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


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


ACA Final Rules (CMS issued ACA Final Rules)
ACA law passed in 2010 is still in effective.  Multiple Presidential Orders have effectively gutted ACA without repealing the law. Two courts have held that an estimated $10.4 BILLION in "risk adjustment" (CSR) payments are not required to be paid to carriers suing for them. Ongoing destabilization of the INDIVIDUAL and SMALL GROUP medical insurance marketplace can be expected. See Trumping Healthcare Reform at, ARTICALS. ACA has not been repealed, but for the individual mandate tax penalty.  Enforcement is lax, or absent on many minimum statutory standards. Cigna, Humana, Coventry, United, and Aetna have abandoned the INDIVIDUAL Marketplace offerings.  Key provisions now avoidable include: MLR (Medical Loss Ratio) definition calculation related to plan costs and premium rebates, Individual/Group actuarial value minimum coverage, and carrier authorization to increase rates up to 15% without state filing or approval.  States appear to be obligated to create INDIVIDUAL plan minimum benefits equal to existing employer GROUP plan limits and benefits. States now allowed to select or mix and match "any" plan accepted in "any" state versus plans meeting minimum ACA EHP QHP statutory mandate.   CMS is eliminating by rule: QHP certification process in INDIVIDUALLY offered marketplace plans distributed by the State Based Federal-faciliated Exchanges (Platform) (SBE-FPs) to enforce FFE standards for network adequacy (re: Medicare lives) and essential cummunity providers. 14 states use FFE.  Marketplace navigator budget is reduced from $27M to $10M, leaving big hole for customers struggling to find and understand plans - especially in 14 states. 3.5% user (premium tax on insureds) fee tax still effective on members enrolling within SBE-FBs. SHOP enrollments now allowed directly with carrier/brokers, without direct SBE-FP's exchange enrollment.  0 SHOP plans being offering in Florida for any small businesses, and states now prohibited from creating platform to secure small group plan insurance for small employers. $0 commission paid by carriers to agents for almost all SEP (Special Enrollment) eligible Individual plan sales has destroyed the individual agency access for customers.

Federal Info at HHS:

ACA Risk Adjustment
See CSR. Bottom line is carriers are not able to trust what CMS did in the past will continue in the future resulting in federally caused destabilization of the INDIVIDUAL and SMALL GROUP (SHOP) carrier product offerings. Most carriers never offered a SHOP plan. Many carriers have already abandoned marketplace offerings, leaving the uninsured little, or no affordable (APTC)options, or explanation from licensed agents. In short, current federal actions have destabilized the market resulting in less consumer choice of plans, smaller provider panel choice in plans that are offered, and massively higher premiums that are now increased to fund unpredictable CSR, and reinsurance recovery from the feds.

Accountable Care Act of 2010 (ACA)
See: Patient Protection and Affordability Act See: Republican Agenda

Accountable Care Organization (ACO)
An organization allowed by CMS that allows medical providers to enter into risk /non-risk bearing contracts to care for assigned Medicare and/or Medicaid lives. Commercial demonstration projects may also be submitted for review by CMS. There are 923 (June 2017) ACO's. 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. FFS contracts are also offered by demonstration project HHS 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.)   UPDATE: (Source: Healthcare Finance) The CMS has proposed overhauling Medicare's Accountable Care Organization program, with proposed changes that include limiting from six years to two years the amount of time an ACO can remain in an upside-risk arrangement, authorizing termination of ACOs with multiple years of weak financial performance and allowing certain ACOs under performance-based risk to offer incentives to patients for taking steps to improve their health. The CMS expects the proposal, estimated to save Medicare $2.2 billion over 10 years, to result in the dropping out of about 107 ACOs. Update September 2018: Source Medical Intelligence: MSSP ACOs with just one to two years of experience in the program actually increased Medicare spending, researchers reported. ACOs in the MSSP for four years reduced Medicare spending the most in 2017. The organizations decrease spending by $115.15 per beneficiary.

ACO Risk Contract/CMS Fact Sheet

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

See ACO, See MACRA, QPP, MSSP Track 1, MSSP Track 3

ACO Performance

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).
Actuarial Value (AV)
An MLR legislated ACA value requirement of "metallic" level plan pricing. "Issuers in the Individual Marketplace can choose to offer one or more “standardized options” with a specific cost-sharing structure at the Bronze, Silver, and Gold levels. Each standardized option consists of a fixed deductible, fixed annual limit on cost-sharing, and a fixed copayment or coinsurance with specified applicability of the deductible for a key set of essential health benefits that comprise a large percentage of the total allowable costs for an average enrollee. Issuers that offer a Silver standardized option must also offer the three associated standardized Silver plan variations for cost-sharing reductions (i.e., 73% actuarial value, 87% actuarial value, and 94%" actuarial value). (source: Source: MLM training by CMS The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care. The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care. •Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40%. •Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30%. •Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%. •Platinum.The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%. 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.
Adjusted Clinical Groups (ACGs)
Johns Hopkins Adjusted Clinical Groups System
Adjusted Gross Income (AGI)
The amount used by a single person to calculate tax credits on ACA compliant plans for people earning between 100%- 400% of FPL. AGI is reduced by child support and student loan interest.
Admitted Carrier
An insurer that is both authorized and eligible to place insurance within a given state. Admitted carriers enjoy protected status against competing Surplus Lines carriers who are not subject to the same premium taxation. Admitted carriers enjoy State Insurance Guarantee Association protection, whereas. Surplus Lines carriers do not.
Advance Payments of the Premium Tax Credit (APTC)
Advance Premium Tax Credit: The premium discount amount a person earning between 100% - 400% of FPL is eligible. The credit is paid by the federal government directly to the health insurance company each month. see Periodic Data Matching (PDM)
Advanced Aggregate
Advanced Aggregate is reinsurance provided to ERISA exempt entities. Reinsurance over multiple self funded employers is provided by advancing aggregated coverage recoveries for risk between specific retention and a percentage of the fully funded and underwritten major medical insurance premium.
Advanced Alternative Payment Models (APMs)
Advanced Premium Tax Credit (APTC)
Tax credit people earning between 100% -400% FPL are eligible related to commercial insurance premiums. It also refers to Medicare eligible beneficiaries that may also be purchasing a tax credit eligible plan. Total advance premium tax credit payments increased to $20 billion, from $12 billion in 2014. (Source: Think Advisor May 2017)
Advancing Care Information (ACI)
Advancing Care Information (ACI), which replaces the Meaningful Use program is one of four components CMS will use to make payment adjustments under MIPS. ACI looks at EHR use as it relates to patient engagement and healthcare quality and is 25% of your MIPS score for 2017. See QPP, MACRA, MIPS
An ACA legislated term defining eligibility for tax credits for individuals purchasing "On- Exchange" or "On Marketplace" plans who earn between 100% - 400% of the Federal Poverty Level. Citizens and non US citizens who file tax returns are eligible. See: Applied Premium Tax Credits, and 2010 ACA law.
Affordability Contribution Percentage
Term used to calculate if a Group (QHP employer offered plan) is affordable for purposes of avoiding a employer tax penalty, or Individual employee eligibility for a ACA available tax credit. (for 2017) Mainland FPL for 2016 affordability determination is $11,770 (9.66%) = $94.75. Means if employee earing $11,770 is required to pay more than $94.75 per month for QHP, that employee is eligible for INDIVIDUAL marketplace tax credit, and the (ALE) employer gets fined $3,240 for EACH employee getting a marketplace plan with tax credit.
Affordable Care Act (ACA, PPACA, Obama Care)
The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA. The ACA (Affordable Care Act) is a 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: 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 regulatory enforced and not part of original ACA. CSR lowers deductibles and max-out-of- pocket costs, and limits personal total annual health expense (spend) from (about) 2% to a maximum of 9.66% (2017) AGI/MAGI. Small employers (under 25 FTEs) are now offered tax credited plans through SHOP, where commercial sponsor offers them. Shop tax credits can be 50% for year one, and 35% for year 2. Insurance is provided be commercial carriers, not the government. See Eligibility for Advance Payment. Similar to Medicare Advantage plans, Individual and Small Group Insurance is offered and managed by commercial carriers, not the government. Means: Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), which are referred to collectively as the Affordable Care Act. Info is not tax advice.
Age Compression Rule
One provision in thePatient Protection and Affordable Care Act (ACA) that compresses the permitted age band premium rating to not exceed a 3:1 ratio. i.e. Meaning that a Medicare Advantage Plan pricing cannot exceed more than three times the premium pricing charged to younger people buying ACA (commercial plans) qualified insurance. It's goal was to help older people aged 54-64 afford lower premiums by shifting cost to younger people that already have low premiums.
Aggregate Pharmacy Reinsurance
Aggregate Pharmacy Reinsurance is a program of coverage which shifts the financial risk of pharmacy benefits from the employer, PBM or risk bearing entity to the reinsurer. Coverage typically triggers at 110%-125% of the expected annual budgeted amount.
Aggregate Stop Loss/Reinsurance
A second-dollar insurance triggering payment after (typically) 125% of last year's medical claims. It is a per population per year coverage, that once triggered pays out without additional (specific) deductible application. Premium 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.
Aggregating Specific Deductible (ASD aka "Inner Ag" or "Split Funded Ar)
A "second" deductible on top of the "specific" deductible that must be paid by the insured to "itself". I.e. If the Specific (per person per year deductible) is $50K and the ASD is $100K, then the insured will pay up to $100K (to itself) of all eligible 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 to be available for "expected" claims payment. This process effectively eliminates: Premium tax, agent commission, and carrier profit margin, carrier overhead load, reinsurance costs, and actuarial fudge factor thereby lowering "expected" costs" on an additional $100K of premium (that was not directly paid by the employer to the carrier to fund the first $100K of stop loss claims.
All-Care Readmission (ACR)
Alternative Payment Models (contracts) (APM)
A term used by LAN (CMS or Medicare administrators under HHS) to describe the identification, reporting and/or creation of new provider payment methodologies, and whose goals include increasing (private payers, providers, employers, state partners, consumer groups, individual consumers, etc) engagement, to drive lower (Medicare, Medicaid, Commercial, Workers Comp, Auto, etc) medical costs and better medical outcomes. Many are watching as republicans move to scrap many methods being tested to align better outcomes with hospital and physician accountability and reimbursement incentives. One goal is to try to change prevailing medical provider FFS procedure maximization behavior driving medical and premium cost out of control increases. Contracting tpes include: Fee for service, Management Fee, Bundled Payment, Shared Savings or Shared Savings & Risk, Performance Incentives (See MIPS, QPP. MACRA)
Ambulatory Surgical Center (ASC)

CMS 2018 advisory of how they are changing ASC payment that includes unburdening rural hospital reductions.


ASC can be just about any site where outpatient surgery is performed outpatient.

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 has essentially ignored the law, and is allowing less expensive plan offerings (see: Scheduled Medical plans Plans) limiting benefits, as well as preexisting medical condition exclusion previously prohibited under ACA law.
Anti-Concurrent - Causation Theories (ACCD)
In context to property policies and theories of recovery - it is a rule or policy provision denying or limiting coverage when the sequence of an uninsured peril causes an insured peril's loss. 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. See: EPC & CCD.
Applicable Federal Rate (AFR)
The applicable federal rate (AFR) is set monthly by the IRS and used for various purposes under the Internal Revenue Code, including for imputed interest and original issue discount rules. The AFR is normally available during the third or fourth week of the month. It is used for purposes of establishing a loan interest rate applied to Collateral Assignment Split dollar Life Insurance ( see SERP)
Applicable Large Employer (ALE)
An employer of sufficient size (typically involving groups over 50 FTEs, but can also include smaller groups) to fall under section 6055 or 6066 of the ACA law, and who is required to file forms 1095B and 1095C (health plan and employee information) with the government.
Applied Premium Tax Credit (APTC)

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

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

APTC is not CSR.

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

Appropriate Use Criteria (AUC)
Assignment of Benefits
A contractual provision of an insurance policy contract allowing payment for services directly to the medical provider, and not directly to the insured.
Association Health Plan (AHP)
See MEWA HHS Final Rules allowing expanded AHP structure across state lines, and under ERISA 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.

Automatic Reinsurance
See Treaty Reinsurance A reinsurance policy that automatically accepts each new policy risk written by the supported carrier. In other words, each new 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 or underwriting protocols or treaty risk transfer terms.


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

Benefit Package
The amount and limit of medical insurance provided within an insurance plan document, or Summary of Benefits. Benefits are typically summarized by: Deductible , Co Insurance, Copay, and out of pocket maximum. Additional benefits may also be part of the Package such as Dental, Life, LTC, STD, etc at customer option.
Best Interest Contract Exemption (BICE)
On April 6, 2016 the DOL published the Conflicts of interest - retirement Investment Advice regulation Implementation of a fiduciary standard for investement advisors, AND plain insurance agent's duty was determined by DOL without distinction from financial products requiring ongoing financial advice.  This caused at least two investment houses to stop offereing services to non-wealthy retirees, ironically the same people that need advice the most to avoid running out of money in retirement. DOL was/is ignoring what ERISA separates into products requiring ongoing advice, and one time commissions like fixed annuities, and life insurance products with "living benefits" provisions (i.e. IUL), typically sold by agents who do not sell anything that can crash with the market like stocks.  5th court of apppeals struck down the entire fiduciary rule March 8, 2018.  DC appeals court hears their case this year. ---- Under the rule, the DOL significantly expands the types of retirement advice subject to fiduciary protections under ERISA, including investment advice provided to Individual Retirement Accounts (IRAs), IRA owners, and other retail retirement plans and participants, Fiduciary status applies when investment advice is provided to existing or prospective clients regarding assets held in a "qualified" (Tax deferred) plan or an IRA account, including ERISA retirement plans, traditional, ROTH, and other IRAs. and certain other tax advantaged saving plans and accounts, such as Health Savings Accounts and Coverdell education Savings Accounts. Those who are fiduciaries under ERISA must satisfy the terms of prohibited transaction exemption in order to receive compensation that varies based on the recommendation (e.g. a commission). The Best Interest Contract Exemption (BICE) and FORM PTE 84-24 are both exemptions available for annuity transactions and applicable life insurance transactions, (Source: Directions: DOL Fiduciary Rule Producer Certification) Note: A fiduciary standard potentially sets the stage for massive Class-Action litigation 20 years from today of just about any insured (or indexed crediting product) alleging higher returns regardless of if that person forgot what they once understood, was taught, or otherwise confused many years later. Customers have a duty to understand what they are purchasing. Provider Risk Recommends speaking with licensed tax specialists to confirm tax benefit, and investment safety of very safe IUL, Fixed annuity, Indexed annuity and whole life insurance policy features protected by contractual guarantees. Most if not all of the new standard has been squelched by the Trump administration. The world if full of people that refuse to be accountable for their decisions. People who cannot remember what they had for dinner last night. The same people who under an unreasonable fiduciary standard duty could sue their agent or broker 10-30 after accepting an investment (including a life product like IUL) claiming, "It should have made more interest". A fiduciary standard recognizing no distinction between products at risk to market crashes, and those guaranteed safe by state insurance guarantee associations with funds not directly invested in the market and exposed to market crashes - makes impossible defending any future dispute over lower than expected interest returns. Our advice is take the time to ask questions about any IUL or investment before accepting the policy, or investing. If you do not understand it, ask questions until you do, or don't buy it. Do the work.

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

BIC (Best Interest Contract)

See BICE Check with DOL for certainty of where the rule applies. DOL delayed Fiduciary Rule until 7/1/19

DOL interpretation of fiduciry rule application to insurance agents AND financial advisors(including ERISA definition) thrown out 3/8/18 5th circut court of apeals.  Court said ERISA separates fiduciary standard by type of product needing CONTINUING advice versus single majority commission product sale (like Fixed annuity, IUL, etc).  Cintinueing advice likely would apply to marketable securities at risk to market down turns, not guaranteed safe products like or using guaranteed safe Fixed indexed annuities. or IUL which guarantees 0% interest crediting floor up to 17% interest crediting cap.

DC appeals court to hear case in 2018.

Book Rate
See Manual Rate
Book to Manual (BTW)
Jargon typically used by underwriters to express the percentage discounted from the manual rating filed with the state.
Brokers are licensed agents who represent multiple carriers, and who are legally obligated to serve their client’s best interest.
Brokerage General Agencies (BGO)
Bundled Payments or Care Payments (BBCP)

A single medical reimbursement amount defined however a medical provider wants to offer there services, or a payer (CMS, commercial insurers, etc) want to contract its providers. (i.e. OB deliveries, dialysis, factor therapy, transplants, or accepted reimbursement amount with and without bonus incentives, etc.) Services are typically stated in terms of a fixed reimbursement amount by specific diagnosis, or episode (period of time) of care. Some refer to them as "full value-based reimbursement". An implied goals to the "value-based" amounts are tied to EBM directing healthier outcomes of care at lowest cost. The Trump Administration has unilaterally decided by CMS regulatory rule to bundle payments for ALL Medicare beneficiaries for 32 types or “episodes” of care. These include hip and knee replacement operations, heart bypass surgery and procedures to open clogged coronary arteries, as well as treatments for heart attacks, stroke, pneumonia and chronic obstructive pulmonary disease. See MACRA, MIPS, PQRS, etc


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.

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


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

See: eCQM

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

Co Insurance
In Stop Loss, Co Insurance is the percentage of eligible charges reimbursed to the stop loss policyholder after the deductible has been satisfied. In major medical insurance, Co Insurance is percentage of eligible charges the individual policy holder is required to pay the medical provider for services rendered after the deductible has been satisfied. In primary medical insurance, co insurance can be the percentage of medical claims paid by the insured up to the maximum allowed by ACA
Co Payment
Co-payment is a fixed (flat) dollar fee an individual insured pays each time he accesses care from physicians, hospitals and medical services providers.
The Affordable Care Act established the Consumer Operated and Oriented Plan (CO-OP) program, which created a new type of private nonprofit, member-run health insurer. CO-OP health plans are governed by their members, must operate with a strong consumer focus, and reinvest any profits into lowering premiums, improving benefits, or otherwise improving the quality of health care delivered to their members. CO-OPs offer health plans through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace.
COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses, and the dependent children when group health coverage would otherwise have been lost due to specific events. 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. Source: DOL

Community Living Assistance Services and Supports (CLASS)
Affordable Care Act (ACA) included an optional program called Community Living Assistance Services and Supports, or CLASS, that would have paid caregivers, including family members with no professional training in caregiving, to help older Americans stay in their own home and not access long-term care in institutional settings. The CLASS program was fashioned, however, as a voluntary endeavor with enrollees choosing whether or not to enroll, unlike traditional social insurance programs such as Medicare that mandate enrollment. But this voluntary enrollment feature, when combined with the ACA’s explicit mandate that the CLASS program be self-financing, made that program unsustainable and it was repealed in early 2013. Nevertheless, a publicly administered and funded social insurance program that would pay family caregivers remains an option beyond its present Medicaid context.
Community Rating
An employer premium rating method based on claims history by region (zip code). ACA promulgates rules employers (over 50 FTE) MUST apply (higher priced) community rating, thereby eliminating potential premium discounts associated with favorable claims experience.
A general term used to loosely or accurately convey meeting or addressing regulatory standards/reporting.
Composit Performance Score (CPS)
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Comprehensive Primary Care Plus (CPC+)

CPC+ is a five-year model that will begin in January 2017. CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations, and Medicare Advantage plans in 14 regions across the nation. Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S.). The care delivery redesign ensures practices in each track have the infrastructure to deliver better care to result in a healthier patient population. The multi-payer payment redesign will give practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback, to guide their decision making.

Comprehensve Joint Replacement (CJR)
a Value based or bundled payment initiative by CMS. A mandatory risk based provider reimbursement model inclusive of complete treatment with outcome reporting.
Computer Assited Coding (CAC)
Term used by CMS related to coding care for MA patient reimbursements.
Concurrent Causation Doctrine (CCD)
A rule or policy provision applying insurance to a loss when both an Insured and Excluded peril(s) (concurrently) cause the loss. See: Anti-Concurrent-Causation, Efficient Proximate Cause
Congenital Heart Disease (CHD)
Consumer Assessment of Healthcare Providers & Systems (CAHPS)
• Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey – Sample PDF: The CAHPS for MIPS Survey measures patient experience and care within a group. The data collected on these surveys will be submitted on behalf of the group by the CMS-approved survey vendor. (The CAHPS for MIPS Survey is optional for groups with two or more MIPS clinicians and is not provided as an option for individual clinicians.) See QPP

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

Contingency Fees
A Contingency Fee is compensation to the agent above the commission. This fee is not usually discussed with the client. It can be similar or identical to an underwriting profit or override on profitable business sales. In larger brokerages, these "fees" are usually negotiated by senior management, where the local agent is unaware the fees exist. RIMS recently mandated a policy statement that these fees be clearly divulged by all agents to avoid the appearance of impropriety.
Continuety of Care Application
An application filed with the insurer to allow continued medical treatment for patients receiving advanced care/therapy at a facility that becomes an out of network (OON) provider DURING treatment. Certain patient protections may apply that require carriers to pay for ongoing episode(s) of care, at the higher rates This is a grey area of ACA mandates, and practice standards.
Continuing Education Unit (CEU)
Contribution Requirements
The minimum percentage of employer paid premium for (QHP) group major medical benefits, typically set at 50%.
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.
Cost of ACA to Taxpayers
According to the Congressional Budget OFfice

Cost Share Reduction (CSRs or Risk Adjustment Program)
A Federal Program reimbursing carriers (estimated at 10.4 BILLION for 2017) for lowering deductible and Maximum Out of Pocket patient costs (to the insured member) based on patient incomes between 100% and 250% FPL. Two courts have held that the government does not owe it, despite the previous administrations payments honoring federal promise. See: Cost Sharing Reductions. October 2017: President Trump issued an Executive Order (EO) removing many ACA requirements, and consumer protections (without passing a law). i.e. Undoing preexisting medical condition exclusion on plans sold during SEP, Eliminating mandatory coverage of unlimited ten essential healthcare benefits, eliminating maximum annual out of pocket costs, CSR reimbursements to carriers.  Several large carriers are suing the Feds at this time. Current Trump interpretation of the ACA law declares the federal government is prohibited from paying funds to carriers for CSR retroactively. For now, HHS has ended CSR payments adds to the destabilization of the marketplace offerings. That said, latest July 2018 CMS advisory declares payments to carriers will re-start September 2018...?

Cost Sharing Reduction (CSR - Risk Adjustment Programs)
Federal reimbursement to commercial carriers (estimated at $10.4 Billion for 2017) applying only to INDIVIAULLY insured Silver level Marketplace sold plan members whose income is between 100% - 250% of FPL. Cost Sharing Reductions apply to lowering the deductible and Maximum Out of Pocket costs. CSR's were not part of the original ACA law. President Trump has moved to eliminate CSR reimbursement payment, but CMS is advising the oppositee...? Two courts have upheld the feds are not obliged to pay it - resulting in even more destabilizing. CMS claims to be asking AZ to reconsider their finding, which was upheld by another state court. Cost sharing reductions can also refer to federal reinsurance (limited) safety net to Marketplace participating carriers offering tax credited major medical plans to offset adverse selection. See Shared Services, which applies to MEDICARE (not Group or INDIVIDUAL commercial Marketplace offered plans). ================  Per the NY Times: "Discontinuing cost-sharing reduction payments to insurers would increase premiums for silver-tier plans, the most popular plan tier sold on Affordable Care Act exchanges, by 20% next year and by 25% by 2020, and would raise the federal deficit by $194 billion through 2026, according to an analysis by the Congressional Budget Office. The move would prompt insurers in some states to exit the market, leaving about 5% of Americans with no insurance options next year, although insurers are expected to rejoin the market in 2020." Source: NY Times August 2017 Many carriers have filed suite to recover CSR for hundreds of millions already paid out to medical providers, and that lowered individual out of pocket accounts, and that carriers they relied upon before rating and binding 2017 and 2018 plans. CSR is sometimes erroneously referred to in the context of Marketplace reinsurance - which is federally offered coverage for claims costs between $45,000 and $250,000.   (note: ACA law mandats unlimited benefits for 10 essential health benefits to comprise QHP, so the reinsurance coverage carrier safety net is inadequate by original reinsurance coverage design.)  ================================== 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, 2017 for those employers who selected to pay the 2016 fee in two installments. For the final year payment, self-funded employers who selected to pay in one installment paid the $27.00 per covered life Jan. 17. Those self-funded employers have no further payment obligations. For those employers who selected two installments, the payment schedule is: •$21.60 per covered life – payment made Jan. 17 •$5.40 per covered life – due Nov. 15 Background Under the Affordable Care Act (ACA), the Transitional Reinsurance fee has been paid by health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance Program in place from 2014 to 2016. •For fully insured clients, UnitedHealthcare pays the fee. •For self-funded employers, the employer is required to pay the fee. For the final year, the fee was determined to be $27 per covered life and was based on enrollment in major medical coverage for the first nine months of 2016, regardless of the plan’s renewal date. Employers were responsible for submitting their enrollment count and selecting their payment date(s) on the government portal ( last fall. See latest July 2018 Trump lead CMS advisory that CSR payments to carriers will restart September 2018....?

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 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.
Current Procedure Terminology
A 5 digit code for Hospital procedures. See: ICD-10
Cyber Security: Medical: HHS Tast Force Recommendations


A Declaration is an addendum to all stop loss and reinsurance policies which warrants all members expected to exceed 50% of retention have been reported prior to binding coverage.
Sometimes referred to as Retention, or threshold, a Deductible is the dollar amount exceeded before a policy pays all, or part of an eligible claim. In most Stop Loss and Reinsurance, deductibles accrue independently of any co insurance or copays. In most individual and Group major medical insurance, a deductible includes most Copays and OOP spent on eligible care.
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, then INCOME tax is due when withdrawn in retirement - and no one knows what Income Tax will be in 10 - 30 years..? Roth IRA contributions are AFTER tax, and are not taxed when withdrawn in retirement,and within IRS compliance. Traditional 401 and IRA contributions are not taxed going in... IMPORTANT: Check out IUL that offers IRS compliant loans in retirement that are not taxed as income, are not directly exposed to market crash risk, and come with interest guarantees up to 17% (currently offered).

Department of Insurance (DOI)
State agency or regulatory authority that, among other things, licenses, oversees, and regulates Issuers, Agents, and Brokers, as applicable.
Designated State Health Programs (DSHP)
Federal Medicaid money to states used to fund various healthcare programs for the poor. Trump administration is ending the program currently used by Arizona, California, New York, New Hampshire, Rhode Island and Washington now have waivers that include DSHP funds. Source: Modern Healthcare
Diagnostic Related Group (DRG - see Bundled Payment)
A Medicare assigned reimbursement by diagnosis code. Many rules apply. Some DRGs allow for "outlier" modifier codes causing certain events to qualify for greatly increased eligible reimbursement to reflect comorbidity events.
In context to medical stop loss or reinsurance, disclosure means the transparent presentation of KNOWN large claimants as defined in the stop loss application. Typical reporting includes anyone existing member known to be in the hospital, or "expected" to exceed 50% of requested retention (deductible) requested coverage. Trigger diagnosis are also typically defined by the underwriter being solicited for stop loss proposal. "Actively at work" provisions can complicate transparent disclosure, prior to policy offer/acceptance and risk transfer.
Dual Eligible’s
A term generally used to identify an individual eligible for both Medicare and Medicaid.


Early Lock Down
A renewal feature offered by some carriers to renew stop loss coverage early, and avoid last minute potential lasers on sick 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.
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 or 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
Electronic Clinical Quality Measure (eCQM)

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

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

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

Eligible Clinician ((Replaces Eligible Professional))
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Employee Retirement Income Security Act (ERISA)
The ERISA Act provides federal laws and regulations pertaining to the operation of self funded health plans for single employers, unions, trusts, and associations. ERISA 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.
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 Management System (EIDM)
CMS offered identity registry created to access multiple entity reporting of QPP related reporting. See PRQS:
Episode of Care
A term used to denote care delivered from beginning to end of a treatment, or typically a hospital inpatient stay. 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 specified period, or by medical outcome desired.
Episode Payment Models (EPM)
Episode Payment Models (EPMs); Cardiac Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model On August 2, 2016, the Centers for Medicare & Medicaid Services (CMS) published four new payment models and refinements to a current model through a notice of proposed rulemaking to further advance care coordination for Medicare fee-for-service (FFS) beneficiaries, which will begin on July 1, 2017. Three new episode payment models (EPMs) would test making participants financially accountable for the quality and cost of episodes of care helping achieve the goal of higher quality at a lower cost for the following episodes: • An acute myocardial infarction (AMI), including both medical therapy and percutaneous coronary intervention (PCI), • A coronary artery bypass graft (CABG), and • A surgical hip/femur fracture treatment, excluding lower extremity joint replacements (SHFFT). The Cardiac Rehabilitation (CR) incentive payment model for EPMs and Medicare FFS participants would test financial incentives for Inpatient Prospective Payment System (IPPS) hospitals that encourage the management of beneficiaries following an AMI or CABG toward greater utilization of CR services. The proposed rule can be found on the Federal Register. See CMS fact sheet and press release.

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

Essential Health Benefits (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.




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

Expected Claim Value
The underwritten expected annual claim value used to rate specific and aggregate insurance premium.
Experience Credit
Experience Credit aka Premium Refund aka Minimum Premium aka Profit Commission aka Terminal liability aka Alternate Funding aka Experience Refund policy. A premium rebating feature that returns excess premium when claims are lower than a negotiated loss ratio typically under 70%. Experience 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.
Expert Medical Advisor (EMA)
An highly qualified medical professional accepted by a workers compensation court for purposes of determining the percentage of medical claims a injury can discern were 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.
External Review
A process that meets minimum standards set forth under ACA/HHS regulation related mostly to coverage exclusions or insurance denials. ACA details greater consumer appeal rights for denied or under-reimbursed medical claims. Self Funded (ERISA) plans are held to a different standard than Individual plans, mostly limited to review of insurance eligibility.


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

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

Federal Poverty Level Guidelines

Federal Provider Penalties
HHS Increases Civil Monetary Penalties September 6, 2016 by Heather Landi The U.S. Department of Health and Human Services (HHS) issued an interim final rule Sept. 2nd that raises various civil monetary penalty amounts to adjust for years of inflation. “The Department of Health and Human Services (HHS) is promulgating this interim final rule to ensure that the amount of civil monetary penalties authorized to be assessed or enforced by HHS reflect the statutorily mandated amounts and ranges as adjusted for inflation. Pursuant to Section 4(b) of the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (the 2015 Act), HHS is required to promulgate a “catch-up adjustment” through an interim final rule. The 2015 Act specifies that the adjustments shall take effect not later than August 1, 2016,” HHS stated in the interim final rule. The rule noted the new maximum penalties apply to any fines assessed after Aug. 1, 2016, as well as all penalties stemming from violations that took place after Nov. 2, 2015. Under the interim final rule, some civil monetary penalties will nearly double due to inflation adjustments. HHS increased the penalty for a HMO or competitive medical plan that implements practices to discourage enrollment of individuals needing services in the future by 106 percent from $100,000 to $206,000. Hospitals with 100 beds or more now face penalties of more than $103,000 if they dump patients needing emergency medical care. That’s up from the $50,000 penalty established in 1987. Circumventing Stark Law’s restrictions on physician self-referrals will now cost $159,000, a 59 percent increase from the original $100,000 penalty established in 1994. Some penalties are relatively small, such as the penalty for payments by a hospital or critical access hospital to induce a physician to reduce or limit services to individuals under the direct care of the physician or who are entitled to certain medical assistance, which increased 115 percent from $2,000 to $4,300. Many updated penalties affect both Medicare and Medicaid managed-care companies. HHS raised the penalty for a Medicare Advantage organization that improperly expels or refuses to reenroll a beneficiary by 47 percent, from $25,000 to $36,794. Medicare Advantage organization that substantially fail to provide medically necessary, required items and services will now face penalties of more than $37,000, an increase from $25,000. The penalty for a Medicare Advantage organization that charges excessive premiums went up from $25,000 to $36,794. And, a Medicaid MCO that improperly expels or refuses to reenroll a beneficiary now faces a $197,000 monetary penalty, up from $100,000.
Federally Facilitated 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 Duty
A legal standard intended to define "investment advice" is always in the customers best interests as defined by the Department of Labor, and subject to ongoing comment/revision/litigation adaptation by DOL. DOL provides guidance upon prohibited transactions related to products that are not subject to market downturns, and that guarantee interest crediting - falling within suitable recommendations. (i.e. Fixed Annuities) Senior Suitability applications are already used to force individual customer analysis investment value and risk - especially involving retirement account funding. Form 84-24 may also provides additional compliance with DOL promulgated consumer oversight protections - where applicable. This may no longer be required due to presidential agenda.... In insurance, it mostly relates to the types of investments suitable for customers - especially those investing with retirement account funds. All licensed and regulated carriers employ dedicated staff who direct agents on required forms to meet perceived DOL compliance. The world if full of people that refuse to be accountable for their decisions. People who cannot remember what they had for dinner. The same customer that may sue a financial planner for an investment that "should have made more interest" 10 -15 years later. A generic fiduciary standard recognizing no distinction between products at risk to market crashes, and those guaranteed safe by state insurance guarantee associations with funds not directly invested in the market and exposed to market crashes - makes defending future disputes 10 years later impossible. Our advice is take the time and do the work to ask questions about any investment or IUL that you do not understand, until you understand or accept the investment/insured IUL product, If you do not understand it, ask questions until you do, or don't buy it. Do the work. DOL explanation of Fiduciary Duty re: AHPs and ERISA. Source : DOL Fiduciary Rules ERISA establishes standards and rules governing the conduct of individuals and companies responsible for running the plans, including AHPs. For example, ERISA requires that plan assets be held in a trust by one or more trustees or by an insurance company as part of an insurance contract. AHPs must also have a written document that describes the benefit structure and guides day-to-day operations of the plan. Among other things, this document must provide for one or more named fiduciaries to control and administer the AHP. The named fiduciary may either be named in the plan ASSOCIATION HEALTH PLANS: ERISA COMPLIANCE ASSISTANCE 3 document or identified as a plan fiduciary pursuant to a procedure specified in the plan document by the group or association of employers that sponsor the AHP. A person may also become a fiduciary of an AHP if the person has any discretionary authority or responsibility in the administration of the plan, exercises any discretion in administering and managing such plan or exercises any authority or control over the plan’s assets. In general, the employers that are members of the AHP have a fiduciary duty to monitor the AHP and get periodic reports on the fiduciaries’ management and administration of the AHP. Under ERISA, fiduciaries must discharge their duties solely in the interest of plan participants and beneficiaries and for the exclusive purpose of providing benefits and defraying reasonable expenses of administering the plan. In discharging their duties, fiduciaries must act prudently and in accordance with ERISA and the documents governing the plan. The fiduciary duty to act prudently extends to the AHP’s hiring of service providers, such as third-party administrators, insurers, and pharmacy benefit managers. When selecting a service provider, the responsible plan fiduciary must engage in an objective process designed to elicit information necessary to assess the qualifications of the provider, the quality of services offered, and the reasonableness of the fees charged in light of the services provided. In addition, such processes should be designed to avoid self-dealing, conflicts of interest, or other improper influences. ERISA also prohibits certain transactions involving plans and related parties called “parties-in-interest.” Parties-in-interest include, for example, the AHP fiduciaries and related entities (e.g. affiliates of the plan fiduciaries) and the employer members of the AHP. An AHP fiduciary that hires one of the association’s member employers to provide services to the AHP would be engaging in a prohibited transaction. Similarly, if a trustee of an AHP or another fiduciary hired an affiliated company to provide services to the AHP, that too would be a prohibited transaction. Are exemptions available for an AHP from any of ERISA’s prohibited transaction provisions? Yes. ERISA includes a number of exemptions (called “statutory exemptions”) that allow AHPs to conduct necessary transactions that would otherwise be prohibited. The Labor Department may also grant additional “administrative” exemptions. “Administrative” exemptions can cover transactions with one specific plan or an entire class of plans. More information on the procedure for applying for an administrative exemption is available at: statutory exemption that is particularly important for AHPs allows AHPs to pay individuals or companies who provide services to the AHP but only if the services are necessary to operate the plan, the contract or arrangement under which the services are provided is reasonable, and the compensation for those services is reasonable. 4 UNITED STATES DEPARTMENT OF LABOR This “service provider” exemption does not cover a fiduciary hiring an affiliate or related person or company to provide services to the AHP — called self-dealing or a “conflict of interest” prohibited transaction. There is a separate statutory exemption for this “conflict of interest” transaction but, in addition to the conditions required by the “service provider” exemption, the affiliate (or related person or company) can be paid only for its direct expenses (not normal fees) incurred when providing services. Fiduciaries of AHPs can apply to the Department for an administrative exemption if they want to hire affiliates or related persons or companies and charge normal fees, but the application would have to prove the arrangement was in the interest of and protective of the plan and its participants and beneficiaries. Does the Department of Labor have any voluntary correction programs for employers or associations who make mistakes in operating an AHP? Yes. The Department of Labor’s Voluntary Fiduciary Correction Program (VFCP) encourages fiduciaries to comply with ERISA by voluntarily self-correcting certain violations. The program covers 19 common transactions including failure to promptly remit participant contributions, payment of duplicate, excessive, or unnecessary compensation, and improper payment of expenses by the plan. Particularly important for AHPs is the ability to correct failures by member employers to promptly send participant contributions to the AHP. The VFCP describes how to correct certain, covered violations. In addition, the Department gives applicants immediate relief from paying excise taxes for late contributions under a class exemption. The Department also has a Delinquent Filer Voluntary Compliance Program under which AHPs and other employee benefit plans can fix failures to file a Form 5500 on time. For an overview of both voluntary correction programs, visit In addition to these correction programs, EBSA has an active compliance assistance effort where the Department works with all types of plans, including AHPs, to help them identify and fix mistakes.

Field Marketing Organization (FMO)
A sales and marketing organization typically organized to sell various kinds of insurance policies. FMO's can be called by several different terms, and require both exclusively, or non exclusivity of their contracted agents.
Finite Reinsurance
Finite Reinsurance is defined by the Reinsurance Association of America as "a highly structured reinsurance contract where structured elements reduce the amount of risk assumed by reinsurers to the point that it may not meet the accounting requirements of risk transfer." Finite reinsurance is typically coverage transferring little or no risk, and is designed to pay known losses, or improve issues related to cash flow from irregular market conditions involving interest rates, and asset values. It typically improves financial ratios related to compliance, and capital surplus reserves. There are many types of finite loss development coverages. The essence of coverage may amount to a line of credit to pay known losses today and reimburse the reinsurer by amortized future premium payments. NAIC has recently agreed on a uniform policy form.
Firm Rate
Sometimes called firm quote, or "a bindable" quote. It is the underwritten rate offered by an carrier who has priced a given policy premium (and quote deadline). This rate typically does not change if the policy proposal is accepted by the customer by deadline. Rules governing last minute claims disclosure & underwriting acceptance are specific to each carrier, and are subject to offering terms, conditions, deadlines, and coverage, etc.
First Dollar Risk
A dollar amount most underwriters consider a likely 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.
Flexible Spending Accounts (FSAs)
Flexible spending accounts (FSAs) enable workers to contribute pre-tax dollars to use towards eligible medical expenses typically related to deductibles, copays, and maximum out of pocket costs. Defined unused remaining balances at year end are forfeited. A small amount may be rolled over for use in future years. See IRS guidelines. 2018 limits: For FSAs, up to $2,650 a year; for HSAs, up to $3,450 annually for individuals and $6,900 for families. See HSA.
Fronting Assignment
Fronting can refer to multiple types of reinsurance and insurance. Fronting can be the leasing of an authorized insurance policy form in an individual state. Sponsoring carriers may elect to assume all, part, or none of the risk being assumed by the entity attempting to establish an insurance program. Fronting carriers may, or may not act as reinsurers. A fronted and reinsured assignment can be a program of transferring an existing book ($1+M) of insurance into an existing authorized policy form that creates a less expensive "compliant" insurance alternative to a fully insured premium, and that allows agents to both commission on the sale, and share in profits. Assumption of “some” risk by the sponsoring agency/entity/ company/broker is usually required to assure a true risk partnership and comfort reinsurers. Fronting and "reinsured" assignments take MANY forms. Where a larger company establishes a (n offshore captive, or on shore "compliant") program to assume and manage their own risk (General Liability, Major Medical, ERISA, Workers Compensation, etc.), the primary purpose is to fund "1st dollar" risk and cede "second dollar" (unpredictable) risk at a cost that can be much less than buying a fully insured coverage to satisfy compliance and/or manage risk. Program managers strive to balance premium savings and liquid-surplus-reserves- funding for known and unknown claims risk. There are many types reinsurance coverages designed to manage unpredictable risk, and/or help improve compliance ratios, and/or solvency risk management. See Finite Reinsurance.
Full Time employee
A term defined under ACA meaning an employee working more than 30 hours per week. It is calculated by summing all part time employee hours and dividing by 30hrs to determine a FTE for purposes of ACA employer-employee count being above or below 50 FTE. Under ACA, the number is used to assess ACA tax penalties for employers employing over 50 FTEs. Employers over 50 FTE not providing ACA compliant medical insurance to their employees get fined $2,000 per employee (after the first 30 FTE exemptions).
Full Time Equivalent (FTE)
An employee working more then 30 hours a week. It should be noted that ACA law calculates part time employees working under 30 hours a week – summed and in total to determine if an employer has over 50 full time employee “equivalents” and is subject to either a $2,000 or $3,000 penalty tax for non compliance.
Fully Disabled Limitation
A Fully Disabled Limitation is a condition of a self funded stop loss policy that excludes members not actively at work, and/or who might be in the hospital at time of “disclosure”. This provision is typically waived by the carrier by proper claims declaration.
Fully Insured
A term to describe an "eligible" and "Authorized" ( or "admitted") insurance policy approved in a state characterized by a significantly LOWER deductible than a Self Funded Plan. The term fully-insured-rate can be associated with an "admitted" insurance policy form and cover offering premium rebates for favorable claims experience. See Minimum Premium Plans, which are a type of fully insured plan that charges the "fully-underwritten-rate", and rebates premium for favorable claims experience while adding no unfunded risk to the policy holder.
Functional Capacity Evaluation (FCE)


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 that typically reimburses the insured for eligible out-of pocket medical charges. 3. In ERISA related matters, it can refer to holes in (1st or 2nd dollar) coverage caused when SPD conflicts between the plan document and any other document – including network contracts, ASAs, stop-loss policies, employee handbooks, PBM agreements, etc., 4. Some Accident only plans can be considered a type of Gap plan.
Gatekeeper Plan
A term used to identify medical plans requiring a primary care physician referral requirement before accessing specialty physician care.
General Agent (GA)
A GA is a General Agent for a single carrier. A GA is bound legally to represent the best interest of their appointing carrier, and sometimes earn commissions, overrides and/or profit sharing.
Geriatric Resources for Assessment and Care of Elders (GRACE)
An ACO program designed to study low income elderly people to determine reductions in ER visits, hospitalization and readmissions by using in home assessments & better-monitored plans.
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.
Grace Period
A Grace Period is the number of days past the premium due date the premium will be accepted before canceling the policy for non-payment of premium. A typical grace period is 30 days. Marketplace plans have an ACA mandated 90 day grace period.
Grandfathered or Grandmothered Plan
An ACA compliant plan allowed that is not ACA compliant (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 non compliance. Many Grandfathered plans have materially less coverage than ACA compliant plans. Group plans issued after 1/1/16 are ACA compliant. Grandfathered plans are exempted from ACA mandated changes like unlimited benefits for 10 essential health benefits. Grandfathered plans are typically prohibited from making any changes that increase MOOP. (Source
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 and outside of OEP.
Guarantee Issue / Guarantee Renewability
A policy feature offering insurance issuance without additional underwriting or exclusion of preexisting medical condition. ACA offers guarantee issue policies during OEP and SEP only each year.
Guaranteed Purchase Option (GPO)
A life insurance rider guaranteeing option to purchase additional permanent protection in the future without providing evidence of insurability.


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

Health and Human Resources (HHS)
Federal Department of Health and Human Resources - the agency charged with managing ACA and CMS, etc.
Health Care Payment Learning and Action Network (LAN)
A HHS-CMS department assigned with tracking & communicating alternative (non FFS) medical provider reimbursement contract successes in lowering cost and maximizing evidence based medicine outcomes. “CMS is proud to achieve the 30% target almost a year ahead of schedule. Moreover, true transformation of our health system cannot be done through Medicare alone, and so CMS looks forward to continuing to work with partners across the country to achieve the goals of tying 30% of spending to APMs by the end of 2016 and 50% by the end of 2018 for the entire U.S. health care system.” “The Health Care Payment Learning and Action Network will bring together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models.” “HHS has set a goal (PDF) of tying 30 percent of Medicare fee-for-service payments to quality (PDF) or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018.” (source: Health Care Payment Learning and Action Network (LAN))
Health Information Exchange (HIE)
Health Information Technology (HIT)
Section 1561 of the Affordable Care Act requires the Department of Health and Human Services (HHS), in consultation with the Health Information Technology (HIT) Policy Committee and the HIT Standards Committee (the Committees),
Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)
The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI.
Health Insurance Claim Number (HICN)
See MBI Health Insurance Claim Number (HICN) in context to a Medicare patient claim patient identifier number.
Health Insurance Exchanges Program (HIX)
Health Insurance Issuer
Health insurance issuer means an authorized insurance company licensed to sell insurance in a state, and is subject to state law that regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act (ERISA)). This term does not include a group health plan. (Source
Health Insurance Marketplace
The name HHS gives to Exchange plans available on the federal or state marketplace.
Health Insurance Portability and Accountability Act of 1996 (HIPPA)
Federal Law created to help people keep their insurance between different employers, and ended up adding massive electronic personal information security requirements and (civil and criminal) penalties. Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, as amended, and its implementing regulations. (source MLN Learning) A law that sets standards for securing privacy of personal health information, and affording people changing jobs guaranteed insurance without preexisting medical condition exclusion or waiting period. Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers, and sets forth privacy and security standards for handling health information Public Law 111–148, Patient Protection and Affordable Care Act, March 23, 2010, 124 Stat. 119, Minimum Acceptable Risk Standards for Exchanges – Exchange Reference Architecture Supplement i Version 1.0 August 1, 2012 1 Centers for Medicare & Medicaid Services Executive Overview • Department of Health and Human Services Final Rule on Exchange Establishment Standards and Other Related Standards under the Affordable Care Act, 45 CFR Parts 155, 156, and 157, March 12, 2012, which establishes privacy and security controls required for processing Exchange applicant information • Internal Revenue Code (IRC), 26 U.S.C. §6103, which establishes criteria for handling Federal Tax Information (FTI) In addition, numerous other federal and state regulations impact the processes for securing information. For example, the Privacy Act of 1974 places limitations on the collection, disclosure, and use of certain personal information, including PHI. The e-Government Act of 2002 requires federal agencies to conduct privacy impact assessments (PIA) associated with collecting, maintaining, and disseminating PII. The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI. There is no integrated, comprehensive approach to security. (Source HHS) See: PII PII Data as defined by CMS, and Marketplace agent training 2019 • 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 Employer Name/"Doing Business As” Employer Federal Tax ID Number Employer Address

Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) is a state-designated insurance entity authorized to sell commercial, Medicare or Medicaid health insurance in certain counties. HMO's are known for emphasizing preventative medicine, and paying their doctors and hospitals a fixed dollar “capitation” for each member assigned to a provider group. An HMO is typically separated from a PPO or Indemnity Health Insurance by two major things: a capitated primary care physician (PCP), and required referral from a PCP for specialty physician access.
Health Reimbursement Account (HRA)
A tax exempt account used to pay eligible health expenses, typically paired with high deductible plans, and that gets funded by the employer. (This is the use it, or lose it account, but for about $500 per year that can roll over to the new year.) See HRA and MSA See IRS quidelines See IRS requirements
Health Resources Account (HRA, cafateria plan)
An HRA is a medical savings account typically funded by the employer, and / or employee for eligible medical expenses such as deductibles, co insurance, Cop Pays, and other eligible out-of-pocket medical expenses during a calendar plan year. Funds are typically accessed with a dedicated Debit card. Funds are typically "use ir or lose it" during the year. Total annual deposits are regulated and limited per calendar year. Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys. Recently the Trump administration has changed the rules to allow use of funds for short term plans - see link. Exactly how state and federal authorities will permit use of funds to by less expensive short term plans with preexisting medical condition exclusions is being evaluated. We recommend caution. ACA tax credit penalties may apply to unwary employers whose low income employees leave their plan and buy a tax credited individual plan.

Health Savings Account (HSA)
A health savings account (HSA) is a special tax-exempt account an individual owns and establishes with untaxed funds to pay for qualified medical expenses. HSAs are used in conjunction with high-deductible health plans (HDHPs) offered by many insurance companies that IRS accepts as eligible. The maximum amount that may be contributed to an HSA is set by law and subject to change each year. Under Sec. 223, individuals who participate in a high-deductible health plan (HDHP) are permitted a deduction for contributions to HSAs set up to help pay their medical expenses. Maximum out-of-pocket limit for 2019 group plans: •$7,900 for self-only coverage ($7,350 in 2018) •$15,800 for family coverage ($14,700 in 2018) The annual out-of-pocket maximum requirement does not apply to transitional relief and retiree only plans. 2019 Limits for High Deductible Health Plans (HDHP) / Health Savings Accounts (HSA) Minimum deductibles for 2019 (no change from 2018): •$1,350 for self-only coverage •$2,700 for family coverage •$2,700 for embedded individual deductible •Compliant HSA plan examples: •Embedded deductible. One plan for self-only and family have an embedded deductible, the minimum deductibles are: $2,700 individual and $2,700 family. •Non-embedded deductible. One plan for self-only and family have a non-embedded deductible, the minimum deductibles are: $1,350 individual and $2,700 family. Out-of-pocket maximum for 2019: •$6,750 for self-only coverage (versus $6,650 in 2018) •$13,500 for family coverage (versus $13,300 in 2018) Watch for the intersection of the HSA and Affordable Care Act (ACA) rules. The 2019 ACA maximum is $7,900 for individual and $15,800 family (versus $7,350 individual and $14,700 family in 2018). •Compliant HSA/ACA plan examples: •Embedded out-of-pocket max. One plan for self-only and family with an embedded out-of-pocket maximum, the maximum amounts are: $6,750 individual and $13,500 family •Non-embedded out-of-pocket max. One plan for self-only and family with a non-embedded deductible, the maximum amounts are: $6,750 individual and $7,900 family HSA contribution limits for 2019: •$3,500 for self-only coverage (versus $3,450 in 2018) •$7,000 for family coverage (versus $6,900 in 2018) •The annual “catch-up” contribution amount for individuals age 55 or older will remain $1,000.

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

http://See Aliera

Healthcare Effectiveness and Information Set (HEDIS)
A good set of clinical measures and rules that can help (along with others like NQF measures) used to identify gaps in care or potentially unnecessary care occurring, and/or who is experiencing it, and/or optimal clinical intervention timing.
Healthcare Research and Quality (AHRQ)
An agency under CMS that uses Clinical Classification Software (CCC) to detail co-morbid conditions grouped into six categories.
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.

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
New & increasing tax ($11.3 B) on Fully-Insured medical carriers, but not ERISA plans.
Hospice Quality Reporting (HQRP)
See: MACRA, QPP, MIPS The Hospice Quality Reporting Program (HQRP) Requirements and Best Practices web page provides updates regarding reporting requirements, and announcements focusing on best practice methods to help hospices be successful specific to the HQRP. In section 3004(c) of the Affordable Care Act, the Secretary is directed to establish quality reporting requirements for Hospice Programs. Currently, there are two requirements for the HQRP: •The Hospice Item Set (HIS) is a component of the HQRP for the FY 2016 annual payment update (APU) and subsequent years. For more information on the HIS, please visit the “Hospice Item Set (HIS)” portion of this webpage.

Hospital Inpatient Quality Reporting (IQR)

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

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.

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


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

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

Independent 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.
Individual Mandate
Under the Affordable Care Act, the individual mandate requires individuals to have health care coverage or pay a tax penalty. Information for 2016 and 2017 Open enrollment in the health insurance marketplace for 2017 begins on November 1, 2016, and runs through January 31, 2017. The penalty for not having coverage in 2016 is the greater of 2.5 percent of income in excess of the filing threshold, or $695 per adult ($347.50 for a child under 18) up to a maximum of $2,085. For 2017 and beyond, the percentage penalty will remain at 2.5 percent of income, but the flat fee will be adjusted for inflation. Source: Florida Agent Licensing Exam course.
Individual Mandate and Tax Credit
The tax penalty imposed on people who refused to buy ACA compliant QHP. The imposed penalty was repealed.
Injured Worker (IW)
A potential workers compensation eligible claimant in process of determining maximum medical improvement and major contribution cause of the injury.
Inner Agg
See Aggregating Specific Deductible
Inpatient (Hospital) Quality Reporting (IQR)

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

2018 Medicare Medicare Hospital Inpatient Prospective Payment System

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

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

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


Learning and Action Network framework (LAN)

See CMMI, ACO, etc

Level Funding (Minimum Premium)

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

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


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

Life Expectancy (LE)
The length of time a person is expected to live. In Life Settlements, it is the length of time in months an insured person is expected to live. LE's are commonly estimated by physicians and entities involved with buying and selling life insurance policies. These estimations help entities purchasing life settlements budget expected premium cost through policy execution. See life settlements.
Life Insurance
There are three to four basic types of life insurance: Term, Universal Life, Whole Life, and Variable life. Only Variable life policies can put cash values at risk to market crashes. Policies goals are typically designed to maximize or balance death benefits, debt relief and/or retirement distributions. Universal Life, Indexed Universal Life and Whole life can guarantee Principal safety & accumulated interest being locked-in MONTHLY. UL, IUL and WL also allow for tax deferred loans up to about 95% of their surrender value. Loans are available without penalty prior to age 59.5, and are pre-planned to remain IRS compliant and generally enjoy tax preferred spending (taken as loans againstt the Surrender Value). All loans are repaid after death with tax free death benefits while the policy remains IRS compliant. Because policy loans do NOT reduce Cash Value, the insured enjoys spending up to his policy Surrender Value in retirement, while still earning interest on the same values spent (taken as loans) for life. IUL, UL and Whole life never place an insured's cash value in the market, and have historically outperformed indexed investments exposed to market-crash risk. Our opinion is these policies generally offer exceptional "tax preferred" retirement benefits without market crash risk, WITH interest guarantees.
Life Settlements
A term referring to the business of buying and selling life insurance policies. It can also be used interchangeably with the process of determining a market value for a given life insurance policy, or portfolio of policies being purchased by investors.
Limited Medical Plan (MiniMed Plan)
See: Short Term Plan

List Bill
An invoice for INDIVIDUAL medical insurance sent and paid by an employer, but that is funded by an employee. It is not Group insurance.
Local Coverage Determination (LCD)
An ICD-10 term used to classify and charge for care.
Locum Tenens
A physician who is typically employed under contract for a period of under one year, and while a permanent physician employee is being sought to fill a position. locum tenens physicians are routinely used for several types of hospital based physician (ER, Pathology, Radiology, Anesthesiology) functions.

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

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


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

http://See MACRA

A state health insurance program for people earning under 100% of FPL, and eligible for Medicaid. Medicaid is different in each state. Medicaid can have about 15 categories of eligible people, and coverage. Typically, the federal government gives 50% of a state’s Medicaid budget. Under ACA, Medicaid eligibility was expanded from 100% to 133% of FPL for eligibility in states electing to expand Medicaid eligibility. 13 states elected not to expand Medicaid under ACA
Medicaid Expansion
A voluntary state expansion of Medicaid eligibility offered under ACA by the Federal Government for three years. The provision allows poor people access to free or less expensive Medicaid insurance by increasing income cut-off eligibility from 100% to 138% of FPL.
A program that the Supreme Court allowed individual (13) states to opt out, despite the federal government funding the first three years of added cost. Under the Affordable Care Act, states have the option to expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household MAGI at or below 138% of the FPL. This is known as "Medicaid expansion."
However, some states have chosen not to expand Medicaid eligibility. Regardless of whether a state chooses to expand its Medicaid eligibility, all state Medicaid programs:
  • Use MAGI as the income methodology for the majority of applicants (generally, all non-elderly, non- disabled populations)
  • Do not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI
  • Streamline income-based rules, systems, and verification procedures (Source
Medical Cost Inflation
Milliman report. Milliman is a company specializing in advanced medical cost analysis and trend. Milliman is well known for establishing underwriting parameters. 2018 Average Medical Plan cost for family of four $28,000 (Plus deductible, copays and Maximum out of pocket costs)

Medical Loss Ratio (MLR)
Medical Loss Ratio is typically defined as Total Premiums/Total claims. ACA mandates premium rebates where the percentage of claims are less than 80%/85% of Individual & Small Group/Large GROUP (employer) charged premium. MLR applies to fully insured group commercial plans and individual plans, not other medical plans. The law requires insurers to spend a minimum percentage of premium dollars (80 percent for individual and small group (1-50, or 1-100 depending on the market) markets and 85 percent for large group (51+ or 101+ depending on the market) on medical services and activities designed to improve health care quality. For the 2017 rebate reporting year (2018 payout year), California, Colorado, New York and Vermont define small group as 1-100 and large group as 101+. Recent Trump inspired rule changes are modifying 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)
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. Additional expenses may also be used that are not directly insured in the policy. i.e. Replacing an AC unit to help with an asthma condition, etc. See HHS/IRS list of eligible uses of funds. See: HSA and HRA MSA can also refer to the Medicare Set-Aside program offered by CMS and related to workers compensation insurance. MSA can also mean Medicare Savings account. " Guide-Version-2_6.pdf

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

Medicare Advantage (MA)
HMO and PPO plans offered by commercial carriers, but paid for by the HHS to people over 65 years of age. Unlike Medicare Supplemental plans, MA plans mandate in-network provider access to reduce or eliminate out of pocket costs. See MAPB
Medicare Advantage Pharmacy Benefit (MAPB)
Pharmacy Plans attached to MA plans.
Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration (MAQI)

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

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

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

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

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

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

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


see eCQM

Milliman Medical Index (MMI)
Milliman is a medical actuarial company estimating medical costs inflation of many things. i.e. Premiums, medical provider costs, Rx. See Milliman Medical Index 2018
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 Essential Benefits (MEB)
The actuarial value percentage a QHP plan must pay of claims as defined by HHS. See: QHP
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.
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 (Faith Based Plans)

A "plan" that costs about 50%-60% of an ACA qualifed major medical plam, but is neither mejor medical insurance, nor discount plan.  Preexisting medical conditions are excluded. These plans REIMBURSE the member up to a maximum limit - typically a percentage of the Medicare Allowable that is below the billed charge.  Members are exposed to hospital and physician balance billing liability.  Buyer Beware.


see: referenced based pricing





Modified Endowement Contract (MEC)
A modified endowment contract is a life insurance contract entered into on or after June 21, 1988, that fails to meet the seven-pay test. Meaning the cumulative premiums paid into the policy during the first seven years exceed the amount needed to produce a paid-up policy based on seven net level annual premiums. If the policy is considered a modified endowment contract, FIFO tax treatment is forfeited, and last in, first out (LIFO) tax treatment takes its place—causing withdrawals to be taxed on an income-first basis. Meaning that if you plan to borrow funds from life insurance surrender values in retirement, any loans must remain in compliance with what IRS considers legitimate life insurance contracts. IRS uses two primary tests to determine if a policy is, or is not life insurance.
Most Favored Nations
A Most Favored Nations clause in a managed care contract guarantees that the lowest charge master will be used when filing claims.
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

Multiple Employer Welfare Association (MEWA)
A MEWA is a Multiple Employer Welfare Association. It is a protected class of health insurance regulated by the Department of Labor under ERISA that provides various exemption from state insurance regulation. Practically speaking, most states despise MEWA’s and will challenge them regardless of ERISA standing. Of the protected classes ERISA legislation governs: (Associations, Trusts, Self funded Employers and Unions), MEWAs are rare. The over-reaching purpose of self funding any of these organizations is to reduce the cost of providing insurance benefits to employees by assuming a higher deductible for each employee's medical costs, and hoping for average medical claims. Two types of stop loss are purchased by the Plan Sponsor to mitigate unexpected catastrophic claims. Self funded MEWAs offer many employers a group structure to command greater buying power. But, because each member employer is typically small in number of employees, MEWA's may not be capitalized to sustain unexpected losses by members outside of an individual employers company - which is one reason states dislike MEWA’s. 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 is long history of states aggressively moving to eliminate MEWA's not meeting DOI compliance. Material legal assistance is required to set these up and maintain them successfully within state guidelines, despite ERISA exemption. The purchase of Specific and Aggregate reinsurance is usually required to transfer the majority of predictable risk to an approved insurance carrier. Historically, structuring reinsurance (or stop loss) placement takes real experience. Historically, small employers are challenged to spend time understanding the nature of risk being assumed and transferred, and/or to prudently fund up-front) typical primary level risk being assumed. ERISA mandates a fiduciary duty of Plan Sponsors, which may be transferable by additional insurance purchase as desired to mitigate additional risk. ACA law would guide successful plan offering management. Federally authorized Executive Orders, and agency non enforcement agenda cloud legal compliance consideration(s). We recommend licensed-seasoned stop loss and legal advice to anyone considering MEWA, or AHP plan offerings. This blog is offered as a courtesy, and is not tax 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.


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

Next Generation ACO (NGACO)

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


See benets eliminating 3 day SNF rule for Medicare Beneficiaries included in NGACO, and or Bundled Payments qualifying initiates.

Non Public Personal Information (NPPI)
Nursing Home Quality Measures (NHQM)
See related measures 16 Quality Measures


Office of the National Coordinator for Health Information Technology (ONC)
A federal office whosepurpose is to refine data collection and disbursement into more effective information public delivery.
Open Access
A type of medical insurance plan offering access to specialty physician care without the requirement of a primary care physician referral. Plans requiring referral from a primary care provider to access specialty care are called Gatekeeper plans.
Out of Network (OON)
A term used for medical claims billed from contracted HMO/PPO/ EPO/ etc. network, subject to a higher deductible, co insurance, and maximum out-of- pocket patient claims liability. ACA does not limit OON patient liability.
Out of Pocket Maximum (OOP)
An Out of Pocket Maximum (OOP) is the annual total liability an individual, or family must pay before the plan pays 100% of all medical charges, including the deductible. Premium is not part of OOP.
A term used to denote a medical condition falling outside of the standard DRG, and that affords increased reimbursement.


Pallative Care (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. 



An informal term used to describe a licensed or Certificate holding “admitted” carrier in a particular state or country. These carriers are both eligible and authorized in states. Surplus lines carriers are eligible, but not authorized to conduct insurance business in a state.
Patient Activation Measure (PAM)
A term used to describe a method of gathering more individual medical history to augment better care.
Patient Centered Medical Home (PCMH)
A term used to describe a team approach to primary care medical management, and centering on primary care coordination with specialty and hospital care.
Patient Centered Outcomes Research (PCQOR)
Patient Centered Outcomes Research 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 Affordable Care Act (ACA / PPACA / Obama Care)
The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA or Obama Care. The ACA (Affordable Care Act) is a 900+ page law encompassing all medical care in the US, but with very limited application to Veterans affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 Essential Healthcare Benefits (EHB) without annual benefit limits, tax credits for individuals earning below 400% of Federal Poverty Level (FPL), and Cost Sharing for people earning between 100%-250% FPL. Federal Cost Sharing Reductions (CSR) have been retroactively denied to carriers already committed, and are in litigation today to resolve. Cost sharing reductionns lower deductibles and max-out-of-pocket member costs, thereby limiting total annual member health spend from (about) 2% to 9.66% AGI/MAGI.  January 2017, the Trump administration denied "risk corridor" (reinsurance recovery safety-net payments to carriers) retroactively as well, thereby causing immediate (alledged $8 BILLION damages) suite by the carriers involved against the federal government. HR1 (Tax Reform law) was passed December 2017, and eliminates the Individual ACA law mandate (2.5% tax penalty), effective plan year 2019.  ACA law is not repealed. 

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


See: H.R. 1

PDM (Periodic Data Matching )
See Advance Payment Tax Credit
PEO Guidelines (NAID PEO Guidelines)
NAIC adopted Guidelines, Regulations and Legislation on Workers’ Compensation Coverage for Professional Employer Organization Arrangements.
Per Admission Deductible (PAD)
An out of pocket cost to an insured member admitted to a hospital for an inpatient stay. These costs are typically in addition to annual plan deductibles, and are subject to maximum out of pocket maximum stated in the policy.
Per Diem Contracts
Per Diem Contracts are contracts reimbursing hospitals a flat amount per day for specified hospital services. Per Diems are common stop loss and reinsurance coverage limitations consisting of average daily maximum allowable amount per day. Per diem contracts can also be vender related pricing sold to various self funded employers or carriers offering insurance in an area.
Per Diem Maximum
A Per Diem Maximum is typically an in-patient hospital coverage in a stop loss or reinsurance contract limiting the carrier's exposure per day for eligible charges. It is generally required in all Provider Excess and HMO reinsurance policies. Special care should be taken to understand how large claims incurred within a small number of days are affected. Expressed as either a Maximum Daily Limit or Average Maximum Daily Limit, this coverage usually reduces the total eligible hospital charges reimbursable in the policy. The Average Daily Maximum Limit is richer coverage and should be sought.
Per Visit Deductible (PVD)
A term used to describe an out of pocket cost to the insured member receiving care at an outpatient medical facility.
Personal Injury Protection (PIP)
A complex law governing auto insurance liability, and providing PRIMARY coverage response for property or medical claims without assignment of fault. I.e. each party gets paid by his own policy up to $10,000 per person, and $20,000 per accident. i.e. "No-Fault insurance". Legal remedy may also be available where damage are severe and/or excess of the $10,000 per person limit. No-Fault insurance is designed to reduce court congestion on low dollar claims.
Personally Identifiable Information (PII)
See: HIPPA PII Data as defined by CMS, and Marketplace agent training 2019 • 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 Employer Name/"Doing Business As” Employer Federal Tax ID Number Employer Address

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

Physician Compensation 2017
Source: Medscape

Medscape report

Physician Fee Schedule (PFS)
CMS term used by CMS when discussing proposed Medicare Part B QPP related matters.

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

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

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


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


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

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

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

ProPublica Treatment Tracker
A report made available by CMS of transactional frequencies between fee-for-service Medicare Providers.
Protected Health Information (PHI)
A HIPPA term used to denote confidential medical information. 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 Services Act (PHS)
The Affordable Care Act reorganizes, amends, and adds to the provisions of title XXVII of the Public Health Service Act (PHS Act) relating to group health plans and health insurance issuers in the group and individual markets.
Public Option
The public option is an ongoing progressive movement to create a government health plan that competes directly with commercially provided plans, and that would be available to both individuals and businesses. Medical Provider Reimbursements have been proposed at 100% of Medicare allowable causing little physician support.


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

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

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

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


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

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

Referenced Based Pricing (RBP)
A term used to define compesation to medical providers typically based on a nationally accepted fee schedule standard.  Payment can be from the carrier, employer, discount plan network, or insured patient.  Payment is typically based on a multiple of Medical allowable billing schedule referenced within a Plan Document or policy.  Balance billing issues can be contentious.  Medical billing disputes litigated in many states are increasing with no end in sight, and will continue revolving around both actual performance, and statutory standards related to what prices hospitals (or doctors) accept as full payment, and in conjunction with nationally accepted fee schedule maximum allowable amounts. ERISA fiduciary, Policy language and Hospital/Physician 501C3 obligations can practically guide pricing, and billing application. 
Registration Completion list (RCL)
CMS published list of certified Marketplace agents/brokers/navigators.
Rehabilitation Facilities (IRF)
See CMS or HHS quality reporting
Reinsurance is an insurance which provides coverage for catastrophic medical charges incurred by a plan member. Generally, the three types of medical reinsurance are HMO reinsurance, Workers Compensation reinsurance, and CHAMPUS/Tricare reinsurance. Reinsurance applies to re-insuring an insurance policy. ===================== As it relates to ACA offered GROUP and self-funded ERISA participants - reinsurance charge 2016-2017 program - per United Healthcare Agent Advisory October 2017 "Final Reinsurance Fee Payment Due Nov. 15 for Self-Funded Employers October 5, 2017 The final installment of the Transitional Reinsurance fee is due by Nov. 15 for those employers who selected to pay the 2016 fee in two installments. For the final year payment, self-funded employers who selected to pay in one installment paid the $27.00 per covered life Jan. 17. Those self-funded employers have no further payment obligations. For those employers who selected two installments, the payment schedule is: •$21.60 per covered life – payment made Jan. 17 •$5.40 per covered life – due Nov. 15 Background Under the Affordable Care Act (ACA), the Transitional Reinsurance fee has been paid by health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance Program in place from 2014 to 2016. •For fully insured clients, UnitedHealthcare pays the fee. •For self-funded employers, the employer is required to pay the fee. For the final year, the fee was determined to be $27 per covered life and was based on enrollment in major medical coverage for the first nine months of 2016, regardless of the plan’s renewal date. Employers were responsible for submitting their enrollment count and selecting their payment date(s) on the government portal ( last fall.
Republican Agenda — Healthcare Reform (A Better Way)

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

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


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

Retiree Drug Subsodie (RDS)
A tax subsidy program available to fully insured and self funded employers. Audits are required that offset costs savings.
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.

Return of Premium
An insurance policy provision allowing for all or part of premiums being refunded where the policy coverage was never accessed by the insured, These are not uncommon in Long Term Care policies. Sometimes the provision is combined with a term life insurance death benefit payout offering both LTC payout to the insured, with up to 20% of death benefit inuring to the beneficiaries. Read the policy carefully.
The probability of gain or loss associated with a choice or investment. Contrary to Merriam Webster's definition (an obvious pessimist!) ... it implies both gain or loss.
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 Corridor
A term typically associated with ACA and related to federal cost sharing payments by the federal government to insurers. These payments essentially lowered the deductible and maximum out of pocket costs for each person earning under between 100% - 250% FPL as a "cost sharing benefit". Payments are funded by participating Individual Marketplace carriers who paid reinsurance premiums, and agreed to the required 3% profit limit with MLR requirement. The payer industry claims $12 billion in unpaid risk corridor payments. Insurers have a big problem, and argue that the government is obligated reimburse payers whose marketplace insured individual member has claims costs exceeding 80 percent medical loss ratio (MLR) threshold. June 19, 2018 - Federal judges in the US Federal Circuit Court of Appeals have issued an opinion stating that healthcare payers, and not HHS, are responsible for the costs of the ACA’s risk corridor program. 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)

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

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


Safety Net Providers (ODF )
CMS term for Safety Net Providers. The “Low-Income Health Access” Open Door Forum (ODF) has been renamed as the “Safety-Net Providers” ODF. A forum for issues of concern to Medicare and Medicaid providers and suppliers who furnish services to low-income and vulnerable populations. Federally-Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Tribal Clinics, Hospitals, and others are encouraged to participate on the calls.
SBM-FP - State-based Marketplace on the Federal platform (SBM-FP )
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 ....
Second Dollar Risk
Relative to "specific" medical stop loss coverages, it can be the amount of eligible claims excess of $50,000 per person per year. The amount is subjective by type and line of insurance.
Section 125 Plans (125 Plans)

Medical benefit plans employers can establish to pay for eligible insurances with pretax funds, and thereby save approximately 7.65% of payroll taxes. Many eligibility rules and regulations apply to maintaining tax preferred funding of employee benefits. Section 125 plans are different from HRA accounts. Section 125 account balances NOT spent on eligibile medical expenses during the policy year DO roll over to subsequent years, and can be used in retirement too. Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys.

Self Funded Plan
A plan typically operating under ERISA that offers medical insurance to employees. Sometimes referred to as "Self Insured", a Self Funded insurance is a statutorily compliant plan of insurance characterized by high deductible. These plans are typically less expensive and more flexible than buying "Fully-Insured" medical plans with lower deductibles. Self funded plans take many forms, and contractual structure. Self Funded Plans are typically characterized by deductibles (to the employer, not the individual employees) over $35,000. Most common are ERISA (employer) Group plans, General Liability, Professional Liability and Workers Compensation self funded plans, etc. Many payment rules, statutes, regulations and standards apply to claims settlements. See Fronted and Reinsured Assignments.
Self Insurance Political Action Committee (SIPAC)
A republican lead committee whose goal is protection of ERISA self funded plan interests.
Self Insured Plan
See Self Funded
Service Area (Blue Cross Blue Shield defined)
Blue Cross defines, " service area means 1) the geographic area certified by the Marketplace through QHP; or 2. if not a QHP, the geographic area approved by the Agency for Health Care Adminstration (AHCA); and in which rates have been approved by the Florida Office of Insurance Regulation (OIR)."

Shared Decision Support (SDS)
A CMMI program

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

Shared Savings Program
See QPP, CSR, MSSP 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. ACOs in the MSSP for four years reduced Medicare spending the most in 2017. The organizations decrease spending by $115.15 per beneficiary."

Short Term Medical Plan (Limited Medical Plan or MiniMed Plan)
A medical plan of coverage for a period of less than 12 months, and that does not have to comply with ACA law per Trump Presidential Order, and various non enforcement of ACA law requirements. See QHP, EHB. 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, Travel Accident plans, etc. Non compliant plans can cause massive balance billing patient liability contentious disputes. Buyers are responsible for understanding the plans they buy, especially when the premium is less than 50% of an ACA compliant plan with unlimited benefits.

Simple or SEP Retirement Plan (SEP)
A retirements plan used by some smaller corporations or sole proprietors.

Single Employer Trust or Association Health Plan
The association health plan is a self funded ERISA major medical group insurance that is exempt from community rating, and operates under ERISA. Advantages include an advanced aggregate reinsurance coverage, lower agent & TPA fees, favorable experience discounts and other significant savings. Typical minimum program requirements include 1,000 lives and retention at $50,000. Pooling of first dollar risk among multiple employers is prohibited (except for possible MEWA where permissible). Favorable experience is rewarded by refunding unused premium and discounting future premium. A single employer trust offers a middle ground between the higher risk of traditional self funding, and the higher cost of a fully insured benefit while providing a fixed monthly premium easily budgeted by the employer. They are different from Level Funded plans by offering higher retention levels which means managing more risk.
Skilled Nursing Facility Quality Reporting Measures (SNF QRP)
The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Review and Correct reports are now available on demand in the CMS Certification and Survey Provider Enhanced Reporting (CASPER) application. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage. These reports: • Contain quality measure information at the facility level • Allow providers to obtain aggregate performance for the past four full quarters (when data is available) • Include data submitted prior to the applicable quarterly data submission deadlines • Display whether the data correction period for a given CY quarter is “open” or “closed” (Source: CMS)
Small Business Health Insurance Options Program (SHOP)
A failed federal medical insurance program generally available to small business under 50 FTE's (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% electronic, and premium payments must be in no later than the 15th of each month. Carriers like Coventry/Aetna pay about 1.5% commission to agents which means a loss to any agent for small group enrollments. 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 and United leading the way. Most carriers do not offer any SHOP plans. Eligibility rules are complicated - employers generally must be "small employers" and have at least one employee on the first day of the plan year. Estimating employer size can be complex and agents and brokers should refer to official Department of Health & Human Services and Internal Revenue Service (IRS) guidance on this topic before advising employers regarding their size.Generally, an employer is a "small employer" if it had one to 50 full-time and full-time-equivalent (FTE) employees (one to 100 in some states) on average, on business days during the preceding calendar year. When counting FTE and full-time employees, do not include the following. PEO is complicated. Under this methodology, a full-time employee is one who is employed for, on average, 30 hours or more per week. An FTE employee is a combination of multiple part-time employees whose combined hours total 120 hours per month. If an employer was not in existence throughout the preceding calendar year, the count of full-time and FTE employees is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. The SHOP coverage must be offered to all full-time employees (full-time employees are those employed for an average of 30 hours or more per week). Employers may offer coverage in a combination of Federally-facilitated SHOP Marketplace states and State-based SHOP Marketplace states, including State-based SHOP Marketplaces not using the federal platform. For an employer group to enroll in SHOP coverage, a certain percentage of employees must enroll, unless the enrollment occurs between November 15 and December 15 of each year. This is called the minimum participation rate (MPR). In most states, during the months when the MPR applies, at least 70% of the business' or group's full-time employees must accept the employer's offer of SHOP coverage or be enrolled in certain other coverage before the group can enroll. A few states with a SHOP Marketplace have set a different MPR, which can be found at The MPR is determined by first adding the number of full-time employees accepting coverage offered by a qualified employer to the number of full-time employees who, at the time the employer submits the SHOP group enrollment, are enrolled in coverage through another group health plan, government-sponsored coverage (such as Medicare, Medicaid, or TRICARE), the individual market, or other minimum essential coverage. This number is then divided by the number of full-time employees offered coverage to calculate the participation rate. The MPR is only calculated at the time of initial enrollment and upon renewal. From November 15 to December 15 of each year, eligible small employers can enroll in SHOP coverage without meeting the MPR requirement. Levels of Coverage and Choice The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care. For purposes of establishing a “employer GROUP” standard, the lowest cost Bronze level plan by zip code region is used. The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40% Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30% Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%. Platinum. The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%.             Very few carriers offer SHOP plans making it almost impossible for employers to consider them.  Existing Agent Commissions on groups under 4 lives have been reduced or eliminated completely, thereby eliminating the line of business for many agents.

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

(Source CMS)

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

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


Tax Tables IRS 2018

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

Sometimes referred to as a Contract Basis, or Contract Period - Term refers to the policy year and claims submission period deadline. A typical stop loss term is for a 12/18 period. Here the policyholder's claimant has 12 months to accrue the claim, and 6 months after the policy year to report it to the carrier. Policies can be written on either a "Reported" or "Paid" bases. The Reported bases is richer coverage. Other Terms are 12/12, 12/15 and 12/24.
The Medicare Access and CHIP Reauthorization Act (MACRA)
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changes the way Medicare rewards clinicians for providing quality care by streamlining multiple quality programs into a new Quality Payment Program tied to Part B Fee-For-Service payments. With the implementation of MACRA and the replacement of the Sustainable Growth Rate, we will pay clinicians participating in the Merit-based Incentive Payment System or Advanced Alternative Payment Models of the Quality Payment Program beginning in 2019
Thrift Savings Plan (TSP)
Similar to 401(k) plans, but for federal employees.

Total Quality Improvement (TQM aka QA aka TQI aka Critical Pathways)
A quality insurance vernacular which is the same or similar to Total Quality Improvement, Medical Pathways, Critical pathways, Total Quality Improvement, etc, and whose goal is to lower costs, and improve outcome of medical care delivery.
Treatement, Payment Health Plan Operations (TPO)
A contractual term used in Plan Documents to denote how HIPPA protected medical information is used for patient care and plan administration.
Treaty Reinsurance (Automatic reinsurance)
Treaty reinsurance is reinsurance of specified types or classes of insured exposures that are automatically "ceded” or accepted by the Reinsurer within the terms of the reinsurance contract or "treaty" without evaluation of each individual exposure. The reinsurance takes effect as soon as the primary insurance is sold. Treaty reinsurance is a general term used to discuss several types of coverages that can include profit sharing features.


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


Value Based Payment Modifier (VM)
See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Value Based Reimbursement (see RBP)
See Bundled Payments. VBR is an amorphous term used to define various types of "bundled", DRG, per diem, cost per confinement, etc priced care packaged as is deemed "valuable" by whatever index the buyer or seller fines valuable. Its implied goal is to improve medical outcomes at a lower cost, improve medical outcomes, and prevent up-coding single procedures into multiple procedures/charges. see Bundled Payments

A life insurance policy that is typically sold to investors by an insured with less than two years to live. Viaticals offer a terminally ill 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.
Voluntary Benefits
Benefit offerings paid for by employer and/or employees. Sometimes referred to as “Ancillary Benefits” these insurances typically insure: Life, Dental, Short term Dissability, Long term care, Critical Illness, Accident only, Cancer, Cardiac,stroke/transplanct, long term disability, Hospital lump sum per diem GAP, etc.


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