Health Care Reform Definitions
Some common health care reform related terms and acronyms:
Accountable Care Organization (ACO)
A network of health care providers that band together to provide the full continuum of health care services for patients. The network receives a payment for all care provided to a patient and is held accountable for the quality and cost of care.
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.
Affordable Care Act (ACA)
Health care reform legislation enacted in 2010. Also known as the Patient Protection and Affordable Care Act (PPACA).
A traditional method of paying for medical services in which doctors and hospitals are reimbursed by insurance companies for each service they provide.
Amendment to ACA that increases Medicare reimbursement rates for some doctors and hospitals in North Dakota and other states that have traditionally received low Medicare reimbursement rates.
Requires insurers to offer and renew coverage, without regard to health status, use of services or pre-existing conditions. The requirement ensures that no one will be denied coverage for any reason.
Health Information Exchange (HIE) or Health Information Technology (HIT)
Systems and technologies that enable health care organizations and medical facilities to gather, store and share information electronically.
Health Insurance Marketplace (HIM) (formerly Health Insurance Exchange (HIX))
A purchasing arrangement through which insurers offer insurance coverage to small employers and individuals. Every state was given the choice of whether to create its own exchange, participate in a regional exchange, or participate in the federally facilitated exchange (FFE) created and managed by the federal government. North Dakota chose to participate in the FFE. HIMs have standards for what benefits are covered, how much insurers can charge and the rules insurers must follow to participate in the HIM. Individuals and small employers select coverage from choices available on the HIM. If an individual is eligible for a federal subsidy to help pay for health insurance, the individual is required to purchase insurance on the HIM.
A requirement that all individuals obtain health insurance beginning in 2014. Also known as the universal coverage requirement. Individuals who do not obtain health insurance coverage may be subject to a fee on their federal tax return.
Insurance premium subsidies
A fixed amount of money or a designated percentage of members' premium cost that is provided to help people purchase health coverage. Premium subsidies are usually provided on a sliding scale based on an individual's or family's income.
ACA imposes an annual fee on health insurance companies to help fund the law. This tax is expected to lead to premium increases for consumers.
Medical Loss Ratio (MLR)
The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. ACA requires insurers to have an MLR of at least 85% for group insurance and an MLR of at least 80% for insurers in the small group and individual markets.
ACA requires that, for new or non-grandfathered products in the individual and small group markets, products conform to actuarial values of 90% (platinum), 80% (gold), 70% (silver) and 60% (bronze) with up to a 2% variance.
Patient-Centered Medical Home (PCMH), medical homes
A health care setting where patients receive comprehensive primary care services, have an ongoing relationship with a primary care provider who directs and coordinates their care, have enhanced access to non-emergent primary, secondary and tertiary care, and have access to linguistically and culturally appropriate care.
An employment-based program used to promote health and prevent chronic disease among employees. The goals of these programs include reducing health care costs, sustaining and improving employee health and productivity, and reducing absenteeism due to illness.
Universal coverage requirement
A requirement that all individuals obtain health insurance beginning in 2014. Also known as the individual mandate. Individuals who do not obtain health insurance coverage may be subject to a fee on their federal tax return.
Blue Cross and Blue Shield Association
Kaiser Family Foundation
Blue Cross Blue Shield of North Dakota
For a full glossary of health care related terms, visit: http://www.bcbs.com/glossary/.
For a full listing of health care reform terms, visit: http://kff.org/glossary/health-reform-glossary/