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.

Cost-sharing Reduction (CSR)

A subsidy available through the ACA Marketplace that lowers out-of-pocket costs like deductibles, copays, and coinsurance for eligible individuals. CSR is available to people who enroll in Silver-tier plans and meet specific income requirements.

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.

Catastrophic Coverage (Medicare Part D)

The phase of Medicare Part D coverage that begins after a beneficiary has spent a specified amount on prescription drugs during the year. During this phase, Medicare covers most prescription drug costs, and the beneficiary pays only a small copayment or coinsurance.

Deductible

The amount an individual must pay out-of-pocket for covered healthcare services before their insurance plan starts to cover costs. Deductibles apply to various types of insurance, including Medicare, Medicaid, ACA, and CHIP plans.

Dependent Coverage

Health insurance that covers not only the policyholder but also their dependents, typically children or a spouse. Under the ACA, dependents can stay on their parents’ health insurance plan until age 26.

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.

Donut Hole (Coverage Gap)

The temporary limit on prescription drug coverage under Medicare Part D. During this phase, beneficiaries may pay a higher percentage of drug costs until they reach the threshold for catastrophic coverage.

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.

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.

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.

Disability Insurance

Insurance that provides income protection to individuals who are unable to work due to a disability. Medicare beneficiaries under age 65 often qualify due to a long-term disability.

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.

Essential Health Benefits (EHBs)

A set of 10 categories of healthcare services that all ACA-compliant health plans must cover. These services include emergency care, hospitalization, maternity and newborn care, prescription drugs, mental health services, and more.

Exchange (Health Insurance Marketplace)

Also known as the Health Insurance Marketplace, the exchange is an online platform where individuals can compare and purchase ACA-compliant health insurance plans. The Marketplace also provides information on subsidies and tax credits for eligible individuals.

Extra Help (Medicare Part D)

A federal program that helps individuals with limited income and resources pay for the costs of prescription drugs under Medicare Part D. Extra Help covers premiums, deductibles, and copayments for eligible beneficiaries.

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.