Health care reform is complicated, and articles and reports on the topic can often be confusing and full of acronyms and jargon with which you may be unfamiliar. This glossary provides definitions for commonly used terms in the health care reform debate.

American Health Care Association (AHCA)
Trade association representing nursing homes and long-term care facilities in the U.S.

American Hospital Association (AHA)
National association that represents allopathic and osteopathic hospitals in the U.S.

American Medical Association (AMA)
National association organized into local and regional groups that represent more than 700,000 medical doctors in the U. S.

Best practices
Actual practices, in use by qualified providers, following the latest treatment modalities that produce the best measurable results on a given dimension.

Blue Cross and Blue Shield Association (BC/BS)
Organization that offers information, consultation, representation and operational services for the Blue Cross and Blue Shield plan members across the country to provide insurance benefits.

Board certified
Clinician who has passed the national examination in a particular field.

Caps
Maximum allowable limits placed on revenue or rates by the federal or state government.

Centers for Disease Control and Prevention (CDC)
Agency within the U.S. Department of Health and Human Services that serves as the central point for consolidation of disease control data, health promotion and public health programs.

Centers for Medicare and Medicaid Services (CMS)
Agency within the U.S. Department of Health and Human Services responsible for the administration of U.S. Medicare and Medicaid programs.

Children’s Health Insurance Program (CHIP)
State-administered program funded partly by the federal government that allows states to expand health coverage to uninsured, low-income children not eligible for Medicaid. See also, the State Children’s Health Insurance Program (SCHIP).

Class Act
Proposed new automatic enrollment disability insurance – opt-out for employees, automatic enrollment by employers, scored at $58 billion.

Community Rating
Method used to determine a health insurance premium that is based on the average cost of the actual or anticipated health services of all subscribers in a specific geographic area or industry. This method spreads the cost of illness evenly rather than charging the sick more than the healthy.

Congressional Budget Office (CBO)
Non-partisan office that provides the U.S. Congress with cost estimates of legislative proposals and calculates estimates related to the federal budget.

“Connector”
Also known as an exchange, a health insurance connector is a mechanism that facilitates the buying, selling and administration of private health insurance in a single market. An example of a state-run health insurance connector is the Massachusetts Commonwealth Health Insurance Connector Authority.

Consolidated Omnibus Budget Reconciliation Act (COBRA)
Health benefit provisions passed by Congress in 1986 amending the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to provide continuation of group health coverage that otherwise might be terminated.

“Co-op”
Concept originally proposed by Senator Kent Conrad (D-ND), created as a compromise on the “public plan” option in the health care reform debate. Conrad offered his co-op proposal to satisfy Democrats who support a Medicare-like public option, and Republicans who oppose a government-run plan. A co-op is a non-profit health care company, owned and run by consumers who buy shares in it and elect its leaders.

Cost shifting
Practice of charging more for services provided to paying patients or third-party payers to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients.

Deductible
Amount of loss or expense that the insured must incur before the insurance company will assume any liability for all or part of the remaining cost of covered services.

Electronic health record
Patient’s computerized health information that is recorded and maintained by a provider system.

Employer Mandate
Proposal to require (mandate) that employers provide health insurance coverage options to their employees.

The Employee Retirement Income Security Act of 1974 (ERISA)
Federal statute enacted September 2, 1974, that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans, including health insurance for employees. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by requiring the disclosure to them of financial and other information concerning the plan; by establishing standards of conduct for plan fiduciaries; and by providing for appropriate remedies and access to the federal courts. Responsibility for the interpretation and enforcement of ERISA is divided among the Department of Labor, the Department of the Treasury (particularly the Internal Revenue Service), and the Pension Benefit Guaranty Corporation.

“Exchange” (See also, “Connector” and National Health Insurance Exchange)
Mechanism that facilitates the buying, selling and administration of private health insurance in a single market.

Exclusions
In an insurance contract, these are specific conditions or circumstances for which the policy will not provide benefit payments. Exclusions can eliminate coverage for select individuals, groups, locations, properties or risks.

Experience rating
When an insurance company evaluates the risk of an individual or group by considering the applicant's loss history, specifically, the applicant's health history.

Federal Employee Health Benefits Program (FEHBP)
Voluntary health insurance program for federal employees, retirees, and their dependents and survivors.

Fee-For-Service (FFS)
System in which physicians and other health care providers receive a fee for services performed.

Fee schedule
Comprehensive listing of fees used by either a health care plan or the government to reimburse providers on a fee-for-service basis.

Firewall
Under a firewall, employers would not be required to provide insurance. If, however, an employee does have access to ESI (employer-sponsored insurance), and they choose to opt out and go into the “exchange,” then the employee is not eligible for any type of subsidy within the exchange. This means that if the ESI is subsidized in any meaningful way by the employer, then there would remain great incentive for employees to stay in the ESI and would limit the amount of people who move into the exchange (and out of ESI).

Follow-on biologics
Second and subsequent versions of biologics, also known as “biosimilars,” that are independently developed and approved after an innovator has developed the original version. Follow-on biologics may or may not be intended to be molecular copies of the innovator's product.

Food and Drug Administration (FDA)
Agency within the federal government that is responsible for regulations pertaining to food and drugs sold in the United States.

"Free Rider" Penalties
Variant of the "play or pay" employer mandate idea; imposing so-called "free rider" penalties on businesses whose workers receive coverage through Medicaid or take advantage of new subsidies to buy health insurance elsewhere.

Generic biologics
Often used to refer to products that would be copies of, and be competitive with, biologics produced by innovative companies that developed and produced the first version of a particular product.

Generic substitution
Dispensing a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary.

Government Accountability Office (GAO)
Non-partisan arm of the U.S. Congress that evaluates federal programs as an oversight of federal spending, efficiency and performance.

Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation enacted in 1996 that mandates regulations governing privacy, security and administrative simplification standards for health care information. HIPAA governs how health care organizations handle all facets of information management, including patient records.

Health Maintenance Organization (HMO)
Entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed fee structure.

Health Savings Accounts (HSAs)
Method of financing health care, previously referred to as medical savings accounts (MSAs), that gives tax advantages to individuals who establish and maintain personal accounts for health care purposes.

Individual mandate
Proposal to require individuals that are opting out of health insurance coverage due to costs be required (mandated) to purchase health insurance coverage in an effort to end cost-shifting of health care treatment costs to people with insurance coverage, largely provided by employers.

Individual market
A part of the health insurance market that is composed of customers not eligible for Medicare or Medicaid who are covered under an individual contract for health coverage.

Integrated delivery system
Cooperation between physicians and hospitals for a variety of purposes, including physician-hospital organizations, management-service organizations, group practices without walls, integrated provider organizations and medical foundations.

Medicaid
United States health program for eligible individuals and families with low incomes and resources that is means-tested, jointly funded by the states and federal government, and managed by the states. Among the groups of people served by Medicaid are eligible low-income parents, children, seniors, and people with disabilities. Being poor, or even very poor, does not necessarily qualify an individual for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the U.S. Due to the aging population, nursing home coverage is the fastest growing aspect of Medicaid.

Medicare
Social insurance program administered by the U.S. government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. Medicare operates as a single-payer health care system that pays part of the cost associated with hospitalization, surgery, doctor visits and nursing care. There are 3 separate programs under Medicare: Part A (hospitalization), Part B (medical) and Part D (prescription drugs).

Medicare Advantage
Also called Medicare Part C or Medicare+Choice, a Medicare program under which eligible Medicare enrollees can elect to receive benefits through a managed care program that places providers at risk for those benefits.

Medicare Part A
The part of the Medicare program covering inpatient hospital services and services furnished by other health care providers such as nursing homes, home health agencies and hospices. Part A coverage is automatically provided for individuals entitled to Medicare.

Medicare Part B
The part of the Medicare program that covers outpatient, physician and medical supplier services. Part B coverage is optional and must be paid for separately through monthly premium payments.

Medicare Part C
(See Medicare Advantage).

Medicare Part D
The part of the Medicare program that covers prescription drug coverage.

Medicare Payment Advisory Commission (MedPAC)
Non-partisan congressional advisory body charged with providing policy advice and technical assistance concerning the Medicare program and other aspects of the health system. MedPAC conducts independent research, analyzes legislation, and makes recommendations to Congress.

Medigap
Supplemental health insurance policy sold by private insurance companies designed to pay for health care costs and services that are not paid by Medicare or any private health insurance benefits.

Mental Health Parity Act (MHPA)
Law prohibiting group health plans from applying more restrictive annual and lifetime limits on coverage for mental illness than for physical illness.

National Health Insurance Exchange
The result of nationalizing the current Health Insurance Exchange.

National Institutes of Health (NIH)
Division within the U.S. Department of Health and Human Services that is responsible for most of the agency's medical research programs.

Office of Management and Budget (OMB)
Federal agency responsible for providing fiscal accounting and budgeting services for the federal government.

Pay-or-play mandate
Under this requirement, employers must provide coverage (Play) and meet minimum contribution levels. Those who do not have to pay penalty amounts (Pay) – amounts have yet to be filled in; monthly penalty obligation plus free-rider penalty.

Pre-existing condition
Medical condition that a patient has experienced before the effective date of insurance coverage.

Preferred Provider Organization (PPO)
Panel of physicians, hospitals and other health care providers to an enrolled group for a fixed periodic payment.

Preventative care
Health care emphasizing prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations.

Public Plan
Government plan offered and administered by the government that would ostensibly operate side-by-side with private insurance choices.

Risk-adjustment
The statistical adjustment of outcome measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient's gender and age, the seriousness of the patient's condition, and any other illnesses the patient might have.

The State Children's Health Insurance Program (SCHIP)
Program administered by the U. S. Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. Every state has an approved plan. SCHIP covered 6.6 million children and 670,000 adults at some point during Federal fiscal year 2006.

Stop loss insurance
Type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum.

Third-party administrator
Person or organization that manages the payment, processing and settlement of life, health, dental, disability and self-insured insurance claims for another person or organization.

U.S. Department of Health and Human Services (HHS)
Department within the executive branch of the federal government responsible for Social Security and federal health programs in the civilian sector.

U.S. House Committee on Energy and Commerce
Congressional committee whose primary jurisdiction includes many health care-related issues, such as public health, patient protection, food and drug safety and oversight of Medicaid and other Health and Human Services programs.

U.S. House Committee on Ways and Means
Congressional committee with primary oversight of Medicare, Social Security and other public welfare programs.

U.S. Senate Committee on Finance
Congressional committee dealing with Medicare, Medicaid, federal bonds, the customs service and related issues, public moneys, revenue sharing, health programs funded by specific taxes, national social security, and general revenue matters. Members of this committee have significant influence over the development of federal health care policy and funding.

U.S. Senate Committee on Health, Education, Labor, and Pensions (HELP)
Congressional committee whose primary jurisdiction includes many hospital- and health care-related issues, including public health, labor practices, workplace safety, care for children and the elderly, biomedical research and social welfare programs.

Wellness programs
Preventive care programs designed to educate and motivate members to prevent illness and injury, and to promote good health through lifestyle choices, such as smoking cessation and dietary changes.