Preventive Services

Healthcare services aimed at preventing illness or detecting health issues early. Medicare, Medicaid, CHIP, and ACA plans cover preventive services, such as vaccinations, screenings, and annual wellness visits, often at no additional cost.

Prescription Drug Coverage

Health insurance coverage that helps pay for the cost of prescription medications. Medicare Part D, Medicaid, CHIP, and many ACA Marketplace plans offer prescription drug coverage.

Primary Care Physician (PCP)

A healthcare provider who acts as the first point of contact for an individual’s healthcare needs and coordinates further specialist care if necessary. Many Medicare Advantage, Medicaid, and ACA plans require enrollees to choose a PCP.

Prior Authorization

A requirement that certain healthcare services or medications must be approved by the health insurance provider before they are provided. Medicare, Medicaid, and ACA plans may require prior authorization for procedures or high-cost drugs.

Qualified Health Plan (QHP)

A health insurance plan that meets the standards set by the ACA and is certified by the Health Insurance Marketplace. QHPs provide Essential Health Benefits and follow established limits on cost-sharing.

Qualifying Life Event (QLE)

A major life event that allows an individual to enroll in or make changes to their health insurance plan outside of the Open Enrollment Period. Examples of QLEs include marriage, divorce, birth of a child, or loss of other health coverage.

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.

Rehabilitation Services

Medical services aimed at helping individuals recover and regain skills after illness, injury, or surgery. These services, which include physical, occupational, and speech therapy, are covered by Medicare, Medicaid, and CHIP.

Referral

A written order from a primary care doctor for a patient to see a specialist or receive certain medical services. Many Medicare Advantage, Medicaid, and ACA plans require a referral before seeing a specialist or undergoing specialized tests.

Respite Care

Short-term care provided to individuals with chronic illnesses or disabilities to give their regular caregivers temporary relief. Medicaid and some Medicare plans may cover respite care as part of long-term care or hospice services.

Resource Limits

The maximum value of assets or resources an individual or household can have and still qualify for programs like Medicaid or the CHIP. Resource limits are typically assessed alongside income limits when determining eligibility.

Risk Adjustment

A process used by health insurance companies to adjust payments based on the health status of their enrollees. It ensures that plans enrolling higher-risk individuals (such as those with chronic conditions) are compensated to maintain financial stability. Medicare Advantage and ACA Marketplace plans use risk adjustment.

Retroactive Medicaid

Medicaid coverage that begins prior to the date of application, covering medical expenses incurred up to three months before the application if the individual was eligible during that time. This retroactive coverage helps ensure that people don’t have unpaid medical bills.

Skilled Nursing Facility (SNF)

A healthcare facility that provides high-level medical care and rehabilitation services after hospitalization. Medicare Part A covers skilled nursing care for a limited period after a qualifying hospital stay, while Medicaid may cover long-term stays for eligible individuals.

Special Enrollment Period (SEP)

A time outside the Open Enrollment Period when individuals can sign up for or change their health insurance plan due to qualifying life events such as marriage, birth of a child, or loss of other coverage. SEPs apply to both ACA Marketplace and Medicare plans.

Subsidy

Financial assistance provided by the government to help individuals and families afford health insurance. ACA Marketplace subsidies include premium tax credits and cost-sharing reductions, which lower the cost of premiums and out-of-pocket expenses.

Supplemental Security Income (SSI)

A federal income program that provides financial assistance to low-income individuals who are aged, blind, or disabled. SSI recipients often qualify for Medicaid automatically to help cover healthcare costs.

Spend-Down (Medicaid)

A process by which individuals who have income above their state’s Medicaid eligibility threshold can still qualify for Medicaid by spending their excess income on medical expenses. Once they spend down to the eligibility level, Medicaid covers remaining healthcare costs.

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.

State Medicaid Plan

A comprehensive program developed by each state, with federal approval, to outline how the state will administer its Medicaid program. Each state Medicaid plan includes details on eligibility, services covered, and how the state will meet federal Medicaid requirements.