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.

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.

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.

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.

Coordination of Benefits (COB)

A process used when a patient is covered by more than one insurance plan. It determines which insurance plan pays first and helps prevent overpayment for services covered by both policies. COB applies to Medicare, Medicaid, and private insurance.

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.

Disability

A physical or mental condition that limits an individual’s ability to perform daily activities. People with disabilities may qualify for Medicare before age 65 or receive coverage through Medicaid.

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.

Dual Eligibility

Refers to individuals who qualify for both Medicare and Medicaid coverage. Dual-eligible beneficiaries often have their Medicare premiums and out-of-pocket costs covered by Medicaid.

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.

Dependent Care

Care provided for children or dependent adults who require assistance with daily living. Medicaid may cover home or community-based services for dependent care under certain circumstances.

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.