Glossary of Terms
The Affordable Care Act (ACA) – The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
Accountable Care Organization (ACO) – A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. Payments to each organization are tied to achieving health care quality goals and outcomes that result in cost savings.
Actuarial Value (AV) – The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Advanced Premium Tax Credits (APTC) – A tax credit that can help you afford coverage bought through the Marketplace. Sometimes known as APTC, “advance payments of the premium tax credit,” or premium tax credit. Unlike tax credits you claim when you file your taxes, these tax credits can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
AHCCCS (Arizona Health Care Cost Containment System) – Arizona’s Medicaid program. Also the state agency that administers the state’s Medical program.
AHCCCS Registered Provider – A contracted provider or non-contracting provider who enters into a provider agreement with AHCCCS and meets licensing or certification requirements to provide AHCCCS-covered services.
ALTCS (Arizona Long Term Care System) – An AHCCCS program, which delivers long term, acute, behavioral health care and case management services to eligible members who are either elderly and/or have physical disabilities, and to members with Developmental Disabilities (DD) through contractual agreements and other arrangements.
Allowed Amount – Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Annual Deductible Combined – Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
Annual Limit – A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.
Appeal – A request for your health insurer or plan to review a decision or a grievance again.
Arizona Department of Insurance (ADOI) – The state agency responsible for overseeing health insurance policies, contracts, advertising, and related forms comply with Arizona law, and that rates for certain categories of health insurance are reasonable.
Attest/Attestation – When you apply for health coverage through the Marketplace, you’re required to agree (or “attest”) to the truth of the information provided by signing the application.
Authorized Representative – Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
Balance Billing – When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Benefits – The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Benefit Package – The set of services, such as physician visits, hospitalizations, prescription drugs, that are covered by an insurance policy or health plan. The benefit package will specify any cost-sharing requirements for services, limits on particular services, and annual or lifetime spending limits.
Benefit Year – A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
Broker – An agent or broker is a person or business who can help you apply for help paying for coverage and enroll in a Qualified Health Plan (QHP) through the Marketplace. They can make specific recommendations about which plan you should enroll in. They’re also licensed and regulated by states and typically get payments, or commissions, from health insurers for enrolling a consumer into an issuer’s plans. Some brokers may only be able to sell plans from specific health insurers.
Catastrophic Health Plan – Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don’t cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a “hardship exemption” because the Marketplace determined that you’re unable to afford health coverage
Certified Application Counselor (CAC) – An individual (affiliated with a designated organization) who is trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers.
Chronic Care Management – The coordination of health care and supportive services to improve the health status of patients with chronic conditions, such as diabetes and asthma. The goals of these programs are to improve the quality of care and manage costs.
CCIIO – Center for Consumer Information & Insurance Oversight. Part of CMS.
CHIP (Children’s Health Insurance Program) – A public health insurance program for children living in families whose incomes are up to 200% of the Federal Poverty Level. Arizona’s CHIP program is called KidsCare. The program is currently frozen, not allowing any new enrollees.
CHIPRA – CHIP Reauthorization Act of 2009. The federal legislation that allowed for the creation of Arizona’s KidsCare program.
CMS – Centers for Medicare & Medicaid Services. Part of the federal Department of Health & Human Services. Administers the Medicare and Medicaid programs and the Children’s Health Insurance Program (known as KidsCare in Arizona).
COBRA – A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Comprehensive Medical and Dental Plan (CMDP) – A Contractor that is responsible for the provision of covered, medically necessary AHCCCS services for foster children in Arizona.
Cost Sharing Reduction (CSR) – A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.
If you’re a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
Co-Insurance– Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Complications of Pregnancy – Conditions due to pregnancy, labor and delivery that require medical care to prove serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarian section aren’t complications of pregnancy.
Co-pay or Co-payment – A fixed amount you pay for a covered health care service, usually at the time you receive the service. The amount can vary by the type of covered health care service.
Co-op – A non-profit organization in which the same people who own the company are insured by the company. Cooperatives can be formed at a national, state, or local level and can include doctors, hospitals, and businesses as member-owners. Co-ops will offer insurance through the Marketplace. Meritus operates the co-op plans offered on Arizona’s Marketplace.
Cost Sharing – The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
Deductible – The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Dependent – A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
Division of Developmental Disabilities (DDD) – The Division of the Arizona Department of Economic Security which is responsible for licensure/certification of facilities that specifically serve individuals with a developmental/intellectual disability, providers, and the reimbursement of services for eligible Arizona residents with a developmental/intellectual disability. AHCCCS contracts with DES to reimburse services for its members with a developmental/intellectual disability.
Dependent Coverage – Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
DES (ADES, the Arizona Department of Economic Security) – Arizona agency responsible for determining eligibility for some Arizona Health Care Costs Containment System (AHCCCS) health insurance programs, as well as other family assistance programs such as SNAP and TANF.
Dual Eligibles – A term used to describe an individual who is eligible for Medicare and for some level of Medicaid benefits. Most dual eligibles qualify for full Medicaid benefits including nursing home services, and Medicaid pays their Medicare premiums and cost sharing. For other duals Medicaid provides the “Medicare Savings Programs” through which enrollees receive assistance with Medicare premiums, deductibles, and other cost sharing requirements.
Domestic Partnership – Two people of the same or opposite sex who live together and share a domestic life, but aren’t married or joined by a civil union. In some states, domestic partners are guaranteed some legal rights, like hospital visitation.
Durable Medical Equipment (DME) – Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DMS may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
Emergency Medical Condition – An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Medical Transportation – Ambulance services for an emergency medical condition.
Emergency Room Care – Emergency services you get in an emergency room.
Emergency Services – Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Essential Community Provider (ECP) – Providers that serve predominately low-income, medically underserved individuals, such as Federally Qualified Health Centers (FQHCs), Ryan White Providers, Critical Access Hospitals, etc. Health plans on the Marketplace are required to include a certain percentage of essential community providers.
Essential Health Benefits (EHB) – The Affordable Care Act ensures health plans offered in the individual and small group markets offer a comprehensive package of items and services, known as Essential Health Benefits. Essential health benefits must include items and services within at least the following 10 categories: 1) ambulatory patient services; 2) emergency services; 3) hospitalization; 4) maternity and newborn care; 5) mental health and substance use disorder services, including behavioral health treatment; 6) prescription drugs; 7) rehabilitative and habilitative services and devices; 8) laboratory services; 9) preventive and wellness services and chronic disease management; 10) pediatric services, including oral and vision care.
EPSDT (Early and Periodic Screening Diagnosis and Treatment) – EPSDT is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical, oral and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.
Exchange – Same as the Marketplace or Health Insurance Marketplace.
Excluded Services – Health care services that your health insurance or plan doesn’t pay for or cover.
Exclusive Provider Organization Plan (EPO) – A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Federal Emergency Services (FES) – The AHCCCS Emergency Services Program (FES) provides emergency health care services only to qualified immigrants and non-citizens who are not eligible for full AHCCCS medical services. These services are provided through the Federal Emergency Services Program. To be eligible for FES services the client must be (1) Pregnant (covers delivery only, no prenatal or postpartum care is provided), (2) a child under the age of 19 or (3) individuals with blindness or another disability and the elderly, or the parent of a child under the age of 19.
Federal Poverty Level (FPL) – A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. *Kaiser Health Insurance Premium Subsidy Calculator: For people under 65, who do not have health coverage with Medicare, Medicaid or employer. With this calculator, you can enter different income levels, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. www.kff.org/interactive/subsidy-calculator
FFM – Federal Facilitated Marketplace. Arizona’s exchange is a federally-facilitated Marketplace.
FQHC (Federally Qualified Health Center) – Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.
Flexible Spending Account (Also called FSA. Also called Flexible Spending Arrangement) – An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.
There is no carry-over of FSA funds. This means that FSA funds you don’t spend by the end of the plan year can’t be used for expenses in the next year. An exception is if your employer’s FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.
Formulary – A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
Grandfathered Health Plan – As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).
Grievance – A complaint that you communicate to your health insurer or plan.
Group Health Plan – In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
Habilitation Services – Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Hardship Exemption – Under the Affordable Care Act, most people must pay a fee if they don’t have health coverage that qualifies as “minimum essential coverage.” One exception is based on showing that a “hardship” prevented them from becoming insured.
Health Insurance – A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Reimbursement Account (HRA) – Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.
Health Savings Account (HSA) – A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit.
Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
Health Status – Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
HHS (U.S. Department of Health and Human Services) – The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).
HMO (Health Maintenance Organization) – These organizations provide health care services directly to their members, who pay a fixed monthly fee to the HMO. These services include such things as hospital care, surgery and routine office visits. The HMO is an alternative to traditional health insurance because it provides actual services rather than just reimbursement for health care expenses. Enrollees usually pay a small co-payment for care or services they receive. There are various ways that HMOs can be set up. Some HMOs employ their own physicians, who treat patients at an HMO center. Others contract with individual physicians or groups of physicians. Patients are treated at the physicians’ offices or health centers. Usually, HMO members must receive health care treatment at a designated hospital, HMO facility or from physicians who contract with the HMO to provide services. Before you pay a fee to join an HMO, ask questions about how it works and where you would receive care, and talk to people who belong to it. Consider whether you may have to stop seeing a specific physician and choose another.
High Deductible Health Plan – A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
Home Health Care – Health care services a person receives at home.
Hospice Services – Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization – Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care – Care in a hospital that usually doesn’t require an overnight stay.
HRSA – Health Resources and Services Administration. Part of the U.S. Department of Health and Human Services.
Individual Mandate – A requirement that most individuals obtain health insurance or pay a penalty beginning in 2014.
In-network Co-insurance – The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
In-network Co-payment – A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Insurance Affordability Programs – Include expanded Medicaid (AHCCCS), State Children’s Health Insurance Programs (KidsCare in Arizona), and the insurance subsidy programs (Advanced Premium Tax Credits and Cost Sharing Reductions) administered through the Health Insurance Marketplace.
KidsCare – A federal/state health insurance program authorized under CHIPRA. In Arizona, the program is administered by AHCCCS and called KidsCare. The KidsCare Program offers comprehensive medical preventive and treatment services and a full array of behavioral health care services statewide to eligible children under the age of 19, in households with income at or below 200% Federal Poverty Level (FPL). The program is currently frozen in Arizona, not allowing any more families to apply on behalf of their children.
Looper – People who have applied for Marketplace coverage who have been told that their income qualifies them for Medicaid, but then told by the state’s Medicaid program that the individual or family qualifies for the Marketplace.
Medically Necessary – Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Medicare – A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare Advantage (MA) (Medicare Part C) – A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Marketplace – The insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans (see QHP). The Marketplace will offer a choice of health plans that meet Essential Health Benefit standards (see EHB).
MAGI (Modified Adjusted Gross Income) – MAGI is part of the effort to simplify financial eligibility rules that states use for most Medicaid and CHIP enrollees (non-disabled adults under age 65 and children). To make the transition to MAGI-based eligibility for Medicaid, states must convert their existing net income standards to equivalent standards based on MAGI. States are required to submit their MAGI-based Medicaid eligibility standards for approval by CMS.
Minimum Essential Coverage – Under health reform, most Americans are required to maintain minimum essential coverage or be subject to a tax penalty. While the term would seem to connote a minimum level of health benefits, it doesn’t Instead, it is defined in terms of the source of coverage: It includes coverage under 1) and employer sponsored plan, 2) a government-sponsored program such as Medicare or Medicaid, 3) a grandfathered health plan, 4) a plan in the individual market purchased on or off the public Marketplace, or 5) other coverage such that offered through state health benefit risk pools approved by HHS.
Narrow Network – Narrow networks are health insurance plans that place limits on the doctors and hospitals available to their subscribers. Narrow network health plans sometimes cost less than other health plans, but may offer fewer choices of providers.
Navigator – An individual or organization that’s trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
Network – The health care facilities (clinics, hospitals, rehab centers) and providers (doctors, dentists, therapists) your health insurance plan has contracted with to provide you with health care services.
Non-Preferred Provider – A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Open Enrollment (OE) Period – The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For coverage starting in 2015, the Open Enrollment Period is November 15, 2014–February 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events.
Out-of-Pocket – Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services plus all costs for services that aren’t covered.
Out-of-Network Co-insurance – The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
Out-of-network Co-Payment – A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
Out-of-Pocket Costs – Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
Out-of-Pocket Maximum or Limit (OOP Limit) – The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Personal Health Information (PHI) – PHI includes information about a member’s health care, such as physical and mental health, as well as payments for health care.
Point of Services (POS) Plan – A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
Prior Authorization – Some medical procedures, surgeries, equipment and services require your primary care physician or specialist to contact the health plan prior to determining if this services is appropriate for your care.
Prior Period Coverage (PPC) – An AHCCCS member was or is in transitional period with regard to coverage while AHCCCS completes the enrollment process.
PPO (Preferred Provider Organization) – Under this program, an insurance company enters into contracts with selected hospitals and doctors to furnish services at discounted rates. As a member of a PPO, you might be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
Physician Services – Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Plan – A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Plan Year – A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).
Preauthorization – A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Provider – A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Premium – The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Premium Tax Credit – The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.
Prescription Drugs – Drugs and medications that by law require a prescription.
Prescription Drug Coverage – Health insurance or plan that helps pay for prescription drugs and medications.
Preventive Services – Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Prior Authorization – Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
Primary Care Physician (PCP) – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Qualified Health Plan (QHP) – An insurance plan, certified by a Health Insurance Marketplace, which provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A QHP will have a certification by each Marketplace in which it is sold. QHPs are required to include a sufficient number and geographic distribution of Essential Community Providers (ECPs), where available, to ensure reasonable and timely access to a broad range of health care providers.
Qualifying Life Event – A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
RBHA (Regional Behavioral Health Authority) – An organization under contract with the Arizona Department of Health Services (ADHS) to administer covered behavioral health services in a geographically specific service area of the state. Tribal governments, through an agreement with the ADHS, may operate a Tribal Regional Behavioral Health Authority (TRBHA) for the provision of behavioral health services to American Indian members living on-reservation.
Reconstructive Surgery – Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Referral – Your primary care physician (PCP) may be required to provide you or your family member with a referral for certain specialists or procedures. The referral can take the form of a document that you must bring the specialist or facility that your PCP has referred you to. The referral tells the specialist or facility that you have seen the PCP for your condition and that additional health care services may be recommended. The referral also tells your plan that your PCP has referred you to a specialist or facility in the provider network.
Rehabilitation Services – Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Respite Care – A service that provides short-term care and supervision to relieve primary caregivers.
Service Area – A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.
SOBRA – AHCCCS provides medical coverage to children under 19 and pregnant women through the SOBRA program. For children under the age of six, the eligibility level is higher than 133% FPL.
Special Enrollment Period (SEP) – A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days.
Summary of Benefits and Coverage (SBC) – An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
SHOP (Small Business Health Options Program) – State health insurance exchanges that will be open to small businesses up to 100 employees.
Specialist – A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Subsidized Coverage – Health coverage that’s obtained through financial assistance from programs to help people with low and middle incomes.
Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.
Tax Credit – A tax credit is an amount that a person/family can subtract from the amount of income tax that they owe. If a tax credit is refundable, the taxpayer can receive a payment from the government to the extent that the amount of the credit is greater than the amount of tax they would otherwise owe.
Tricare – A health care program for active-duty and retired uniformed services members and their families
UCR (Usual, Customary and Reasonable) – The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.