ACA (Affordable Care Act)

A comprehensive healthcare reform law enacted in 2010, aimed at increasing health insurance coverage, reducing healthcare costs, and improving healthcare outcomes. It established the Health Insurance Marketplace and expanded Medicaid in many states.

ACA Marketplace

An online platform where individuals can shop for, compare, and purchase health insurance plans offered under the ACA. It offers tiered plans (Bronze, Silver, Gold, Platinum) with varying coverage levels and costs.

Annual Enrollment Period (AEP)

A yearly period (October 15 to December 7) when Medicare beneficiaries can make changes to their health and prescription drug coverage, including switching between Medicare Advantage plans or enrolling in Medicare Part D.

Appeal

A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.

Asset Test

A financial assessment used by Medicaid and certain other programs to determine eligibility based on the value of an individual’s or family’s assets, such as savings and property.

Assisted Living Facility

A residential facility providing support and care for individuals who need assistance with daily activities, such as dressing, bathing, and managing medications. Coverage of assisted living varies by Medicaid program and state.

Automatic Enrollment

The process by which individuals are automatically enrolled in a health insurance plan, often through programs like Medicare when they reach age 65 or when they begin receiving Social Security benefits.

Behavioral Health Services

Healthcare services that focus on treating mental health conditions, emotional disorders, and substance use issues. These services are covered under programs like Medicaid, CHIP, and Medicare.

Benefits Period

In Medicare Part A, a benefits period begins the day a person is admitted to a hospital or skilled nursing facility and ends when the individual has not received inpatient care for 60 consecutive days. Each new benefit period resets costs like deductibles.

Brand-name Drugs

Prescription drugs sold under a trademark-protected brand name, typically more expensive than generic drugs. Covered under programs like Medicare Part D, Medicaid, and CHIP.

Bronze Plan

The lowest level of coverage available on the ACA Marketplace, providing the most basic coverage with the lowest premiums but the highest out-of-pocket costs, such as deductibles and copays.

Buy-In Program

A Medicaid program that allows certain individuals, such as people with disabilities or those with higher incomes, to "buy into" Medicaid by paying a premium. It provides Medicaid coverage without meeting traditional income or asset limits.

Balance Billing

The practice of billing a patient for the difference between the provider’s charge and the amount covered by the insurance plan. In Medicare, Medicaid, and CHIP, balance billing may be prohibited or limited.

Benefit Verification

The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.

Block Grant

A type of federal funding provided to states with broad guidelines for spending, often used in discussions around reforming Medicaid. States may receive a fixed amount of money to cover program costs rather than open-ended federal funding.

Catastrophic Health Plan

A low-premium, high-deductible health insurance plan available under the ACA Marketplace, primarily covering major medical expenses. Catastrophic plans are available to people under 30 or those with a hardship exemption.

CHIP (Children’s Health Insurance Program)

A joint federal-state program providing low-cost health insurance for children in families that earn too much to qualify for Medicaid but cannot afford private insurance. CHIP covers a wide range of health services including doctor visits, immunizations, and prescription drugs.

Coinsurance

The percentage of medical costs a patient must pay after meeting their deductible. For example, a Medicare plan might require patients to pay 20% of the cost of services after Medicare has paid its share.

Copayment (Copay)

A fixed amount an individual pays for a covered healthcare service, such as a doctor visit or prescription, after meeting their deductible. The amount varies by service and insurance plan.

Coverage Gap (Donut Hole)

A temporary limit on what Medicare Part D will cover for prescription drugs. After reaching a certain spending threshold, beneficiaries may pay more out-of-pocket for prescriptions until they reach the catastrophic coverage phase.