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.

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.

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.

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.

Community Health Center

A nonprofit clinic that provides primary care and preventive services to low-income individuals, often funded by federal programs such as Medicaid and CHIP. These centers serve uninsured, underinsured, and Medicaid-eligible populations.

CMS (Centers for Medicare & Medicaid Services)

A federal agency within the U.S. Department of Health and Human Services (HHS) that administers the nation’s major healthcare programs including Medicare, Medicaid, and CHIP, as well as oversight of the ACA Marketplace.

Disenrollment

The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.

Durable Medical Equipment (DME)

Equipment prescribed by a healthcare provider that can be used at home to help with medical conditions, such as wheelchairs, crutches, oxygen tanks, and hospital beds. Medicare, Medicaid, and CHIP cover DME when deemed medically necessary.

Drug Formulary

A list of prescription medications covered by a health insurance plan, such as Medicare Part D or CHIP. Medications on the formulary are categorized into tiers, with different levels of cost-sharing for generic, brand-name, and specialty drugs.

Eligibility

The criteria that individuals must meet to qualify for healthcare programs such as Medicare, Medicaid, CHIP, or ACA Marketplace plans. Eligibility is typically based on factors such as age, income, residency, and health status.

Emergency Services

Immediate medical care provided for acute, life-threatening conditions. Medicare, Medicaid, CHIP, and ACA-compliant plans all cover emergency services, often without requiring prior authorization.

Exclusions

Services or treatments that are not covered by a health insurance plan. Exclusions vary by plan, and they may include specific treatments, procedures, or prescription drugs that are not considered medically necessary.

Enrollee

An individual who is covered by a health insurance plan, such as those offered through Medicare, Medicaid, CHIP, or the ACA Marketplace.

Federal Poverty Level (FPL)

A measure of income issued annually by the Department of Health and Human Services (HHS) to determine eligibility for various government assistance programs, including Medicaid, CHIP, and ACA subsidies. The FPL varies based on household size and geographic location.

Formulary

A list of prescription medications that are covered by a health insurance plan, such as Medicare Part D or CHIP. Drugs listed on a formulary are usually divided into tiers, with different levels of cost-sharing based on the type of drug (generic, brand-name, or specialty).

Federally Qualified Health Center (FQHC)

A community-based health clinic that provides comprehensive primary and preventive care services, including dental, mental health, and substance use services. Medicaid, Medicare, and CHIP typically cover services received at FQHCs, which serve low-income, uninsured, and underserved populations.

Federal Medical Assistance Percentage (FMAP)

The federal government’s share of the costs of providing Medicaid and CHIP services to eligible individuals. The FMAP varies by state and is based on the state’s per capita income, with lower-income states receiving a higher federal match.

Generic Drugs

Medications that contain the same active ingredients as brand-name drugs but are sold at lower prices. Medicare Part D, Medicaid, and CHIP often cover generic drugs to reduce costs for beneficiaries.

Gross Income

The total income earned before any deductions, such as taxes or retirement contributions, are taken out. Gross income is used to determine eligibility for programs like Medicaid, CHIP, and ACA Marketplace subsidies.

Home Health Care

Medical and personal care services provided to individuals in their own homes, often after hospitalization or surgery. Medicare, Medicaid, and CHIP cover home health care services, including nursing care, physical therapy, and assistance with daily activities.