Term
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Definition
| A tendency for the utilization of health services in a population to be higher than average. From an insurance perspective, adverse selection occurs when people with poorer than average health status apply for, or continue insurance coverage to a greater extent than people with average or better health expectations |
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Term
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Definition
| Insurance premiums that are set at the same price for everyone, based on the average cost of providing health care |
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Term
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Definition
| A list of the specific drugs a drug plan will cover subject to limits and conditions. Every Medicare prescription drug plan must have on its formulary at least two drugs in every class of drugs, unless there are not two drugs in the class or the drugs are excluded from coverage under part D. |
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Term
| Health Insurance Exchange |
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Definition
| A market set up to give individuals, small businesses, and others access to affordable private health insurance. |
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Term
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Definition
| the ratio of total losses paid out in claims plus adjustment expenses divided by the total earned premiums. For example, if an insurance company pays out $60 in claims for every $100 in collected premiums, then its loss ratio is 60%.Loss ratios for health insurance (called the medical loss ratio, or MLR) generally range from 60% to 110% |
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Term
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Definition
| occurs when the behavior of the insured party changes in a way that raises costs for the insurer, since the insured party no longer bears the full costs of that behavior. Because individuals no longer bear the cost of medical services, they have an added incentive to ask for pricier and more elaborate medical service—which would otherwise not be necessary. In these instances, individuals have an incentive to over consume, simply because they no longer bear the full cost of medical services. |
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Term
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Definition
| Health problems that existed before the policy was purchased. Insurance policies often exclude pre-existing conditions. This is another way to discourage people from waiting to buy coverage until they need to use it. |
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Term
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Definition
| Bringing several risks together for insurance purposes in order to balance the consequences of the realization of each individual risk. Insurance companies usually try to have the largest pool possible in order to balance out the costs of those who are high consumers of healthcare services versus those who are low consumers. A larger risk pool is a financial benefit for an insurance company |
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Term
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Definition
| an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life or health insurance). As part of the underwriting process, health information may be used in making two related decisions: whether to offer or deny coverage; and what premium rate to set for the policy. The use of medical underwriting may be restricted by law in certain insurance markets. Where allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system |
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Term
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Definition
| Review by an insurer of health care services to evaluate the appropriateness, necessity and quality of a requested service. |
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Term
| Accountable Care Organization |
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Definition
| A network of health care providers that band together to provide the full continuum of health care services for patients. The network would receive a payment for all care provided to a patient, and would be held accountable for the quality and cost of care. Proposed pilot programs in Medicare and Medicaid would provide financial incentives for these organizations to improve quality and reduce costs by allowing them to share in any savings achieved as a result of these efforts. |
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Term
| Center for Medicare and Medicaid Innovation |
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Definition
| created by the Affordable Care Act to test, evaluate, and expand in Medicare, Medicaid, and CHIP different payment structures and methodologies to reduce program expenditures while maintaining or improving quality of care. |
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Term
| Comparative Effectiveness Research |
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Definition
| A field of research that analyzes the impact of different options for treating a given condition in a particular group of patients. These analyses may focus only on the medical risks and benefits of each treatment or may also consider the costs and benefits of particular treatment options. |
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Term
| Consumer-Directed Health Plans |
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Definition
| Consumer-directed health plans seek to increase consumer awareness about health care costs and provide incentives for consumers to consider costs when making health care decisions. These health plans usually have a high deductible accompanied by a consumer-controlled savings account for health care services. There are two types of savings accounts: Health Savings Accounts (HSAs) and Health Reimbursement Arrangements (HRAs). |
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Term
| Independent Payment Advisory Board |
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Definition
| created by the Affordable Care Act and comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate, beginning in January 2015. The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing (including Parts A and B premiums), or would result in a change in the beneficiary premium percentage or low-income subsidies under Part D. |
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Term
| Patient-Centered Outcomes Research Institute |
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Definition
| an independent non-profit organization created by the Affordable Care Act to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels. Findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage |
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Term
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Definition
| A health care payment system in which providers receive incentives for meeting or exceeding quality, and sometimes cost, benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay for performance programs is to improve the quality of care over time. |
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Term
| America's Health Insurance Plans |
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Definition
| a national political advocacy and trade association with about 1,300 member companies that sell health insurance coverage to more than 200 million Americans. AHIP was formed through the merger of Health Insurance Association of America (HIAA) and American Association of Health Plans (AAHP). |
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Term
| American Medical Association |
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Definition
| association founded in 1847 and incorporated in 1897 that is the largest association of physicians and medical students in the United States. The AMA's stated mission is to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public health, to lobby for legislation favorable to physicians and patients, and to raise money for medical education. |
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Term
| National Federation of Independent Businesses (NFIB) |
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Definition
| a lobbying organization with offices in Washington, D.C. USA, and in all 50 state capitals. NFIB claims a membership base of about 350,000, down from an excess of more than 600,000 members. NFIB's lobbying efforts are focused on the impact of current and proposed legislation on businesses and professional practices at all levels of government, but primarily at the federal and state levels |
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Term
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Definition
| - a term based on a public figure's favorable image among the populace and among other important factors in or out of the government. Political capital is essentially the opinion of another person, group of people, or nation about you, your organization, or your government. A politician gains political capital by virtue of his or her position, and also by pursuing popular policies, achieving success with initiatives, performing favors for other politicians, etc. Political capital must be spent to be useful, and will generally expire by the end of a politician's term in office. President George W. Bush frequently used the terms in the 2004 presidential elections. |
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Term
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Definition
| any organization, governmental entity, or individual that has a stake in or may be impacted by a given approach to environmental regulation, pollution prevention, energy conservation, etc. In healthcare, this may include but is not limited to insurance companies, health organizations, providers, and groups who are the consumers of healthcare (individuals covered through government programs or private insurers.) |
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Term
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Definition
| Provision of the U.S. Constitution (Article III, Section 8, Clause 3) which gives Congress the power “to regulate commerce with foreign nations, and among the several states, and with the Indian tribes.” The Supreme Court’s existing commerce clause cases establish that Congress can regulate any economic activity that Congress rationally concludes is “in the stream of” or “substantially effects” interstate commerce. The constitutional arguments about ACA’s individual mandate center around this provision of the U.S. Constitution. |
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Term
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Definition
| the “power” of a Court to decide a case. As a preliminary issue and before reaching the constitutionality of the individual mandate, the Court must decide whether the federal Anti-Injunction Act (AIA) prevents it from deciding a lawsuit about ACA at this time. If the Court decides that the ACA’s financial penalty is considered a “tax” under the AIA, this challenge to the mandate is dismissed, and Courts cannot hear cases about whether the mandate is constitutional until 2015, after 2014 tax returns are due. If the Court decides that the AIA does not apply, the Court will decide whether the mandate is constitutional now. |
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Term
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Definition
| capable of being severed or separated; separable into legally distinct rights or obligations. If the Supreme Court invalidates the individual mandate, it will then consider whether the mandate is severable from the rest of the law. In this case, “severable” means that the rest of the ACA could function without the mandate as Congress intended it to. |
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Term
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Definition
| The only procedure by which the Senate can vote to place a time limit on consideration of a bill or other matter, and thereby overcome a filibuster. Under the cloture rule (Rule XXII), the Senate may limit consideration of a pending matter to 30 additional hours, but only by vote of three-fifths of the full Senate, normally 60 votes. |
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Term
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Definition
| A temporary, ad hoc panel composed of House and Senate conferees which is formed for the purpose of reconciling differences in legislation that has passed both chambers. Conference committees are usually convened to resolve bicameral differences on major and controversial legislation. |
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Term
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Definition
| Informal term for any attempt to block or delay Senate action on a bill or other matter by debating it at length, by offering numerous procedural motions, or by any other delaying or obstructive actions. |
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Term
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Definition
| A proposal to create a new insurance plan administered and funded by federal or state government that would be offered along with private plans in a newly-created health insurance exchange. |
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Term
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Definition
| A process established in the Congressional Budget Act of 1974 by which Congress changes existing laws to conform tax and spending levels to the levels set in a budget resolution. Changes recommended by committees pursuant to a reconciliation instruction are incorporated into a reconciliation measure. Because health reform concerns the budget, the Democrats and President Obama used reconciliation to pass health reform. The House passed the Senate bill (“The Patient Protection and Affordable Care Act”) and a second bill containing amendments (“The Health Care and Education Reconciliation Act of 2010”). Using reconciliation, the Senate only needed to pass The Health Care and Education Reconciliation Act of 2010 by 51 votes, rather than 60 votes necessary to avoid a filibuster. |
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Term
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Definition
| The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes (e.g., to fund specific federal departments, agencies, and programs). The formal federal spending process consists of two sequential steps: authorization and then appropriation |
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Term
| Centers for Medicare and Medicaid |
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Definition
| Agency in the U.S. Department of Health and Human Services that regulates the big public health programs |
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Term
| Congressional Budget Office |
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Definition
| A nonpartisan congressional staff agency, one of CBO’s most important responsibilities is estimating the effect of legislation on the federal budget. The estimated cost of a piece of legislation is often called its “CBO score.” CBO scores that show budget deficits can make it far more difficult to garner legislative support |
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Term
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Definition
| Legislation in the form of a joint resolution enacted by Congress, when the new fiscal year is about to begin or has begun, to provide budget authority for Federal agencies and programs to continue in operation until the regular appropriations acts are enacted. |
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Term
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Definition
| a health care setting where patients receive comprehensive primary care services; have an ongoing relationship with a primary care provider who directs and coordinates their care; have enhanced access to non-emergent primary, secondary, and tertiary care; and have access to linguistically and culturally appropriate care. |
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Term
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Definition
| The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. |
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Term
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Definition
| Spending (budget authority and outlays) controlled by laws other than annual appropriations acts. Mandatory programs include Social Security, Medicare, and Medicaid. Under the ACA, subsidies available to help people buy insurance in 2014 are considered “mandatory.” |
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