Glossary
Tags
- ACA
- ACA Marketplace
- ACA subsidies
- CHIP
- CMS
- ESRD
- Extra Help
- FMAP
- FPL
- FQHC
- FSA
- HCBS
- HMO
- HRA
- HSA
- IEP
- IRMAA
- Joint Commision
- KFF
- LCD
- LIS
- Marketplace
- Medicaid
- Medicaid (rare)
- Medicaid expansion
- Medicare
- Medicare Advantage
- Medicare Part A
- Medicare Part B
- Medicare Part D
- Medicare coordination
- Medigap
- NCD
- NEMT
- NOMNC
- Original Medicare
- PCP
- Part A
- Part B
- Part C
- Part D
- QLE
- QMB
- SEP
- SNF
- SNP
- SSI
- Section 1115
- Silver Plan
- Silver plan
Coinsurance
The percentage of medical costs a patient must pay after meeting their deductible. For example, a Medicare plan might require patients to pay 20% of the cost of services after Medicare has paid its share.
The percentage of medical costs a patient must pay after meeting their deductible. For example, a Medicare plan might require patients to pay 20% of the cost of services after Medicare has paid its share.
Cost-sharing Reduction (CSR)
A subsidy available through the ACA Marketplace that lowers out-of-pocket costs like deductibles, copays, and coinsurance for eligible individuals. CSR is available to people who enroll in Silver-tier plans and meet specific income requirements.
A subsidy available through the ACA Marketplace that lowers out-of-pocket costs like deductibles, copays, and coinsurance for eligible individuals. CSR is available to people who enroll in Silver-tier plans and meet specific income requirements.
Deductible
The amount an individual must pay out-of-pocket for covered healthcare services before their insurance plan starts to cover costs. Deductibles apply to various types of insurance, including Medicare, Medicaid, ACA, and CHIP plans.
The amount an individual must pay out-of-pocket for covered healthcare services before their insurance plan starts to cover costs. Deductibles apply to various types of insurance, including Medicare, Medicaid, ACA, and CHIP plans.
Formulary
A list of prescription medications that are covered by a health insurance plan, such as Medicare Part D or CHIP. Drugs listed on a formulary are usually divided into tiers, with different levels of cost-sharing based on the type of drug (generic, brand-name, or specialty).
A list of prescription medications that are covered by a health insurance plan, such as Medicare Part D or CHIP. Drugs listed on a formulary are usually divided into tiers, with different levels of cost-sharing based on the type of drug (generic, brand-name, or specialty).
Formulary Tiers
Categories within a drug formulary that determine the level of coverage and cost-sharing for medications. Typically, Tier 1 includes generic drugs with the lowest copays, while higher tiers include brand-name and specialty drugs with higher costs.
Categories within a drug formulary that determine the level of coverage and cost-sharing for medications. Typically, Tier 1 includes generic drugs with the lowest copays, while higher tiers include brand-name and specialty drugs with higher costs.
Financial Assistance (ACA)
Subsidies provided through the ACA Marketplace to help eligible individuals and families pay for health insurance premiums and out-of-pocket costs. There are two main types of financial assistance: premium tax credits and cost-sharing reductions.
Subsidies provided through the ACA Marketplace to help eligible individuals and families pay for health insurance premiums and out-of-pocket costs. There are two main types of financial assistance: premium tax credits and cost-sharing reductions.
Flexible Spending Account (FSA)
A tax-advantaged account that allows individuals to set aside pre-tax dollars to pay for eligible healthcare expenses, such as medical, dental, and vision care. FSAs are commonly offered by employers as part of health benefit plans, and the funds must be used within a specified period.
A tax-advantaged account that allows individuals to set aside pre-tax dollars to pay for eligible healthcare expenses, such as medical, dental, and vision care. FSAs are commonly offered by employers as part of health benefit plans, and the funds must be used within a specified period.
Generic Drugs
Medications that contain the same active ingredients as brand-name drugs but are sold at lower prices. Medicare Part D, Medicaid, and CHIP often cover generic drugs to reduce costs for beneficiaries.
Medications that contain the same active ingredients as brand-name drugs but are sold at lower prices. Medicare Part D, Medicaid, and CHIP often cover generic drugs to reduce costs for beneficiaries.
Health Insurance Marketplace
An online platform established by the ACA where individuals and small businesses can compare and purchase health insurance plans. It also provides information on eligibility for subsidies and cost-sharing reductions.
An online platform established by the ACA where individuals and small businesses can compare and purchase health insurance plans. It also provides information on eligibility for subsidies and cost-sharing reductions.
Health Savings Account (HSA)
A tax-advantaged account used to save and pay for qualified medical expenses. HSAs are available to individuals enrolled in high-deductible health plans (HDHPs) and offer tax-free contributions, growth, and withdrawals for healthcare costs.
A tax-advantaged account used to save and pay for qualified medical expenses. HSAs are available to individuals enrolled in high-deductible health plans (HDHPs) and offer tax-free contributions, growth, and withdrawals for healthcare costs.
Health Reimbursement Arrangement (HRA)
An employer-funded arrangement that reimburses employees for qualified medical expenses. Unlike an HSA, only the employer can contribute to an HRA, and the funds can be used for various healthcare costs, such as copayments and deductibles.
An employer-funded arrangement that reimburses employees for qualified medical expenses. Unlike an HSA, only the employer can contribute to an HRA, and the funds can be used for various healthcare costs, such as copayments and deductibles.
Medicare Part D
The prescription drug coverage component of Medicare, available through private plans. Part D helps beneficiaries pay for the cost of prescription medications, with cost-sharing determined by drug formularies and tier levels.
The prescription drug coverage component of Medicare, available through private plans. Part D helps beneficiaries pay for the cost of prescription medications, with cost-sharing determined by drug formularies and tier levels.
Out-of-Pocket Costs
Medical expenses that are not covered by insurance, such as copayments, deductibles, and coinsurance, which must be paid directly by the individual. Out-of-pocket costs apply to Medicare, Medicaid, CHIP, and ACA plans.
Medical expenses that are not covered by insurance, such as copayments, deductibles, and coinsurance, which must be paid directly by the individual. Out-of-pocket costs apply to Medicare, Medicaid, CHIP, and ACA plans.
Part D (Medicare)
Prescription drug coverage for Medicare beneficiaries, offered by private insurance plans. Part D helps cover the cost of prescription drugs and has a formulary, or list of covered medications, categorized by cost tiers.
Prescription drug coverage for Medicare beneficiaries, offered by private insurance plans. Part D helps cover the cost of prescription drugs and has a formulary, or list of covered medications, categorized by cost tiers.
Qualified Medicare Beneficiary (QMB) Program
A Medicaid program that helps low-income Medicare beneficiaries pay for Medicare Part A and Part B premiums, deductibles, copayments, and coinsurance. Beneficiaries must meet specific income and resource limits to qualify.
A Medicaid program that helps low-income Medicare beneficiaries pay for Medicare Part A and Part B premiums, deductibles, copayments, and coinsurance. Beneficiaries must meet specific income and resource limits to qualify.
Silver Plan (ACA)
A mid-level health plan available through the ACA Marketplace that covers approximately 70% of healthcare costs, with the enrollee paying the remaining 30%. Cost-sharing reductions are only available for those who select a Silver plan and meet income requirements.
A mid-level health plan available through the ACA Marketplace that covers approximately 70% of healthcare costs, with the enrollee paying the remaining 30%. Cost-sharing reductions are only available for those who select a Silver plan and meet income requirements.
Tiered Drug Formulary
A system used by health insurance plans to categorize prescription drugs into different cost tiers, with generic drugs typically in the lowest tier and specialty or brand-name drugs in higher tiers. Medicare Part D and ACA plans often use a tiered formulary system.
A system used by health insurance plans to categorize prescription drugs into different cost tiers, with generic drugs typically in the lowest tier and specialty or brand-name drugs in higher tiers. Medicare Part D and ACA plans often use a tiered formulary system.
Yearly Out-of-Pocket Maximum
The maximum amount an individual must pay for covered services in a calendar year before their health insurance plan covers 100% of additional costs. This applies to ACA Marketplace, Medicare Advantage, and some Medicaid plans. Once the yearly out-of-pocket maximum is reached, the insurer pays all remaining covered expenses.
The maximum amount an individual must pay for covered services in a calendar year before their health insurance plan covers 100% of additional costs. This applies to ACA Marketplace, Medicare Advantage, and some Medicaid plans. Once the yearly out-of-pocket maximum is reached, the insurer pays all remaining covered expenses.