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.

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.

Fee-for-Service (FFS)

A traditional healthcare payment model in which healthcare providers are paid separately for each service provided to a patient, such as doctor visits, tests, or procedures. Medicare and Medicaid offer FFS options, although many states are moving towards managed care models.

Full Medicaid Benefits

Comprehensive healthcare services provided to individuals who qualify for Medicaid based on income, age, disability, or other criteria. Full Medicaid benefits include hospital care, doctor visits, preventive services, prescription drugs, and long-term care, among others.

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.

Grace Period

The extra time given to policyholders to pay their health insurance premiums after the due date. During the grace period, coverage continues, but failure to pay by the end of the grace period may result in termination of coverage. This applies to ACA, Medicare, and Medicaid plans.

Global Payment

A type of payment arrangement in which a provider is paid a fixed amount for all care provided to a patient over a specified period, regardless of the actual number of services rendered. Global payment models are sometimes used in Medicare and Medicaid to improve cost control.

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.

Geriatric Care

Specialized healthcare services for older adults, focusing on age-related conditions such as mobility issues, chronic diseases, and dementia. Medicare and Medicaid provide coverage for many geriatric care services, including nursing home care and home healthcare.

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.

Hospice Care

End-of-life care provided to individuals with terminal illnesses, focusing on comfort and quality of life rather than curative treatment. Medicare and Medicaid cover hospice care, including medical services, emotional support, and pain management.

Home and Community-Based Services (HCBS)

Services that allow individuals, particularly those with disabilities or chronic illnesses, to receive care in their homes or communities rather than in institutional settings. Medicaid provides coverage for HCBS, including personal care, nursing, and therapy.

Hospital Indemnity Insurance

A type of supplemental insurance that provides a cash benefit for each day an individual is hospitalized. This insurance can help cover out-of-pocket costs not paid by Medicare, Medicaid, or private health insurance.

Health Maintenance Organization (HMO)

A type of health insurance plan that provides coverage through a network of doctors, hospitals, and other healthcare providers. Enrollees must typically choose a primary care physician and get referrals to see specialists. ACA, Medicaid, and CHIP offer HMO options.

Hospice Respite Care

Short-term inpatient care provided to hospice patients to give their primary caregivers temporary relief. Medicare and Medicaid cover respite care as part of hospice services for individuals receiving end-of-life care.

Income Limits

The maximum income level a household can earn and still qualify for government programs like Medicaid, CHIP, and ACA subsidies. Income limits are typically based on a percentage of the Federal Poverty Level (FPL).

Inpatient Care

Medical treatment provided to a patient who is admitted to a hospital or facility for at least one overnight stay. Medicare Part A, Medicaid, and CHIP cover inpatient care, which includes hospital stays, surgery, and rehabilitation services.