MEPs) to business owners who shared the same geographic location or industry—creating a new type of MEP. Under the Secure Act, employers will be able to offer MEPs, association retirement plans (ARPs) and pooled employer plans (PEPs)." "Association Retirement Plans (ARPs): The 2019 DOL Regulations In 2019, the DOL released regulations designed to expand access to MEPs. Some in the industry began referring to these new MEPs as association retirement plans (ARPs) to differentiate from the original “closed” MEP, and to clarify that ARPs must satisfy additional criteria in order to be treated as qualified plans. Essentially, the ARP is a type of MEP, and the terms have mostly been used interchangeably. Under the ARP structure, employers that share only the same geographic location or industry are permitted to join together in the MEP. The participating employers can be located in the same city, county, state or even multi-state region. Companies operating in the same industry can join together even if they operate in entirely different regions. The ARP can be sponsored by a permitted group of employers if certain formalities are satisfied (the organization of employers must be bona fide, with organizational documents and control over the MEP in substance and in form, directly or indirectly, among other requirements). In the alternative, ARP members can now join together in a plan sponsored by a professional employer organization (PEO). When a PEO is used, that PEO must accept administrative responsibility for substantial employment-related duties, such as responsibility for paying wages to the participants’ employees, including all withholding and reporting responsibilities. The PEO must also have a role in recruiting, hiring and firing employees of the participating employers, and must play a substantial role in administering the employers’ benefit offerings." "Pooled Employer Plans (PEPs) Post-Secure Act Building upon the momentum surrounding MEPs, beginning in 2021, the Secure Act permits MEP participation for employers who share no common interest apart from the desire to offer a retirement plan. The Secure Act also eliminated many concerns about the “one bad apple” rule by providing that the entire plan would not be disqualified based on a single participant’s actions. Under the Secure Act, these types of MEPs are also called pooled employer plans (PEPs)—another name for a type of MEP that meets certain additional requirements to avoid the commonality of interest requirement and one bad apple rule. The PEP will be treated as a single retirement plan." "This type of “open MEP” must be administered by a pooled plan provider (generally, a financial services firm). Use of the pooled plan provider to act as both plan administrator and a fiduciary with respect to the plan is intended to ease both the administrative burden and fear of fiduciary liability for small business owners." "The pooled plan provider must register as a fiduciary with the Treasury Department and the DOL. The pooled plan provider also must have a trustee responsible for monitoring contributions and dealing with subsequent issues that arise." Small business clients should understand that, as employer, they continue to bear fiduciary responsibility with respect to selecting and monitoring the pooled plan provider. Pooled plan providers can outsource investment decisions to another fiduciary (likely what is known as a “3(38) fiduciary”). This arrangement does spread the costs of investment advice among the MEP participants to reduce expenses, but the extent of the employer’s fiduciary exposure still remains unclear under the law." Source Think Advisor: June 2020

Secure Act
A law guiding ARP's, MEPs, PEPs that effectively removed the commonality rule that used to be required for multiple employer (ERISA) associations to insure their employees inside of states, and across state lines. See: MEWA, and try to differentiate what they offer that MEWA's did not already offer...? Focus on why States would challenge them, and the state's ultimate power to impose cease and desists authority over any insuring entity failing to meet state solvency, or certificate of authority mandate. See: MEWA
The mechanisms in place to protect the confidentiality and privacy of personal information (PII). Source: Federal Marketplace Exam 2022
Security Contral
See: HIPPA, etc.
Security Incident
See: Glossary of Office of Management and Budget. A ambiguous category of unauthorized or perhaps even criminal hacking/release of PII. See HIPPA, and good luck figuring out who is guiding what standard, and when it becomes whose responsibility to inform who that their data "may" have been hacked? See: Security Control, Responsible Official,
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
Self Insurer's Bond
A bond purchased by a self insured employer to cover retnetion, and free up lines of credit while meeting state guidelines to have money on hand in the event of a loss. I.e. For Wokers Compensation SIR
Self Referral
See: Stark and complicated safe harbors. "Centers for Medicare & Medicaid Services (CMS) finalized changes to outdated federal regulations that have burdened health care providers with added administrative costs and impeded the health care system’s move toward value-based reimbursement. The Physician Self-Referral Law, also known as the “Stark Law,” generally prohibits a physician from sending a patient for many types of services to a provider that the physician owns, is employed by, or otherwise receives payment from—regardless of what that payment is for. The old federal regulations that interpret and implement this law were designed for a health care system that reimburses providers on a fee-for-service basis, where the financial incentives are to deliver more services. However, the 21st century American health care system is increasingly moving toward financial arrangements that reward providers who are successful at keeping patients healthy and out of the hospital, where payment is tied to value rather than volume." Source: CMS

Senate Health, Education labor and Pensions Committee (HELP (Senate Committee))
Republican lead committee vetting various healthcare bills, and that passed (November 2019 - vote of 20-3) the "Lower HealthCare Costs Act" aimed at eliminating surprise (in-network) billings, and allows the federal government to directly negotiate pharmacy (entitlement programs: Medicare, Medicaid, Tricare, etc.), instead of the health plans directly negotiating them at smaller scale, authority and effect. Source: Squire Patton Boggs
Senate Health, Education, Labor, and Pensions Committee (HELP)
A Senate committee that passed the Lower Healthcare Costs Act (i.e. Surprise Billings prohibition on IN NETWORK care) You are still out of luck with unlimited MOOP on OUT OF NETWORK care. See: Balance Billing
SEP IRA (Simple IRA)

Seriously Ill Population (SIP)
See Primary care first webpage at CMS. "Primary Care First Model Options Select link to open options for Share Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the underlying principles of the existing CPC+ model design: prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. Primary Care First Model Options will be offered in 26 regions for a 2020 start date: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide)."

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 Accountability
See: Value Based Pricing. "The new goals for adoption of shared accountability alternative payment models include increasing the percentage of payments tied to quality and value to 50% for Medicaid and commercial health care expenses, and to 100% for Medicare Advantage and traditional Medicare expenses — all by 2025." Source: Think Advisor Jan 2020
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 during the Benefit Year The transitional reinsurance and permanent risk adjustment programs functioned smoothly for 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. It can also be a loose term used to detail the 50% of Shared Savings a provider group can earn for managing care costs below the targeted budgeted claims.

Shared Risk (Medicare Risk Contract)
A term usually applied to a Medicare risk bearing contracts offering downside financial risk, and upside splitting of surplus(es) achieved during a contracted period of time - typically 3 years in duration. "Direct Contracting Risk-Sharing Options - Direct Contracting Risk-Sharing Options: Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations. CMS is testing two voluntary risk-sharing options: Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation" Source: CMS
Shared Savings Program (MSSP - Medicare Shared Savings Program)
See QPP, CSR, MSSP, Direct Contracting Risk-sharing 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. Shared Savings does apply to ACO's entering track 2 or 3 of available at risk contracting with CMS for targeted ACO accepting risk. Savings below target are "shared" with the providers. Per Medical Intelligence update September 2018, "MSSP ACOs with just one to two years of experience in the program actually increased Medicare spending, researchers reported. "Direct Contracting Risk-Sharing Options - Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10 Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations. We will test two voluntary risk-sharing options: Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation" Source: CMS

From IRS: asic Information Two provisions of the Affordable Care Act apply only to applicable large employers (ALEs): The employer shared responsibility provisions; and The employer information reporting provisions for offers of minimum essential coverage Whether an employer is an ALE is determined each calendar year, and generally depends on the average size of an employer’s workforce during the prior year. If an employer has fewer than 50 full-time employees, including full-time equivalent employees, on average during the prior year, the employer is not an ALE for the current calendar year. Therefore, the employer is not subject to the employer shared responsibility provisions or the employer information reporting provisions for the current year. Employers who are not ALEs may be eligible for the Small Business Health Care Tax Credit and can find more information about how the Affordable Care Act affects them on the ACA Tax Provisions for Small Employers page. If an employer has at least 50 full-time employees, including full-time equivalent employees, on average during the prior year, the employer is an ALE for the current calendar year, and is therefore subject to the employer shared responsibility provisions and the employer information reporting provisions. To determine its workforce size for a year an employer adds its total number of full-time employees for each month of the prior calendar year to the total number of full-time equivalent employees for each calendar month of the prior calendar year and divides that total number by 12. The Surface Transportation and Veterans Health Care Choice Improvement Act of 2015 provides that an employee will not be counted toward the 50-employee threshold for a month in which the employee has medical care through the military, including Tricare or Veterans’ coverage. This is solely for the purpose of determining whether an employer is an “applicable large employer” subject to the employer shared responsibility rules of § 4980H. For more information, see IRC § 4980H(c)(2) subparagraph (F) “Exemption for Health Coverage Under Tricare or the Veterans Administration.” Full-time Employees and Full-Time Equivalent Employees A full-time employee for any calendar month is an employee who has on average at least 30 hours of service per week during the calendar month, or at least 130 hours of service during the calendar month. A full-time equivalent employee is a combination of employees, each of whom individually is not a full-time employee, but who, in combination, are equivalent to a full-time employee. An employer determines its number of full-time-equivalent employees for a month in the two steps that follow: Combine the number of hours of service of all non-full-time employees for the month but do not include more than 120 hours of service per employee, and Divide the total by 120. An employer’s number of full-time equivalent employees (or part-time employees) is only relevant to determining whether an employer is an ALE. An ALE need not offer minimum essential coverage to its part-time employees to avoid an employer shared responsibility payment. A part-time employee’s receipt of the premium tax credit for purchasing coverage through the Marketplace cannot trigger an employer shared responsibility payment. The Employer Shared Responsibility Provision Estimator helps employers understand how the provision works and learn how the provision may apply to them. Employers can use the estimator to determine: The number of full-time employees, including full-time equivalent employees, Whether an employer might be an applicable large employer, and For employers that are an applicable large employer, an estimate of the maximum amount of the potential liability for the employer shared responsibility payment that could apply, based on the number of full-time employees reported if an employer fails to offer coverage to its full-time employees. Basic ALE Determination Examples Example 1 – Employer is Not an ALE Company X has 40 full-time employees for each calendar month during 2018. Company X also has 15 part-time employees for each calendar month during 2018 each of whom have 60 hours of service per month. When combined, the hours of service of the part-time employees for a month totals 900 [15 x 60 = 900]. Dividing the combined hours of service of the part-time employees by 120 equals 7.5 [900 / 120 = 7.5]. This number, 7.5, represents the number of Company X’s full-time equivalent employees for each month during 2018. Employer X adds up the total number of full-time employees for each calendar month of 2018, which is 480 [40 x 12 = 480]. Employer X adds up the total number of full-time equivalent employees for each calendar month of 2018, which is 90 [7.5 x 12 = 90]. Employer X adds those two numbers together and divides the total by 12, which equals 47.5 [(480 + 90 = 570)/12 = 47.5]. Because the result is not a whole number, it is rounded to the next lowest whole number, so 47 is the result. So, although Company X has 55 employees in total [40 full-time and 15 part-time] for each month of 2018, it has 47 full-time employees (including full-time equivalent employees) for purposes of ALE determination. Because 47 is less than 50, Company X is not an ALE for 2019. Example 2 – Employer is an ALE Company Y has 40 full-time employees for each calendar month during 2018. Company Y also has 20 part-time employees for each calendar month during 2018, each of whom has 60 hours of service per month. When combined, the hours of service of the part-time employees for a month totals 1,200 [20 x 60 = 1,200]. Dividing the combined hours of service of the part-time employees by 120 equals 10 [1,200 / 120 = 10]. This number, 10, represents the number of Company Y’s full-time equivalent employees for each month during 2018. Employer Y adds up the total number of full-time employees for each calendar month of 2018, which is 480 [40 x 12 = 480]. Employer Y adds up the total number of full-time equivalent employees for each calendar month of 2018, which is 120 [10 x 12 = 120]. Employer Y adds those two numbers together and divides the total by 12, which equals 50 [(480 + 120 = 600)/12 = 50]. So, although Company Y only has 40 full-time employees, it is an ALE for 2019 due to the hours of service of its full-time equivalent employees. Additional examples can be found in section 54-4980H-2 of the ESRP regulations. Employer Aggregation Rules Companies with a common owner or that are otherwise related under certain rules of section 414 of the Internal Revenue Code are generally combined and treated as a single employer for determining ALE status. If the combined number of full-time employees and full-time equivalent employees for the group is large enough to meet the definition of an ALE, then each employer in the group (called an ALE member) is part of an ALE and is subject to the employer shared responsibility provisions, even if separately the employer would not be an ALE. Example 3 – Employers are Aggregated to Determine ALE Status: Corporation X owns 100 percent of all classes of stock of Corporation Y and Corporation Z. Corporation X has no employees at any time in 2018. For every calendar month in 2018, Corporation Y has 40 full-time employees and Corporation Z has 60 full-time employees. Neither Corporation Y nor Corporation Z has any full-time equivalent employees. Corporations X, Y, and Z are considered a controlled group of corporations. Because Corporations X, Y and Z have a combined total of 100 full-time employees for each month during 2018, Corporations X, Y, and Z together are an ALE for 2019. Corporation Y and Z are each an ALE member for 2018. Corporation X is not an ALE member for 2019 because it does not have any employees during 2018. There is an important distinction for employers to keep in mind regarding these aggregation rules. Although employers with a common owner or that are otherwise related generally are combined and treated as a single employer for determining whether an employer is an ALE, potential liability under the employer shared responsibility provisions is determined separately for each ALE member. Also, a special standard applies to government entity employers in the application of the aggregation rules under section 414. Because section 414 relates to common ownership and ownership isn’t a typical arrangement for government entities, and because specific rules under section 414 of the Code for government entities haven’t yet been developed, government entities may apply a good faith reasonable interpretation of section 414 to determine if they should be aggregated with any other government entities. See Q&A #s11 and 44 on our employer shared responsibility provisions questions and answers page for more information. Seasonal Workers When determining if an employer is an ALE, the employer must measure its workforce by counting all its employees. However, there is an exception for seasonal workers. An employer is not considered to have more than 50 full-time employees (including full-time equivalent employees) if both of the following apply: The employer's workforce exceeds 50 full-time employees (including full-time equivalent employees) for 120 days or fewer during the calendar year, and The employees in excess of 50 employed during such 120-day period are seasonal workers. A seasonal worker is generally defined for this purpose as an employee who performs labor or services on a seasonal basis. For example, retail workers employed exclusively during holiday seasons are seasonal workers. For more information about how seasonal workers affect ALE determinations, see our Questions and Answers page. For information on the difference between a seasonal worker and a seasonal employee under the employer shared responsibility provisions see Q&A #26. And for the full definition of seasonal worker, see section 54.4980H-1(a)(39) of the ESRP regulations. Application to New Employers A new employer (that is, an employer that was not in existence on any business day in the prior calendar year) is an ALE for the current calendar year if it reasonably expects to employ, and actually does employ, an average of at least 50 full-time employees (including full-time equivalent employees) on business days during the current calendar year. See Q&A #7 on our employer shared responsibility questions and answers page for more information. More Information More information about determining ALE status can be found in our Questions and Answers and Publication 5208 PDF, Affordable Care Act – Are you an applicable large employer? The Department of the Treasury and the IRS have also issued the following legal guidance related to the employer shared responsibility provisions: Regulations on the employer shared responsibility for employers. In particular, section 54.4980H-2 of the regulations addresses rules for determining ALE status. Notice 2013-45 PDF, announcing transition relief for 2014. More information is also available in this fact sheet PDF issued by the U.S. Department of the Treasury. Employers Topics

SHOP Eligibility
Employers must meet specific eligibility requirements to purchase SHOP coverage, which include: 1) having a principal business address or eligible employee worksite in the SHOP service area where the employer is applying for and offering coverage, 2) being a small employer, as defined under federal and state law, and 3) offering SHOP coverage to all full-time employees. A small employer can purchase a SHOP plan any month throughout the year, but the group must meet any applicable MPR, except for enrollments occurring between November 15 and December 15. Small employers that offer SHOP coverage can offer health coverage only, dental coverage only, or both health and dental coverage. To qualify for the Small Business Health Care Tax Credit, small employers must have fewer than 25 FTE employees (based on a 40-hour work week), must contribute a uniform percentage (at least 50%) of the premium cost of employee-only insurance coverage on behalf of each employee who enrolls in a SHOP QHP, and must pay average annual employee wages of less than $55,000 in 2019 per FTE employee (adjusted annually for inflation). The tax credit is generally available only for qualified employers who have purchased and have qualified employees enrolled in a SHOP plan. Qualified employers directly pay each issuer in which qualified employees are enrolled. Source: Marketplace SHOP Exam
SHOP Eligibility Determination Tool
SHOP customers must have 1-50 employees (FTEs)

SHOP Enrollment Tool

SHOP FTE Calculator Tool
SHOP Fulle TIme Equivelent Calculator tool.

SHOP MPR Calculator Tool
Minimum Participation Rate Calculator for SHOP tool
SHOP Plans & Prices Tool

SHOP Privacy and Security
SHOP Section II(a) of the SHOP Privacy and Security Agreement identifies the following authorized functions for which an agent or broker may create, collect, disclose, access, maintain, store, and use PII in the SHOP. The references below to the “SHOP Marketplace” include both FFMs and SBM-FPs. 1. Assisting with application, eligibility, and enrollment processes for QHPs offered through the SHOP Marketplace 2. Supporting SHOP Marketplace QHP selection and enrollment by assisting with plan comparisons and plan selection 3. Facilitating employer premium contribution amount selections through the SHOP Marketplace 4. Facilitating payment of the initial and subsequent group premium amount for SHOP Marketplace coverage 5. Facilitating employee and dependent enrollment and disenrollment in QHPs offered through the SHOP Marketplace 6. Handling SHOP Marketplace coverage changes throughout the plan year that may impact eligibility, including adding a new hire, removing an employee no longer employed at a company, removing an employee no longer employed full-time, and adding a newborn or spouse during a special enrollment period 7. Assisting with filing appeals of SHOP Marketplace eligibility determinations 8. Providing customer service activities related to SHOP Marketplace coverage if permitted under state and federal law, including correction of errors on SHOP Marketplace applications and policies, handling complaints and appeals regarding SHOP Marketplace coverage, responding to questions about SHOP Marketplace insurance policies, assisting in communicating with SHOP Marketplace issuers, assisting with communicating with state regulatory authorities regarding SHOP Marketplace issues, and assistance in communicating with CMS and SHOP Marketplace Workforces 9. Conducting quality assurance activities, including assessment of consumer satisfaction related to the agent’s or broker’s assistance with SHOP Marketplace coverage 10. Providing information, materials, and programs to educate consumers, applicants, employers, employees, qualified employers, qualified employees, and enrollees about the use and maintenance of their SHOP Marketplace health coverage and policies 11. Carrying out the agent’s or broker’s legal responsibilities related to QHP issuer functions in the SHOP Marketplace as permitted or required by the agent’s or broker’s contractual relationships with QHP issuers 12. Other functions substantially similar to those enumerated above and such other functions that may be approved by CMS in writing from time to time. Source: Marketplace Exam 2022
SHOP Tax Credit Estimator
For tax years beginning in 2014 and beyond, the Small Business Health Care Tax Credit may be worth up to 50% of the qualified employer’s contribution toward premium costs (up to 35% for tax-exempt employers) for two consecutive taxable years. The credit is decreased for eligible small employers if the number of FTE employees exceeds 10, or if the average annual wages for FTE employees exceeds $25,000 (as adjusted for inflation). For a qualified employer with both more than 10 FTE employees and average annual FTE employee wages exceeding $25,000, the credit is reduced based on the sum of the two reductions. This may reduce the credit to zero even for some qualified employers with fewer than 25 FTE employees and average annual FTE employee wages less than $55,000 in 2019 (as adjusted for inflation). Source: Marketplace Exams 2021

Shoppable Procedures
An ambiguous terms used to describe RBS, and in context to varying levels of "accepted" or mandated maximum reimbursements established by a specific fee schedule, or reimbursement contract. More common ones might be fore: • Knee replacements; • Hip replacements; • Cataract surgery; • Colonoscopies; and Imaging, Ect.
Short Term Limited Duration Insurance (STLDI)
See: STM Its what United Healthcare typically calls STM
Short Term Medical Plan (STM, STCI, Scheduled Medical, Limited Medical, Min)
A medical plan available to people both inside and outside of Open Enrollment, and whose term of coverage is typically less than 364 days. Trump EO and ACA non-enforcement of ACA law prohibition against preexisting medical conditions, and QHP allows plans to exist in the US now. Plans cost about 10%-60% of ACA compliant insurance. Do the work to understand what you are buying, or don't buy the plan. Beware exclusions, and balance billing liability. See: Balance Billing, QHB, EHB, coverage denials, policy rescission, etc. Most important in the current status is that STM can exclude preexisting medical conditions (apparently during both Open Enrollment and Special Enrollment Periods). Most STM's are not "faith based" plans. Many other types of medical plans are available, that may also be a type of short term plan inclusive of: Limited Medical Plans, or Cancer-Cardiac-Critical care plans, Hospital indemnity (gap) plans, Travel Accident plans, Accident only plans, etc. Most STM provide little or no Rx insurance. AARP plans to roll out a STM in 2020 to members, and is expected to exclude several medical conditions and underwrite both height and weight - a practice that is prohibited on ACA compliant plans.

SIC codes (Class codes)
See NCCI who issues about 700 work type codes for purposes of assigning workers compensation premium (risk) assignment. Means, dangerous jobs cost more than white collar jobs. See: MOD's.
Silver Loading
A carrier practice of disproportionately increasing the premiums of "silver" (metallic) ACA QHP offered plans. I.e. Blue Cross Plan increased my Silver Plan 45% on 2018 in my renewal. The term can also mean republican administrative "actions" to disrupt ACA law.
Silver Tsunami
Term used to warn everyone about (baby-boomers) 10,000-11,000 people a day turning 65, and federal/state/municipal/employer/individual preparation needed to fund and treat a much older population. Just know that Medicare medical utilization is about 3 times greater than for people under 65 years old cost of care. This is much bigger than people are prepping for, and could mean tremendously faster pace (marginal change) of change at a speed that would further make unaffordable commercial premiums. If commercial premiums (currently subsidized APTC) fail to insure the under 65 population, then hospitals who rely on 240% average greater reimbursement from commercial patients (Medicare cost-shifts costs which is a tremendous subsidy for Medicare insured lives) will fail in their current high cost, fragmented structures.
Simple or SEP Retirement Plan (SEP)
A retirements plan used by some smaller corporations or sole proprietors.

Simultaneous Funidng
A stop loss policy feature that if offered, and/or requested, allows for simultaneous processing of a specific and aggregate claims, even 7-10 days after the end of the policy (well before three month policy term). These get a bit squirrely to manage where aggregated claims are not well above aggregate attachment stipulated in the policy.
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.
Single Payor System
A make believe term used by conservatives to describe a government offered major medical plan for everyone. See Medicare for all, Medicaid for all, Medicare supplemental plans, SHOP plans, Marketplace offered plans, off marketplace offered plans, Commercially offered group/small group/ERISA self-funded etc.
Single Premium Life (SPL)
Life insurance IRS compliance mandates following at least one of two IRS tests. Single premium policy's can be funded lump sum, but apportioned from a holding account (Paid up additions, "account A", account B, etc). Be sure you understand how a life insurance policy may convert to a MEC and lose its tax preferred status. Funds held in the holding account are typically guaranteed a minimum interest crediting similar to a fixed rate annuity rate.
Site Neutral Rule (HHS site neutral Rule)
HHS *Medicare and Medicaid) started paying less for hospital owned outpatient surgeries in 2019, and AHA sued to overturn it, which it did, then AHA lost it (again) on appeal, and the Supreme Court dismissed AHA appeal. Hospital outpatient costs at stand alone facilities are considerably less then hospital based outpatient surgeries, the the dissmissal effectively lowers reimbursements to hospitals trying to upcharge outpatient services at area clinics that are not the Hospital ER, and whose costs of providing care are materially less.

Site oF Service Instead of Specific Providers (SISC)
See: RBP in California. Basically boils down to hospitals and some providers agreeing to accept a multiple of the MA amount for targeting arthroscopy, cataract surgery, colonoscopy, upper GI endoscopy with or without biopsy. Note: recent research declares Commercial payers pay about 240% more than MA amount.
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 25 FTE's (whose employee average income is under $50K), that offers potential BUSINESS tax credit up to 50% (year one) and 35% (year two, and nothing for years 3+) of what the employer contributes towards an employee’s premium. Tax credits are offered up to two years. Enrollment is 100% on-line, and premium payments must be in no later than the 15th of each month. Carriers like Coventry/Aetna pay about 1.5% of paid premium for commission to agents - which usually meas loss to an agent. Federal and commercial efforts to enroll small employers has essentially failed under the current non-commissioned agency structure. Carriers have for many years done their best to not write small group, with Aetna, Cigna and United leading the way. Most carriers do not offer any SHOP plans. most people cfail to acknowledge that no "government" SHOP plans are available, but only commercially offered SHOP plans if any at all. Eligibility rules are complicated - employers generally must be "small employers" and have at least one employee on the first day of the plan year. Group "participation" rules are no longer waived, and mandate 50% minimum (QHP plans). ACA defines ALE. 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 25 full-time and full-time-equivalent (FTE) employees (one to 100 in some states 0 so it no straight forward in all states) on average, on business days during the preceding calendar year. When counting FTE, its complicated and includes combined part time employees working 30+ hours per week. PEO is complicated. A 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, and with equal employer premium contribution, and minimum participation rate (MPR) of 70%. What counts toward participaion is complicated. 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. For an employer group to enroll in SHOP coverage, a certain percentage of employees must enroll during what the feds detail in OEP (Nov 15 - Dec 15, unlike "off-exchange employer "group" plans). 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 QHP coverage through another group health plan, government-sponsored coverage (such as Medicare, Medicaid, QHP, 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. 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 probably used in most states used. Multiple states run their own healthcare marketplaces, so good luck. 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. I.e. Bronze plan with actuarial value of 60% of the total claims costs of care on average. Means an average enrollee can expect to pay about 40% of all care until reaching MOOP. Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30% until reaching MOOP. 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 Existing Agent Commissions on groups under 4 lives have been reduced or eliminated completely, thereby eliminating the line of business for many agents.  Historical actions by many carriers detail agressive actions to limit small group enrollments with guarantee issue plans.   "The Small Business Health Options Program (SHOP) provides quality, affordable health and dental insurance for small businesses and their employees, in many states. SHOP plans are offered by private insurance companies and cover essential health benefits and pre-existing conditions. There is no limited enrollment period for small employers interested in purchasing SHOP insurance; they can start offering SHOP coverage to their employees any time of year. Regardless of when SHOP coverage starts, the plan year typically lasts for 12 months. To purchase SHOP insurance, small employers must meet the enrollment requirements." Source: CMS ===== Employer-sponsored insurance is considered unaffordable for an employee, and/or their employee’s family if the amount the employee must contribute exceeds the maximum percent of (AGI/MAGI) set by the federal government, for the lowest-cost regionally adjusted plan price. . The percentage is 9.86% (check it, because Biden temporarially lowered it) for plan years 2021. Re: Employer penalties (over 50 FTEs) are assessed on each employee who elects to enroll in a Marketplace plan with APTC, and who rejects the employer offered plan because the employee contribution exceeded affordibility (percentage of AGI/MAGI). Source: Agent Marketplace Exam See: Contribution, Participation, ALE, APTC, SHOP tax credit, IQHRA, HSA, etc.

Small Group Medical (Sall Group, or Group)
An amorphous term defined differently by many carriers, and states. In Florida, it typically means FTE's insured being 3 lives or less. It can mean groups under 50 or 100 too. Florida has a special one-person small group plan option too, available in August of each year, but practically requiring an agent to process for material chance of enrolling within a 30 day period each year. Most if not all carriers aggressively structure to avoid offering or issuing one-person-only groups for a long history of risk aversion.
Small Underserved Rural Support (SURS)
Over the past 5 years, the Centers for Medicare & Medicaid Services (CMS) has successfully implemented a technical assistance initiative for clinicians in small practices participating in the Quality Payment Program (QPP) known asA CMS sub program for rural MIPS measurment, etc. Underserved, and Rural Support (SURS). This initiative provides free, customized technical assistance to practices with 15 or fewer Merit-based Incentive Payment System (MIPS) eligible clinicians
Small Message Service is a text to you cell phone in context to multi-factor Athorization process. See: Interactive Voice Response (IVR), Google Authenticator, Okta Verify, and Yubikey.
SNF Quality Reporting Measures
Social Determinants of Health (SDOH)
Measured and tracked behaviors (i.e. drinking, smoking, access to care, etc) studied to determine: financial, co-morbidity and mortality causality. SDOH purpose is to effect healthier behaviors resulting in better health, and lower costs. One of the latest terms used to focus on what matters in "value Based reimbursements" (or treatments of highest efficacy to EBM outcome at lowest cost). Its direction today is to place monetary benefits for members making healthy lifestyle choices, and/or complying with medication and treatment regimens. Plainly, SODH looks to derive practical monetary incentives to "members" (under a stakeholders financial responsibility) smoking cessation, hypertension, diabetes, eating high salt/fat/sugar foods, drinking, resting, etc. See: CHW See: Aetna's "Resources for Living" program that draws on information from the social isolation index to recommend social interaction opportunities that are tailored to the member's independence, mobility and health. See: Humana's community relationships and social determinants of health focus to pursue grocery benefits and home improvements for patients at risk for falls. See: Blue Cross' grocery, home finance and patient transportation program.
Social Justice
A phrase used to denote a juries holding larger corporations responsible for larger awards for punitive damages.
Social Security
A federal entitlement program offering many benefits, among which are monthly pension payments to qualified people over 66 (now 66) who have worked and paid taxes for 40 quarters into the system. Social Security pension payments are typically accompanied by Medicare major medical insurance coverage entitlement too. *2020 earning limit for people UNDER full retirement age (65) all year is $18,240. Social Security Administration deducts $1.00 from you benefits for each $2.00 earned over $18,240. *The 2020 earnings limit for people turning FULL RETIREMENT age (66) is $48,600. Social Security deducts $1.00 for every $3.00 earning over $48,600 until the month you reach full retirement. Social Security is not Medicare, but does deduct Medicare Part B premiums (about $135/m depending on income and age) each month on people qualifying for coverage. Social Security: Medicare: 800-633-4227

Social Security

Social Security Administration (SSA)
Social Security eligibility
An individual 62 years of age or greater, who has contributed FICA taxes himself or by his employer for a minimum of 40 quarters (10 years). Filing an application with Social Security is required.
Social Security Payments (Deciding to start at 62 or full retirement agenot)
Definitely worth waiting one year after "full retirement" age. I.e. A 62 year old in 2022 will get about 8% more (about $1,000/each year - assuming an annual eligibility based on pre-retirement income of about $20,000 - inflation adjusted income for the rest of their life) by waiting to age 70. Remember, in finance, everything follows a term. Inflation adjusted income is very important to understand. I.e. if Inflation is 3% per year, than over a 10 year retirement it means needing (3% x 10 years is 30%) $1.30 to buy what costs $1.00 today. Over a 20 year term, one would require $1.60 to buy what costs $1.00 today. Failing to understand this may mean living in poverty in old age. The social security "step-up increase" for a 62 year old (in 2022) is about 6.66% at age 64. (its about 5% a year from age 62-64) These numbers are not exact, and this is not investment advice - recommend confirming information with licensed CPA's, Securities brokers, or Social Security administration. See: COLA

Social Security Retirement Age
See: link, and confirm it with Social Security

Society of Acturies (SOA)
A professional association for certified and uncertified actuaries. If an actuary passes their exams, the designation is an ASA, and for the big exam, it's FSA (Fellow of Society of Actuaries). The masters degree they get is the MAAA. I.e. FSA, MAAA.
Special Enrollment Period (SEP)
Under ACA, (in context to commercial, and not Medicare, Group, or Medicaid lives) a special enrollment period is a 60-day period following a qualifying event where individuals may enroll in permanent (QHP) major medical insurance coverage through the health insurance marketplace, and/or privately administered web portals inclusive of APTC. 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 birth, 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. 2022 - YEAR OPEN - SEP applies to APTC eligible people earning under 150% (of prior year's earnings) FPL.,of%20the%20federal%20poverty%20level

Special Enrollment Period Pre-Enrollment Verification (SPEV)
A defined time slot of eligibility outside of OEP to enroll in Marketplace (or Medicare plans) offered plans as defined by HHS/CMS. See: Marketplace eligibility SEP.
Special Forms
A standard GL policy form that typically insures Theft, and perhaps many other additional coverages that make it more expensive then the bare-bones GL policy. Always check for EPLI, and BI. The term is used many ways, and can mean many things in different kinds of policies in different states.
Special Populations CMS
Groups of people CMS authorizes improved access to various care and insurance programs - typically related to open enrollments, discounted Marketplace plans access through increased APTC, Tribal, refugees, veterans, INS, clinics, etc.
Specialty Drug (Tier 4 or 5 drugs )
A super expensive "brand name" drug that is typically protected by patent and much higher pricing that may, or may not be insured, depending on the plan. Very contentious situation where the FDA approves the drug, and the carrier denies coverage. A specialty drug can also be called an Orphan Drug, even though an orphan drug term is used to denote a drug whose high manufacturing cost and low demand prevents active commercial sale due to no profits. The federal government has some programs for some orphaned drugs. " Drug makers have built a lucrative business around drugs developed to treat rare diseases, according to an AHIP study that found prices for orphan drugs are 25 times higher than prices for traditional drugs. Average annual orphan drug prices increased from $7,136 in 1997 to $186,758 in 2017, 88% of them cost more than $10,000 per patient each year, and drug makers are increasingly focused on rare diseases." (Source: AHIP update September 2019) These drugs can cost $30,000 to over a million a year to buy. There is no one definition.
Specific Stop Loss/Reinsurance
A stop loss or reinsurance coverage that triggers after a deductible. Specific coverage is a per person per year coverage that can reimburse: employers, HMO's, ACO's, and ERISA entities' catastrophic claims excess of (typically) $50,000. Higher deductibles are common.
Specified Low-Income Medicare Beneficiary (SLMB)
Help pay for Part B premiums. See SLMB+ (that some people are eligible for full Medicaid Benefits.
Sposal Top-Ups
The increased social securty monthly payment an eligible person recieves in context to when their spouse retires. Talk to an expert to consider non-working versus working spousal classification of the claiming spouse, and when the (typically higher earning) spouse retires and elects to start social security payments. spouseSee: FRA, Social Security, PIA
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.
Stand Alone Dental Plans (SADPs)
Dental plans added to individual major medical plans. These are dental plans enrolling one at a time, even for individual employees each electing a voluntary benefit offered or not offered by their employer.
Stand Alone Dental Plans (SADPs)
Dental plans like marketplace plans can be QHP certified provided they comply with the standards issued by CMS.
Star Ratings
A CMS - one to five star rating of Medicare Advantage and their pharmacy plans that includes beneficiary feedback. (including dual eligible erollees) "Each year, CMS publishes the Medicare Advantage and Part D star ratings that include measures on the experiences of beneficiaries. Medicare Advantage with prescription drug coverage contracts are rated on up to 45 unique quality and performance measures; MA-only contracts (without prescription drug coverage) are rated on up to 33 measures; and stand-alone PDP contracts are rated on up to 14 measures." Source Healthcare Finance Oct 1090.
Star Ratings (Medicare Advantage and Part D Star Ratings)
Ratings published by CMS on MA and Part D plans that help consumers evaluate offered Plans.

Stare decisis
Under the principle of stare decisis, all other state and federal courts will follow state supreme courts decisions in insurance coverage matters. US Supreme Court MUST apply each state's Circuit Court (federal Court) INSURANCE law precedent, and establish its own law without consideration of each state's insurance laws judgements.
Stark Law (Anti-Kickback law - Medicare)
A federal law making illegal Medicare member referrals from doctors to entities they have a financial interest. This gets complicated, so speak with an expert before making any referral to an entity offering or producing a profit (or inuring a valuable benefit) from medical care delivered at that entity. Penalties are big, and can cause Medicare participation and reimbursement to be revoked. Ask Columbia HCA and Sutter Health, etc. Some of these rules are intentionally being vetting to allow greater physician collaboration "safe-harbour" with Health Systems assuming risk contracts, or trying to establish reimbursement incentive contracts (bundled payments, diabeties care, etc) offering better medical outcomes and lower costs, but without running afoul of Start kickback laws which prohibit provider-self-referrals. See: EO

State Based Marketplace (SBM)
A term referring to states that operate their own separate INDIVIDUAL and / or SHOP health insurance on line exchange charged with selling ACA compliant medical plans. See: SBM-FP, FFM. ect
State Based Marketplace on the Federal Platform (SBM - FP)
On online site that is similar or identical to the Federal Marketplace platform offering individual and SHOP (employer small group) medical plans. See: FFM, COOP, etc.

State Data Resource Center (SDRC)

State Health Insurance Assistance Program (SHIP)
See: Medicaid, Dual Eligible, SSI
State Health Options Program (State Business Health Options Program)
See: Overview, FTE calculator (penalties start after 50, but credit off first 30, SMHCTE tax estimator. Know that in many states (like FL) no SHOP plans are offered in all or even most counties by commercial carriers. Means, small employers don't get the option. This gets complicated.

State Laws Impacting Healthcare Cost and Quality (SLIHCQ Database)
A 116 page report detailing state (not federal) laws impacting price, cost and quality. Reports that two similarly sized same region hospitals merging likely to increase hospital prices by 9%. "Studies like the RAND Hospital Price Transparency Study show that prices in some markets have reached extraordinarily high levels -- at the highest end of the spectrum, some health systems can command over 400% of what Medicare pays on average. Nationally, the chasm between Medicare and commercial prices grew significantly over the past two decades: in the 1990s, the average hospital received 110% of Medicare’s rates for inpatient care; by 2017 the gap widened to 204% of Medicare's rates for inpatient care, and almost 300% of Medicare for outpatient care.i" Source: the catalyst for Payment reform, and The Source on Healthcare Price & Competition (project of the University of California) March 2020

State Operations Manual (SOM)
See: CAHs

State Partnership Exchange
Means a type of FFE in which a State assumes responsibility for carrying out certain activities related to (ACA QHP) plan management, consumer assistance or both. (Source: CMS Marketplace Exam study material.
State-based Marketplace on the Federal Platform (SBM-FP-SHOP)
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).
Stranger Owned Life Insurance Policy (STOLI)
Depending on the state and Agent Appointment contract, there may be a prohibition against financing, or paying premium (on a new policy) by an unrelated third party without a "insurable interest" beyond an investment return. These policies have historically been used by investor groups with no insurable interest to the insured. As always, fraud in any application is fraud. Most carriers will not knowingly issue STOLI's. Many states prohibit them as violating life insurance public interest value. NJ Supreme Court upheld that these policies are not enforceable, with premium refund being potential remedy. See: Life Settlements
Streach IRA
A term used to describe an IRA that could be bequeathed in a will to a potential avoid RMD. The rules have changed, to check with your agent or CPA.
Structured Settlement Annuity
A lump sum payout to an annuity owner. Generally, properly done structured settlements are done to comply with IRS so that incoem taxes are not owed by the original (injured) annuitant. If the person is not injured, the rules are different. Call a CPA and a lawyer to assure its processed properly.
Subhealth Plan (SHP)
Meaning set forth in 45 CFR 162.103
Subhealth Plan (SHP)
See: ACA : 45 CFR 162.103
Subject Matter Experts (SME)
What administrators of the federal marketplace call helpers who may not be certified (by exam) and are not Navigators (employed for 45 days during open enrollment. See: Navigators, Agents, Brokers - good luck with untrained people supervising unlicensed agents selling / enrolling people in Marketplace plans. One has to ask why bother with any certifying exam is SME's can complete an enrollment without even a license.
Subrogation (Primary, secondary and/or tertiary payer)
Subrogation is the right of recovery of one party against another party. It may also be defined as the order of insurance company liability and payment sequence. This can refer to the rights of the HMO, or provider group (or carrier) to recover additional monies from a second insurance policy. In Medicare subrogation, federal law makes Medicare primary payer over 20 FTS's. In managed care, it can refer to an obligation of a provider group to use all legal remedies to repay the (stop loss) insurer for any claims paid, and whatever else they can collect. There are standard rules that usually apply to the order of liability for medical, and/or liability recovery. Medicare and Medicaid Subrogation rules are different from Commercial (individual and "group" employer plans) rules. I.e. These types of coverage usually pay first - for services related to each type services also insured by: No Fault insurance (PIP) including Auto Liability insurance, Black Lung Benefits, workers compensation (which is always first). Medicaid and TRICARE never pay first for Medicare- covered services. They only pay after Medicare, employer group health plans, and/or MediGap (Supplemental) have paid. Source: 2020 Medicare Handbook

Suitability (Senior Suitability)
In context to a recommended financial transactions inclusive of insurance need(s), suitability means putting the client's interests first. In context to Senior Suitability, it means completion of a state designated Senior Suitability application by the potential annuity buyer, and carrier approval to sell the annuity. Suitability relates to the buyers financial ability to sustain a loss, or invest for appropriate periods subject to their age, investment's Principal safety, and expectation of interest returns over time. See: NAIC / DOL mandates and guidelines and BIC and/or fiduciary requirements. Risk, like beauty, it is in the eye of the beholder. But, when it comes to funds moved from retirement funds, there is a higher standard to vet for suitability in annuity sales. Suitability can mean several things in context to what person is buying something with funds from (qualified or unqualified) retirement accounts, or taxed funds invested with safety and/or interest guarantees. Investments, like annuities that do not crash when the stock market crashes, and that enjoy contractually (stated) promised interest crediting and safety are not the same as investments that do crash when the stock market crashes, and that offer no interest crediting or safety guarantees.

Summary Plan Document (SPD, SBC)
An ERISA mandated description of medical benefits that gets distributed to employees of self funded plans. Some carriers offering Level Funded plans use the term Summary of Benefits Coverage.
Supervising General Agent (SGA)
See: FMO
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.
Supplemental Security Income (SSI)
See: Social Security. SSI is what disabled people get each month from the federal government. See: Medicaid, and Medicare dual eligible - and good-luck trying to figure it out.
Supplimental Security Income (SSI)
The check from Social Security to individuals. Also known as Social Security Income check.
Group Health Plan (GHP) Reporting forSubstance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT). Source: CMS See: GHP
Suprise Balance Bills (Balance Bills)
See: Balance Billing Bills from non-contracted (PPO) physicians (technically out of network doctors) received at in network facilities. It can also be a balance bill to the patient calculated at the difference between what the carrier pays (their allowable reasonable and customary charge) and the (non-contracted provider) bill. Ex. ER doctor, Anesthesiologists, infectious disease specialists, surgeons in emergency surgery... See: Surprise billing, and know there are several contentious proposed "bills" in congress in process. See: MOOP

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
Surprise Billings
See: Balance BIlling, No Surprises Act Section 202(c), AMTALA, All Payor Model Agreements i.e. in MD, VT, PA

Surprise Bills
Generally used - means balance billing to patients entering in-network (contracted) facilities, but who get treated by out of network physicians, like ER, radiology, pathology, anesthesiology, CRNA contracted doctors/personnel. Several states have laws prohibiting such billing (in network). It can also mean, high deductible, MOOP, or excluded medical treatments, etc, patients ignored, failed to consider, or hoped would never happen from a sickness or accident events. See: QHP, STM, Critical care plans, Gap, etc.

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)
See: CMS
System of Record Notice (SORN)
System of Record Notice (SORN)
"record" means a notice published in the Federal Register notifying the public of a System of Records maintained by Federal agency. The notice describes privacy considerations that have been addressed in implementing the system (as a result of extreme security issues caused by federal errors allowing unlicensed people collecting PII for Marketplace plan enrollments without adequate security controls) Note: Marketplace Agent Exam material for "SORN" has two definitions.... What?
System Record Notice (SORN)
Good luck with this one. Means: any item, collection or grouping of information about an individual that is maintained by an agency including but not limited to that individual's PII, and transactions...and can also include voice/fingerprint or photo. See: System of Records


Tax Identification Number (TIN)
See: FEIN, and ask you CPA if that is the correct number IRS recognizes from providers who do or do not meet reporting deadlines - especially for QPP.
Tax Rates - Historical
Super important to understand what your tax liability will cost in retirement. Note: highest historical Federal Tax rate was 94% in WWII. See: IUL if you can qualify and want a life insurance product to protect your family. resources/federal-income-tax-rates.aspx.

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.
Technical Expert Panel (TEP)
What CMS calls clinical experts working on MIPS
Technical Expert Panel Clinician Committee (TEP)
See: QPP, MIPS, etc.
Jargon used to describe professional care delivered over the phone or internet, and eligible for (Medicare, Medicaid, workers compensation, Commercial, etc.) insurance coverage. See: Notice of Informed Consent

TeleMedicine or TeleHealth
Healthcare advice delivered over electronic media and not in person. Technology is causing real savings in chronic care treatments in many areas like Cardiovascular Disease, Diabetes, COPD/smoking, etc. "Currently chronic illnesses account for roughly 75 percent of all physician visits, 80% of all hospital admissions, and 90 percent of all prescriptions." Source: BenefitsPRO Magazine March 2020 Jon Wiesen, MD. Bottom line: Avoiding the super expensive ER or ICU visit means far better health (EBM), and lower costs. See: QPP 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). March 2019, Medicare final rules allow Medicare Advantage plan members to more aggressively use telehealth. See: CMS.
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.
Terminal Reserve Option Rider (Level Funded stop loss)
A type of level-funded plan stop loss that triggers when a catastrophic claim happens (early in the plan year) before enough (fully funded and separately estimated, accrued accounted) premium is there to cover stop loss deductibles and/or aggregated (or Inner aggregate deductible) SIR. Call for details. Coverages are manuscripted, and not all the same. See: Terminal Aggregate Liability
Terminal Run Off (TRO, or Terminal Reserve)
A term used by some carriers to estimate IBNR. In Level Funded plans, it typically involves a 120% aggregate factor, plus trend (along with specific stop loss retention application/claims to estimate potential (profit sharing) surplus split with the carrier on a 15 month claims payment cycle (i.e. 12/15 contract terms). In traditional (higher deductible) ERISA self funded plans governed by the same entity offering the plan, it can mean many things.
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
The Patient Driven Payment Model (PDPM)
A developing model of payment for SKF patients based on the individual patients needs. See Value Based Pricing
Third Party Marketing Organizations (TPMO)
What CMS calls FMO's. See: FMO
Thrift Savings Plan (TSP)
Similar to 401(k) plans, but for federal employees.

Time Element Losses
A business that suffers a direct damage loss also may suffer a loss of income or an increase in operating expenses as a result of not being able to use the damaged property while it is being repaired or replaced. See: BI, Loss of use homeowners, Car Rental (during repair) reimbursement coverages.
Tobacco Rating
A rating term used to increase marketplace rated plans for smokers up to 1.5 times the standard rate. For those under age 35 it can range from 1.2 - 1.5 the standard rates. Employer rules are different for SHOP.
Tobacco Rating Standards
In context to Marketplace plans, it means premiums for smokers cant be more than 1.2 - 1.5 times the cost of a non smoker.
The "Defendant" being sued in a civil dispute. The person sued by the Plaintiff.
Total Patient Responsibility
The total amount a patient or patient's family is responsible to pay a medical provider. See: MOOP, Deductible, Co insurance, Copay, ACA standards that apply.
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.
Transparancy Rule(s) (Tri-Agency Transparancy Rule(s))
Federal regulations mandating insurers, self-funded employers, and hospitals to report their best contracted prices publically in machine readable formats. Beginning 1/1/22 negociated rated must be disclosed, including drug rates. 1/1/22 each carrier must also provide a cost estimator for about 500 bundled care-groups. Many insurers already have "cost-estimators" but anyone who has dealt with it, knows they are generally not used, and require real training to navigate usable information.Giving away their "best" negociated-rates the biggest carriers/hospitals/physician groups pau (or get paid) will definitely put pressure on hospitals that already charge smaller plans much higher rates for the same treatments. See; RAND: Employer Hospital Trpice Transparance Project Definitely a work in process. Talk to an experienced broker-consultant.

Transparency in Coverage Rules
See: IDR, No Surprises Act, CAA 2020, etc. It's about internet accessible price comparison tool, and Cost sharing for an individual's estimated costs.
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)
A term that can mean many things, but is most often used to describe the ceding arrangements amoung multiple reinsurers taking risk on the same exposure. Treaty reinsurance can be 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 (automatic reinsurnace).The reinsurance takes effect as soon as the primary insurance policy is sold to the customer. Treaty reinsurance is a general term used to discuss several types of coverages that can include profit sharing (profit commission) features.
A percentage increase for medical cost inflation and or utilization estimated for the following year's premium rate. Typical trend increases for large group are 4%-7%. Trend for second dollar risk is typically double first dollar risk. See: Wear Off
TRICARE (DoD Tricare)
A department of defense health insurance program available to military personnel and their families that typically pays FFS to medical providers. Most of the civilian component access is to solve the problem of bases being in locations with limited access to doctors and hospitals that participate with medicare and/or medicaid. It typically pays prevailing rates to local doctors in underserved areas who agree to accept what TRICARE pays which can be less than what a doctor typically charges.
Jargon used to detail when a reinsurance coverage accrues and/or pays.
Trigger Event (Trigger Diagnosis)
A term that means many things, but typically relates to targeted disease class of illness being actively managed to lower coss, and improve medical outcomes. It can be a diagnosis causing, or expected to cause a claim bigger than $10K (or $50K), or targeted diagnosis case management event. A triggering event in context to RPM includes all costs of that event, and not just the cause of medical care after the initial event to improve claims costs accuracy results. ========= A Trigger Diagnosis is defined by an underwriter by whatever the underwriter requires to evaluate stop loss pricing, etc, and is part of the stop loss underwriting process.
Trigger Threashold
An insured cause (peril) and/or amount of loss creating (triggering) an eligible claim.
Triggers (Coverage Trigger(s))
See: Occurance v. Claims made. The term means different things in different types of policies, especially reinsurance treaties, excess of loss, and some stop loss polices. The differences might be differenciated by how the trigger responds to policy pay out in terms of an insured peril and/or amount of loss "triggering claim eligibility payout" per the "insurance contract".
Trusted Data Sources
A term the federal Marketplace uses to define reliable income data to verify accurate APTC. i.e. SSA, SSI, IRS, etc. See: MAGI, AGI.


U.S.C. 1024(b)(4) records request
Call your attorney
UB-04 Form
A standard form that many carriers require to submit eligible claims for medical services, procedures, etc. See: CMS 1500 form (for Medicare lives, and for some carriers for commercial lives)
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.
Uncompensated Care (UCC)
See: Bad Dept, up-coding
Uncompensated Care (Bad Debt)
See: KFF
In context to insurance: A process of building a premium and assigning it to a particular risk. It essentially boils down to the seven components of premium, and assigning credibility weights. See: Insurance professional designations - CLU, CPCU, ARe, FLMI, FSA, etc.
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.
Unearned Premium
A carrier liability
Uninsured Motorist (UM)
Coverage triggering upon an auto accident caused by another driver (not the driver) that pays medical benefits to persons in the drivers car. Florida statute appears to detail that coverage applies to family members residing in the named insured's home at time of accident. UIM is underinsured motorists auto coverage triggering when liability limits purchased by the other (at fault) driver are not sufficient to indemnify the injured party 's damage in accidents caused by the other driver (not the driver). Different states have different requirements. :::::Travelers states it like this: "UNINSURED MOTORISTS AND PERSONAL INJURY PROTECTION COVERAGE IMPORTANT - PLEASE READ CAREFULLY YOUR OPTIONS REGARDING UNINSURED MOTORISTS COVERAGE ARE DESCRIBED BELOW We are required by Florida law to notify you as the person(s) identified in the Named Insured section of the Dec­larations of all options available to you regarding Uninsured Motorists Coverage. They are: 1. You are entitled to Uninsured Motorists Coverage in an amount equal to your limits for Bodily Injury Liability coverage. 2. You may reject Uninsured Motorists Coverage entirely or elect limits as low as $10,000 each person, $20,000 each accident. 3. You may elect either of two types of Uninsured Motorist coverages, known as "stacked" and "non-stacked." a. Under the more expensive stacked coverage, your policy limits for each motor vehicle insured under the policy are added together to determine the maximum limits available to you, your resident spouse and any resident relatives in your household. Also, under the stacked coverage, the policy limitations set forth in b.(i)-(v) below do not apply. b. Under the lower cost non-stacked coverage, the coverage and benefits are limited relative to the available "stacked" option. Under the "non-stacked" coverage: (i) The coverage provided as to two or more motor vehicles shall not be added together to determine the limit of insurance coverage available to an injured person for any one accident, except as provided in paragraph (iii). (ii) If at the time of the accident the injured person is occupying a motor vehicle, the uninsured motorist coverage available to the injured person is the coverage available as to that motor vehicle. (iii) If the injured person is occupying a motor vehicle which is not owned by the injured person or by a family member residing with the injured person, the injured person is entitled to the highest limits of uninsured motorist coverage afforded for any one vehicle as to which the injured person is a named insured or insured resident relative. Such coverage shall be excess over the coverage on the vehicle the injured person is occupying. (iv) The uninsured motorist coverage provided by the policy does not apply to the named insured or resi­ dent relative residing in the named insured's household who are injured while occupying any vehicle owned by such insureds for which uninsured motorist coverage was not purchased. (v) If, at the time of the accident the injured person is not occupying a motor vehicle, the injured person is entitled to select any one limit of uninsured motorist coverage for any one vehicle afforded by a policy under which the injured person is insured as a named insured or as an insured resident of the named insured's household." " UNINSURED MOTORI STS AND PERSONAL I NJURY PROTECTION COVERAGE IMPORTANT - PLEASE READ CAREFULLY YOUR OPTIONS REGARDING PERSONAL INJURY PROTECTION ARE DESCRIBED BELOW Personal Injury Protection (PIP) must be provided for any motor vehicle subject to the Florida Motor Vehicle No­ Fault Law. We will pay, in accordance with the Florida Motor Vehicle No-Fault Law, as amended, to or for the benefit of the injured person as follows: (a) 80% of medical expenses, if an insured receives initial services and care within 14 days after the motor vehicle accident, and (b) 60% of work loss and (c) replacement services ex­ penses, and (d) death benefits of $5,000 per each insured. The total limit available for medical expenses, work loss, and replacement services expense is $10,000. We will pay up to $10,000 for medical expenses that have been determined to be an Emergency Medical Condition and up to $2,500 for medical expenses that have been determined to be a Non-Emergency Medical Condition in accordance with the Florida Motor Vehicle No-Fault Law. Please refer to your Travelers policy and endorsement(s) for a detailed explanation of PIP coverage. There are several premium-saving Personal Injury Protection options available to you as the person(s) identified in the Named Insured section of the Declarations. A premium reduction will result from these elections. The named insured may elect a deductible and exclude coverage for loss of gross income and loss of earning capacity ("lost wages" or "work loss benefits"). A premium reduction will result from these elections. A named in­ sured can select a deductible of $250, $500, or $1,000. When making your decision on whether to choose a de­ ductible and for what amount, consider your ability to pay a portion of your medical expense and/or whether your health insurance carrier will meet the costs of these expenses. You also have the option to exclude benefits for lost wages due to an auto accident. If the insured or dependent resident relatives are unemployed or retired, you may want to select this exclusion.You are advised not to elect the lost wage exclusion if the named insured or dependent resident relatives are employed, since lost wages will not be payable in the event of an accident. You may choose to have these options (deductible and/or exclusion of work loss benefits) apply to the "named insured alone" or to the "named insured and all dependent resident relatives". In making this election, a resident spouse is treated as a named insured and not a dependent resident relative. THIS NOTICE DOES NOT ALTER, AMEND OR CHANGE THE COVERAGES AFFORDED BY YOUR POLICY. The coverages currently provided by your policy are indicated in the Declarations provided with this No­tice.If you would like to make any changes to your Personal Injury Protection coverages, please do not hesitate to call your agent or representative." Source: 2021 Auto Travelers policy See: PIP
Uninsured Rates
Report used by CD to estimate uninsured US population rates.

A deliberate action, typically by hospitals to classify a patient's medical charges with a sicker diagnosis to increase reimbursement. The practice takes many forms. In context to Medicare, see DRG with outlier codes. See: Bundled payments.
US Core Date for Interoperability (USCDI)
A term related to interoperability of data set reporting CMS uses primarily for Medicare. See: API, Interoperability 2021 in context to getting date (information) to patients and higher engagement that is expected to reduce costs and improve EBM outcomes.
US Department of Heatlh and Human Resources (HHS)
See: CMS
Jargon to describe user obvious medical care programs like telemedicine, primary care coordination, automated appointment bookings, and lately estimated cost estimations of care, etc.


Valuation Based Tables (VBT)
A more weighted input (factor) used throught the life insurancce industry to calculate life expectancies. See: Life Settlements, Life Insurance, LE, etc.
Value Based insurance Design (VBID)
According to CMS, the seamless test of carving in the Medicare hospice benefit into Medicare Advantage (that's Medicare HMO/PPO, not supplemental), as part of the Value-Based Insurance Design focused on Hospice care. Just know that palliative care costs massive. See related (not just Hospice care: MACRA, QPP, PQRS


Value Based Partnership
A newer term typically associated with workers compensation care from medical providers willing to accept some form of financial risk treating injured workers. They aslo use the term accountable-providers". See: EBM and Outcomes based return to work
Value Based Payment Modifier (VM)
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment KEY TAKEAWAYS (Source Healthcare Leaders Dec 2018) More than 1,550 hospitals (over 55%) will share higher Medicare payments totaling about $1.9 billion in fiscal year 2019. The average net increase in payment adjustments is 0.61%, and the average net decrease is -0.39%. For 2019, average Total Performance Score across all participating hospitals increased.
Value Based Reimbursement
See: RBP, Bundled Payments, VBP, Stark, DRG, etc. VBR is an amorphous term used to define various types of "bundled", DRG, per diem, cost per confinement, and/or fixed budget outcome based chronic care Medicare provider contract - priced "valuable" by whatever criteria the buyer / seller finds valuable. Medicare has its own standard - specifically in context to Stark Law prohibiting any provider from profiting from Medicare referrals to self. Its implied goal is to improve medical outcomes at a lower cost, and prevent up-coding single procedures into multiple procedures/charges. See: Bundled Payments "The Scorecard showed early investments in pay-for-performance (P4P), with 12.8 percent of payments stemming from one of these models in 2014. That percentage increased to 16.6 percent of payments by 2017. However, shared savings arrangements outpaced the models by that time. Most value-based payments (29.7 percent) made in the commercial sector in 2017 were part of a shared savings arrangement, the Scorecard found. Shared savings arrangements were also the most popular form of value-based payment in 2016, with 23.7 percent of payments. READ MORE: More States Require Value-Based Reimbursement in Medicaid CPR pointed out that the rate of growth in payment reform was largest at the beginning of the period in 2012 but has since tapered off. From 2012 to 2013, the proportion of commercial dollars coming from a value-based payment model more than doubled from 10.9 percent to 27.1 percent. From 2016 to 2017, however, the percentage of value-based payments only increased from 48.5 percent to 53.0 percent." Source RevCycle Intelligence 12/2019. See: Safe Harbour

Value St Authority Center (VSAC)
See: eCQM

Value-Based Care (VBC)
Term Cigna uses to describe provider payments that are not FFS.
Variable Universal Life (VUL)
Carrier acknowledgement of a claim. See: Verification
Vermont Risk & Insurance Strategy Collective (RISC)
In contexts to Defined Benefit and Contribution plans sponsored by employers. … The period of time required to transfer ownership of plan or policy assets. The idea is to create a big asset, like in a overfunded life insurance policy, but keep these assets from being accessed until fully "owned" by the insured. These get complicated, and have all sorts of compliance issues involved. See: Retirement Plans - Golden Handcuffs, Cadillac tax
Veterans Health Administration (VHA)
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 persons access to funds prior to death. There are primary, secondary and tertiary markets for Viaticals. (See LE) Viaticals are sold for ore than their "cash value", but less then the policy death benefit.
Virtual Care
A blanket term used differently by different stakeholders. In context to a carrier, United defines it, "3 key takeaways about virtual care and digital tools Virtual care may help streamline access to quality care for people in need, lower the total cost of care and improve flexibility for both members and providers. Almost 70% of organizations plan to emphasize mental health offerings, especially virtual care and digital tools, over the next 2 years. UnitedHealthcare’s virtual behavioral coaching program has delivered high patient engagement and positive outcomes, including a 50% decrease in depression score." UHC Agent Bulletin 2022. FYI: Large group access to more expensive EAP is not the same at what small groups, and individual get offered (and effectively managed).
Virtual Proviate Network (VPN)
A security program installed on a mobile or desk top computer that allows its owner greater privacy over their internet searching and reviewing behavior. Regardless, each person has an ISP (Internet Service Provider) who can see these histories, and depending on the privacy options elected by the user, the ISP can sell that information to strangers who can then target advertisements directly to your personal tastes, etc.
Virtual-First Plans
Plans that market themselves by emphasizing care delivery-access through the internet, and not just face-to-face with the physician or physician-extender. Most major medical plans, and indeed most ancillary-services medical plans offer telemedicine benefits too.
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/transplant, Short term disability, LTC, Hospital lump sum per diem GAP, AFLAC, etc.
Voluntary Data Sharing Agreement (VDSA)


Wage Hour Division (WHD)
The Florida insurance department's section of enforcement officers charged with finding companies who fail to meet the law mandating workers compensation insurance coverage for construction companies with one or more employees, or non-construction companies with 4 or more employees. There are exceptions to these standard rules. Failure to buy the coverage can mean conviction of a third-degree felony, with all kinds of penalties. Employers (and their owners) are recommended to be vigelent in assuring they are meeting state-federal (perhaps matching, but defined differently) FTE, 1099 and part time employees they pay payroll taxes on (W2), and cash-paid employees used in temporary full-time employment.
Wage index Formula
A Medicare formula based on MAGI / AGI that establishes the premium rates charged for Medicare Part B, (and Part A for qualifying people over age 65).
Waiver of Premium (WOP)
A policy provision typically, part of a Long Term Care policy meaning premium payments stop when the policy coverage triggers after meeting 2 of 6 ADLs. See: ADL, Continuation of Coverage Provisions, Inflation riders, combined Life whole life combined coverages.
Wear Off
An underwriting term expressed as a percentage increase used by Aetna - that is not a standard term. The percentage reflects expected claims inflation increase and individual employer's high dollar known (diagnosis) employee's claims expected in the coming year. See: fudge factor
Web Broker
See: ACA law - 45 CFR 155.22(s)(3) and 155.21, IMO, FMO, etc. "Web-brokers A web-broker is an individual agent or broker, group of agents or brokers, or business entity registered with the Marketplace that develops and hosts a non-Marketplace website that interfaces with the Marketplace to assist consumers with direct enrollment in QHPs offered through the Marketplace. Web-brokers generally offer online resources for agents and brokers, such as enrollment and client management functionality. Under the Classic Direct Enrollment Pathway, approved web-brokers can provide a website that enables consumers or agents and brokers working with consumers to apply for APTC and CSRs and select and enroll in an Individual Marketplace QHP through the web-broker’s website. Consumers using the Classic Direct Enrollment Pathway are able to initiate the QHP shopping experience on a web-broker’s website, connect securely to the website to complete the eligibility application and determination process, and return securely to the web-broker’s site to compare plans and select a QHP. Some web-brokers may also offer the Enhanced Direct Enrollment Pathway, which operates without the redirect to and from the website and allows the consumer to complete the eligibility application and plan selection on the web-broker’s website. Through secure data transfers, the Marketplace will determine a consumer’s eligibility for QHP coverage, Medicaid, or CHIP, as well as the applicable APTC or CSR amounts. Web-brokers approved to participate in the Enhanced Direct Enrollment Pathway may provide a range of custom features and capabilities, enabling agents and brokers to more easily assist clients with year-round policy and client relationship management. Agents and brokers may find a web-broker who is approved by CMS to offer these services via the Issuer and Direct Enrollment Partner Directory. In the Enrolling in a QHP module, you will learn more about how to use the Classic Direct Enrollment and Enhanced Direct Enrollment Pathways to assist consumers complete the application and select Marketplace health coverage online. All web-brokers must comply with federal regulatory requirements for the content and user functionality of their websites, including providing language access services, as well as the FFM privacy and security requirements for collecting and handling consumer information. Web-brokers offering the Classic Direct Enrollment Pathway and/or Enhanced Direct Enrollment Pathway must also retain an independent third-party auditor to validate compliance with program requirements". Source: Marketplace Exams See: SB-FFM, FMO
Wellness Care
A term whose meaning is tied to "participation" of insured people in "social determinants of health" and medical programs designed to manage chronic high cost medical conditions (i.e. hypertension, diabetes, drinking, obesity, etc.) in return for customer financial incentives that can stretch into concierge primary care privileges. See: Prevention care
What ifs products (Income for Life Annuities)
A term some agents or financial planners use to describe an Indexed annuity performance with, or without a guaranteed income-for-life rider. People buy income-for-life annuities to not run out of money in old age. Income for Life annuities offer contractually promised interest crediting rates that look very high (typically 5%-8% cap), but allow only a maximum percentage of the contract fund "income" disbursements each year - (typically) 4%, 5% each year for life. "What if" annuities relate to interest crediting being dependent upon actual annual index performance growth, and the caps contractually promised, or minimum interest crediting (over the life of the annuity, not just one year) guaranteed outright in the annuity. I.e. "What if" the index grows 50% in one year, then the index only earns up to (Ex 8%) cap, and the annuity owner can take as an income disbursement up to 5% (if he started the payments after age 75) of total annuity contract fund value. Annuities are typically taxed as INCOME, and typically offer much lower caps than IUL's. If you are insurable, talk to an experienced agent to know all your costs, taxes, penalty trade-offs - especially lifetime income tax liability, and forced annuitization provisions. Any indexed annuity takes effort to understand, so ask questions until you do, or do not buy it.
Wind Deductible Buy Back (WDBB)
An separate policy coverage designed to reduce an insureds windstorm deductible. i.e $10M property with a 5% windstorm means $500,000 deductible, and the WDBB is rated to pay at a much lower deductible before the primary policy responds. Access to this coverage for lower value property is available with deductibles as low as $5,000.
The perfection of prudence. Source: Book of Wisdom. Concievably there is a test for real wisdome... It must be loving, radically inclusive, and simple to understand. "He who seeks wisdom, it shall be revieled." (paraphrasing) Source: New Testiment.
Wokers Compensation (Comp)
A state mandated insurance coverage offering four primary coverages, and liability immunity to employers. There are four coverages: Unlimited Medical insurance, Life insurance, disability income, and liability cover. Maritime standards are not the same as state requirements. Each state defines "statutory" coverage. Employers purchasing compliant comp enjoy some liability immunity. Employers not purchasing statutory cover may be guilty of a third degree felony. There are at least three states that offer the coverage directly to employers, believing it to be the most competitive. Other staes allow competition amoung authorized and eligible carriers, and perhaps ERISA exempt entities. Florida Worker Compensation Requirements for Construction businesses with one or more employees and non-construction industry employers with four or more employees (full-time or part-time, including corporate officers and LLC members) must carry coverage. Florida allows the business owner to exempt himself. Agricultural businesses with six or more regular employees and/or 12 or more seasonal employees who work for more than 30 days must carry coverage. Sub-contractors are responsible for providing coverage for their workers, but primary contractors are responsible for ensuring that the sub-contractor has it. Out-of-state employers must immediately notify their carrier that they have employees working in Florida, carry a Florida workers’ compensation policy, or have the out-of-state policy include Florida and/or provide an "all-states coverage" provision. This gets complicated, expecially for trucking companies. Details/Exceptions: Corporate officers are considered employees, unless they choose to exempt themselves from coverage. Sole proprietors and partners in the non-construction industry are not considered to be employees unless they choose to be. Members of an LLC will be considered as corporate officers/employees, unless they choose to be exempt. Options: Purchased from a commercial provider. Approved businesses may self-insure. Source: NFIB ***These brief jargon definitions are not advice. We recommend speaking with a licensed agent, NCCI, the state of Florida, or a licensed attorney specializing in workers compensation. These definitions are provided as a layman's courtesy. *** See MCC, IME, EMA, DWC25 form, MSA, MMI, IW, etc.

Workers Comp (NFIP)
See link: NFIP can also mean National Flood Insurance Program
Workers Compensation Research Institute (WCRI)
See: COVID special rules,and state by state comparision to the total claims, especially medical.

Workers Compensation Set Aside (WCMSA)
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease. These funds must be depleted before Medicare will pay for treatment related to the workers’ compensation injury, illness, or disease. All parties in a workers’ compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving cases that include future medical expenses. The recommended method to protect Medicare’s interests is a WCMSA. The amount of the WCMSA is determined on a case-by-case basis. To assist you in determining if a WCMSA is reasonable, please review Section 15.1 (Criteria) in the WCMSA Reference Guide. The guide contains information for attorneys, Medicare beneficiaries, claimants, insurance carriers, representative payees, and WCMSA vendors and is available in the Downloads section at the bottom of this page.

In context to people using/working/enrolling members on the Federal Marketplace that are not employees of the FFM::: A Non-Exchange Entity's FFE's, SBE-FP's employees, agents contractors, subcontractors, officers, directors, agents, representatives, etc.
Working Owners
An atypical interpretation by a Texas Judge of what constitutes an (limited partner) eligible employee for a single group health plan. Just know that traditionally most of ERISA association offered medical plan used to require more then just taking a health plan to be considered an eligible association plan available to its members, and the association had tohave other real purposes such as professional developement. See: MEWA Next stop is the appeals court. ERISA plans must offer ACA compliant QHP just like fully-insured plans.
Wrap plan
A term used many ways. It can be an umbrella plan, a gap plan or a plan over an EGWP.
Jargeon used to describe life insurance policies used by to hide assets from IRS. Swiss Life agreed to pay $77M to dismiss criminal charges.
Write Your Own (WYO)
An expression used in Flood policies sponsored by commercial carriers (with risk assumed by the federal government).


Year To Date (YTD)
A common reporting measurement period.


Z codes (ICD-10 Z Codes)
Diagnosis codes characterizing SDOH, access and patient-provider communication (or non communication/care inaccessibility to appropriate providers or medical facilities). The purpose is to improve efficient and effective health care access and delivery. See: Outliers, DRGs, QPP, MACRA. Mental Health Parity, etc, etc.