Glossary

Key terms across regulatory, healthcare, and legal topics, defined plainly. An educational reference, part of the Andrew Hillman Advisory resources.

Regulatory and Advisory Terms

Core regulatory and advisory concepts referenced across the Andrew Hillman Advisory resources.

351(a) BLA: A Biologics License Application under section 351(a) of the Public Health Service Act, the full approval pathway for a biologic.
510(k): A premarket submission demonstrating a medical device is substantially equivalent to a legally marketed device.
Operating Discipline: The cadence and controls that turn a strategy into a functioning company.
Pre-IND: An early meeting with the FDA to align on a development plan before an Investigational New Drug application.
RMAT: Regenerative Medicine Advanced Therapy, an FDA designation that can expedite eligible regenerative therapies.

HIPAA Terms

Privacy and security terms grounded in the HIPAA rules at 45 CFR Parts 160 and 164. Educational reference only.

Access: The ability or means to read, write, modify, or communicate data or otherwise use a system resource. Under the Security Rule the term describes technical entry to electronic systems. Under the Privacy Rule an individual also holds a right of access to inspect and obtain copies of their protected health information in a designated record set.
Accounting of Disclosures: An individual's right to receive a list of certain disclosures of their protected health information made by a covered entity or business associate. The accounting generally covers the six years before the request and excludes disclosures for treatment, payment, health care operations, and several other specified categories.
Administrative Safeguards: Administrative actions, policies, and procedures used to manage the selection, development, implementation, and maintenance of measures that protect electronic protected health information and to govern workforce conduct. Examples include security management processes, workforce training, and contingency planning.
Administrative Tribunal: A non-judicial body authorized to hear disputes and issue rulings. A covered entity may disclose protected health information in response to an order from an administrative tribunal, subject to conditions similar to those that apply to a court order.
Agent: A person or entity that acts on behalf of a covered entity or business associate and under its control. Agency is determined by the federal common law of agency, and an agent's conduct can create liability for the principal, including for breach notification timing.
Alternative or Confidential Communications: An individual's right to ask a covered entity to communicate protected health information by alternative means or at alternative locations. Providers and health plans must accommodate reasonable requests under specified conditions, for example sending mail to a post office box rather than a home address.
Amendment: An individual's right to request that a covered entity correct or supplement protected health information in a designated record set that the individual believes is inaccurate or incomplete. The covered entity may deny the request on limited grounds and must follow a defined process.
Authentication: The process of verifying that a person or entity seeking access is the one claimed. The Security Rule requires procedures to verify identity before granting access to electronic protected health information and to confirm that data has not been altered or destroyed without authorization.
Authorization: A detailed written permission from an individual that allows a covered entity to use or disclose protected health information for purposes not otherwise permitted by the Privacy Rule. A valid authorization must contain specified core elements and statements, including a description of the information, the recipient, an expiration, and the right to revoke.
Availability: The property that data or information is accessible and usable on demand by an authorized person. Availability is one of the three core security objectives that must be protected for electronic protected health information.
Breach: The acquisition, access, use, or disclosure of protected health information in a manner not permitted by the Privacy Rule that compromises its security or privacy. An impermissible use or disclosure is presumed to be a breach unless a low probability of compromise is demonstrated through a defined risk assessment.
Business Associate: A person or entity that performs functions or services for a covered entity that involve the use or disclosure of protected health information. Examples include claims processors, billing companies, and cloud storage vendors. Subcontractors that handle protected health information are also business associates.
Business Associate Agreement (BAA): A written contract between a covered entity and a business associate, or between a business associate and its subcontractor, that sets the permitted uses and disclosures of protected health information and requires the business associate to safeguard it. The agreement must include provisions specified by the Privacy and Security Rules.
Confidentiality: The property that data or information is not made available or disclosed to unauthorized persons or processes. Confidentiality is one of the three core security objectives for electronic protected health information.
Covered Entity: A health plan, a health care clearinghouse, or a health care provider that transmits health information electronically in connection with a transaction for which HHS has adopted a standard. Covered entities carry direct compliance obligations under HIPAA.
Data Aggregation: The combining by a business associate of protected health information from one covered entity with that of other covered entities to permit data analyses relating to their health care operations. A business associate agreement may authorize this activity.
De-Identified Health Information: Health information from which identifiers of the individual and of relatives, employers, and household members have been removed so that it no longer identifies a person and provides no reasonable basis to do so. It is achieved through the Expert Determination method or the Safe Harbor method and is not protected health information.
Designated Record Set: A group of records maintained by or for a covered entity that includes medical and billing records, enrollment and claims records held by a health plan, or any records used to make decisions about individuals. The rights of access and amendment apply to information in this set.
Disclosure: The release, transfer, provision of access to, or divulging of information outside the entity that holds it. Disclosure differs from use, which refers to handling information within an entity.
Electronic Protected Health Information (ePHI): Protected health information that a covered entity or business associate creates, receives, maintains, or transmits in electronic form. The Security Rule applies specifically to this information.
Encryption: The use of an algorithmic process to transform data into a form with a low probability of assigning meaning without a confidential key. When applied to a standard specified by HHS, encryption can render protected health information unusable, unreadable, or indecipherable, which affects breach notification duties.
Facility: The physical premises and the interior and exterior of a building or buildings controlled by a covered entity or business associate. Physical safeguards address protection of facilities and the equipment within them.
Facility Directory: A directory maintained by a health care provider that typically contains a patient's name, location in the facility, general condition, and religious affiliation. A provider may use and disclose limited directory information under specified conditions unless the individual objects.
Fundraising: Activities conducted by or on behalf of a covered entity to raise funds for its own benefit. The Privacy Rule permits limited protected health information for fundraising, requires that fundraising materials describe how to opt out, and prohibits conditioning treatment on a fundraising decision.
Health Care Operations: Certain administrative, financial, legal, and quality improvement activities necessary to run a covered entity and support treatment and payment. Examples include quality assessment, competency review, underwriting, auditing, and business planning.
HHS: The United States Department of Health and Human Services, the federal department responsible for adopting, administering, and enforcing the HIPAA rules. Its Office for Civil Rights enforces the Privacy, Security, and Breach Notification Rules.
HIPAA: The Health Insurance Portability and Accountability Act of 1996, a federal law that, among other purposes, directed the creation of national standards to protect the privacy and security of individually identifiable health information.
HIPAA Breach Notification Rule: The regulations that require covered entities and business associates to notify affected individuals, HHS, and in some cases the media when unsecured protected health information is breached. The rule defines the timing, content, and method of notification.
HIPAA Enforcement Rule: The regulations that govern how HHS investigates complaints, conducts compliance reviews, imposes civil money penalties, and resolves violations. It sets penalty tiers based on the level of culpability.
HIPAA Privacy Rule: The regulations that establish national standards for protecting protected health information and define individual rights, permitted and required uses and disclosures, and the minimum necessary standard. It applies to protected health information in any form.
HIPAA Security Rule: The regulations that establish national standards for protecting electronic protected health information through administrative, physical, and technical safeguards. It requires that confidentiality, integrity, and availability be ensured.
HITECH Act: The Health Information Technology for Economic and Clinical Health Act of 2009, which strengthened HIPAA by extending direct liability to business associates, establishing the breach notification framework, increasing penalties, and promoting adoption of electronic health records.
Individual: The person who is the subject of the protected health information. In certain circumstances a personal representative may act on behalf of the individual.
Individually Identifiable Health Information: A subset of health information, including demographic data, that relates to a person's health, care, or payment for care and that identifies the person or provides a reasonable basis to identify the person.
Information System: An interconnected set of information resources under the same direct management control that shares common functionality, including hardware, software, information, data, applications, communications, and people. The Security Rule requires activity review at the system level.
Institutional Review Board (IRB): A body established to review and oversee research involving human subjects in order to protect their rights and welfare. Under the Privacy Rule an IRB or a privacy board may approve a waiver or alteration of the authorization requirement for research use of protected health information.
Integrity: The property that data or information has not been altered or destroyed in an unauthorized manner. Integrity is one of the three core security objectives for electronic protected health information.
Limited Data Set: Protected health information from which specified direct identifiers have been removed but which may retain certain dates and geographic detail. It may be used or disclosed for research, public health, or health care operations under a data use agreement.
Malicious Software: Software, for example a virus, designed to damage or disrupt a system or to gain unauthorized access to information. The Security Rule requires procedures to guard against, detect, and report malicious software.
Marketing: A communication about a product or service that encourages the recipient to purchase or use it. With limited exceptions the Privacy Rule requires a valid authorization before protected health information is used for marketing.
Medical Record: The set of documents describing an individual's health history, care, and treatment maintained by a health care provider. Medical records typically form part of a designated record set and are subject to the rights of access and amendment.
Minimum Necessary Standard: The principle that a covered entity or business associate must make reasonable efforts to limit the use, disclosure, and request of protected health information to the least amount needed for the intended purpose. The standard does not apply to certain disclosures such as those for treatment or under a valid authorization.
Notice of Privacy Practices: A document that a covered entity must provide describing how it may use and disclose protected health information, the individual's rights, and the entity's legal duties. Direct treatment providers must make a good faith effort to obtain written acknowledgment of receipt.
Office for Civil Rights (OCR): The office within HHS responsible for enforcing the HIPAA Privacy, Security, and Breach Notification Rules through complaint investigation, compliance review, and the imposition of penalties or corrective action.
Opt-out: A mechanism by which an individual can decline to receive certain communications or to have protected health information used for certain purposes, for example fundraising communications or inclusion in a facility directory.
Password: Confidential authentication information composed of a string of characters used to verify identity before access is granted to a system. The Security Rule addresses password management as part of security awareness and access control.
Payment: The activities of a health plan to obtain premiums or provide benefits and the activities of a provider to obtain reimbursement for care. Payment activities include billing, claims management, eligibility determination, utilization review, and collection.
Personal Representative: A person with authority under applicable law to act on behalf of an individual in making health care decisions. A covered entity must generally treat a personal representative as the individual with respect to protected health information, subject to specified exceptions.
Physical Safeguards: Physical measures, policies, and procedures that protect electronic information systems and related buildings and equipment from natural and environmental hazards and unauthorized intrusion. Examples include facility access controls, workstation security, and device and media controls.
Privacy Breach: An impermissible use or disclosure of protected health information that violates the Privacy Rule. Whether it requires notification is determined under the Breach Notification Rule.
Privacy Incident: An event that may involve an unauthorized use or disclosure of protected health information and that warrants review to determine whether it is a reportable breach. The term is often used for events under investigation before a formal breach determination.
Protected Health Information (PHI): Individually identifiable health information transmitted or maintained in any form or medium by a covered entity or business associate. Certain records, such as employment records held by a covered entity as an employer and specified education records, are excluded.
Provider: A person or organization that furnishes, bills, or is paid for health care in the normal course of business. A provider that transmits health information electronically in connection with a covered transaction is a covered entity.
Psychotherapy Notes: Notes recorded by a mental health professional documenting or analyzing a counseling session that are kept separate from the rest of the medical record. They receive heightened protection and generally require a specific authorization for use or disclosure.
Research: A systematic investigation, including development, testing, and evaluation, designed to develop or contribute to generalizable knowledge. The Privacy Rule sets conditions for using protected health information in research, including authorization, waiver, or a limited data set with a data use agreement.
Security Incident: The attempted or successful unauthorized access, use, disclosure, modification, or destruction of information, or interference with system operations. The Security Rule requires procedures to identify and respond to security incidents.
Security Measures: The administrative, physical, and technical controls that a covered entity or business associate implements to protect electronic protected health information and to meet the standards of the Security Rule.
Security Risk Assessment: A required analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information. It is the foundation of the security management process and informs the selection of safeguards.
Technical Safeguards: The technology and the policies and procedures for its use that protect electronic protected health information and control access to it. Examples include access controls, audit controls, integrity controls, and transmission security.
Treatment: The provision, coordination, or management of health care and related services by one or more providers, including consultation between providers and referral of a patient from one provider to another.
Unsecured PHI: Protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through a technology or methodology specified by HHS, such as approved encryption or destruction. A breach of unsecured protected health information triggers notification obligations.
Use: The sharing, employment, application, utilization, examination, or analysis of protected health information within the entity that maintains it. Use differs from disclosure, which involves release outside the entity.
User: A person or entity with authorized access to an information system. The Security Rule requires that access be granted based on a defined role and that user activity be controlled and reviewed.
Whistleblower: A workforce member or business associate who discloses protected health information because they believe in good faith that the covered entity has engaged in unlawful conduct or violated professional or clinical standards. The Privacy Rule protects certain such disclosures made to appropriate authorities or attorneys.
Workforce: Employees, volunteers, trainees, and other persons whose conduct in the performance of work for a covered entity or business associate is under its direct control, whether or not they are paid. Workforce members are subject to the entity's policies and training.
Workstation: An electronic computing device, for example a laptop or desktop computer, and the electronic media in its immediate environment, used to perform functions involving protected health information. The Security Rule requires policies governing proper workstation use and physical security.

Pharmacy and Medical Terms

Common medication, prescribing, and pharmacy-benefit terms explained in plain language.

Adverse Drug Reaction: A harmful or unintended response to a medication taken at a normal dose. Reactions range from mild effects such as nausea to severe events such as an allergic reaction, and reporting them helps regulators monitor drug safety.
Adverse Event: Any undesirable medical occurrence in a patient who has been given a medication, whether or not it is caused by the drug. Serious adverse events include those that are life threatening or that result in hospitalization.
Agonist: A substance that binds to a receptor in the body and activates it to produce a biological response. A full agonist produces a maximal response and a partial agonist produces a lesser one.
Analgesic: A medication that relieves pain. Some analgesics are available over the counter and others require a prescription, and they work through different mechanisms.
Anaphylaxis: A rapid, severe, and potentially fatal allergic reaction that can cause difficulty breathing, swelling, and a drop in blood pressure. It requires immediate emergency treatment.
Antagonist: A substance that binds to a receptor without activating it and blocks other substances from activating it. Antagonists are sometimes called blockers.
Boxed Warning: The strongest warning the FDA requires on a drug label, set apart in a border to call attention to serious or life threatening risks. It is also called a black box warning.
Brand Drug: A medication sold under a manufacturer's proprietary name, usually the original version protected by a patent for a period of time. It is typically more expensive than its generic equivalents.
Coinsurance: A share of the cost of a covered medication or service that a patient pays as a percentage after meeting any deductible, with the health plan paying the remaining percentage.
Compounding: The preparation of a customized medication by a pharmacist who combines or alters ingredients to meet a specific patient's needs, for example changing a dosage form or removing an allergen. Compounded drugs are not FDA approved.
Contraindication: A specific situation in which a medication should not be used because the risk of harm outweighs any benefit. An absolute contraindication rules out use entirely and a relative contraindication calls for caution.
Controlled Substance: A drug whose manufacture, possession, and distribution are regulated by the government because of its potential for misuse or dependence. Controlled substances are placed in DEA schedules and carry added prescribing and dispensing restrictions.
Copay: A fixed amount a patient pays for a covered medication or service, for example fifteen dollars per prescription, with the health plan covering the rest.
DAW (Dispense as Written): A code a prescriber places on a prescription to instruct the pharmacy to dispense the specific product ordered and not substitute a generic. It is used when a particular brand is medically required.
DEA Schedule: A classification under the Controlled Substances Act that ranks drugs from Schedule I to Schedule V based on accepted medical use and potential for abuse and dependence. Schedule I has the highest abuse potential and no accepted medical use and Schedule V the lowest.
Deductible: The amount a patient must pay out of pocket for covered medications or services before the health plan begins to pay.
Dosage Form: The physical form in which a medication is produced and taken, for example tablet, capsule, liquid, patch, or injection.
Dose and Dosage: A dose is the amount of medication taken at one time. A dosage describes the dose together with how often and how long it is taken.
Formulary: A list of medications a health plan or pharmacy benefit manager covers, often organized into tiers that determine the patient's cost share. Drugs not on the formulary may cost more or require special approval.
Generic Drug: A medication that contains the same active ingredient as a brand drug and is approved as therapeutically equivalent, though it may differ in appearance and inactive ingredients. It is usually less expensive than the brand version.
Interaction: A change in the way a medication works caused by another drug, food, supplement, or health condition. Interactions can reduce effectiveness or increase the risk of side effects.
Loading Dose: A higher initial dose given to bring the amount of medication in the body to an effective level quickly, followed by lower maintenance doses.
Maintenance Dose: The regular dose taken to keep the amount of medication in the body at a steady, effective level over the course of treatment.
Maximum Dose: The highest dose of a medication considered safe and effective. Exceeding it tends to increase side effects without added benefit.
Metabolism: The process by which the body chemically changes a medication, most often in the liver, either to activate it or to prepare it for elimination.
NDC (National Drug Code): A unique numeric identifier assigned to a medication that specifies the labeler, product, and package size. Pharmacies and payers use it to identify and bill for drugs.
OTC (Over the Counter): A medication that can be purchased without a prescription because it is considered safe and effective when used according to the label directions.
PBM (Pharmacy Benefit Manager): A company that administers prescription drug benefits for health plans and employers, negotiating with manufacturers and pharmacies and managing formularies, claims, and pricing.
Placebo: An inactive substance with no therapeutic effect used as a comparison in clinical trials to measure whether a medication works.
Prescription (Rx): An order for a medication written by an authorized health care provider that directs a pharmacist to dispense a specific drug, dose, and quantity with instructions for use.
Prior Authorization: A requirement that a prescriber obtain approval from a health plan before a specific medication will be covered. It is used to confirm medical necessity or to steer toward preferred options.
Prodrug: A medication that is inactive when taken and becomes active only after the body processes it. Prodrugs are designed to improve absorption or targeting.
Prophylaxis: Treatment or measures taken to prevent a disease or condition rather than to treat one that already exists.
Quantity Limit: A cap a health plan places on the amount of a medication it will cover over a given period, based on approved dosing or safety considerations.
Receptor: A protein on or inside a cell that receives chemical signals. Many medications work by binding to receptors to activate or block their effects.
Refill: A subsequent supply of a medication dispensed under an existing prescription without a new order, up to the number of refills the prescriber authorized.
Step Therapy: A coverage rule that requires a patient to try one or more preferred or lower cost medications before the plan will cover a more expensive or non-preferred option.
Therapeutic Equivalence: A determination that a generic drug can be substituted for its brand reference because it delivers the same clinical effect and safety when used as directed. The FDA rates equivalence in its Orange Book.

Laboratory and Specimen Handling Terms

Terms used in clinical laboratory testing and the collection, handling, and transport of specimens.

Aliquot: A portion of a specimen separated from the original sample and placed in its own container for testing, storage, or shipment. Aliquoting divides a sample so several tests can run without repeated freezing and thawing.
Ambient Handling: Storage and transport of a specimen at room temperature, generally around 15 to 25 degrees Celsius. Specimens designated for ambient handling should not be refrigerated or frozen unless the test directs otherwise.
Analyte: The specific substance measured in a laboratory test, for example glucose, cholesterol, or a particular protein or hormone.
Assay: A laboratory procedure that detects or measures an analyte in a specimen. The term also refers to the test method itself.
Centrifuge: A device that spins specimens at high speed to separate components by density, for example separating serum or plasma from blood cells. Centrifugation is a required step for many chemistry tests.
Chain of Custody: A documented record of every person who handles a specimen from collection through analysis and disposal. It preserves the integrity and legal defensibility of results and is required for tests such as forensic or employment drug screening.
Frozen Handling: Storage and transport of a specimen at a temperature below freezing, often at or below minus 20 degrees Celsius, to preserve analytes that degrade at higher temperatures. Repeated freezing and thawing should be avoided.
Hemolysis: The rupture of red blood cells that releases their contents into the surrounding serum or plasma, giving the sample a pink or red tint. Hemolysis can interfere with certain tests and may require a new specimen.
Icterus: A yellow discoloration of serum or plasma caused by elevated bilirubin. An icteric sample can interfere with some measurements and may be noted during specimen inspection.
Lipemia: A cloudy or milky appearance of serum or plasma caused by a high concentration of fats. Lipemia can interfere with certain assays and may require special processing.
Plasma: The liquid portion of blood collected in a tube containing an anticoagulant and separated from the cells by centrifugation. Plasma still contains clotting factors because the blood was prevented from clotting.
Qualitative and Quantitative Results: A qualitative result reports whether an analyte is present or absent, for example positive or negative. A quantitative result reports a specific measured amount, for example a concentration value.
Reference Range: The range of values expected for a healthy population for a given test, used to help interpret whether a patient's result is typical or unusual. Ranges vary by method, age, sex, and laboratory.
Reflex Testing: Additional testing that a laboratory performs automatically when an initial result meets defined criteria, for example confirming a positive screen. Reflex testing follows preset rules rather than a new order.
Refrigerated Handling: Storage and transport of a specimen at cold temperatures, generally 2 to 8 degrees Celsius, to slow degradation of analytes that are stable when chilled but not frozen.
Requisition: The order form, paper or electronic, that accompanies a specimen and specifies the patient, ordering provider, tests requested, and relevant clinical information. Accurate requisitions are essential for correct testing and reporting.
Serum: The liquid portion of blood that remains after the blood has clotted and the clot and cells are removed by centrifugation. Serum lacks clotting factors and is used for many chemistry and immunology tests.
Specimen Integrity: The condition of a specimen with respect to its suitability for accurate testing. Integrity depends on proper collection, labeling, handling, temperature, and timing, and compromised specimens may be rejected.
Turnaround Time: The interval between collection or receipt of a specimen and the reporting of the result. Turnaround time varies by test and affects clinical decision making.
Whole Blood: A blood specimen that has not been separated into components and retains its cells and liquid together, usually collected with an anticoagulant. Some tests, such as certain cell counts, require whole blood.

Healthcare Billing and Pricing Terms

Terms that describe hospital and provider charges, insurance processing, and what a patient owes. Cost-sharing terms such as copay, coinsurance, and deductible are defined in the Pharmacy and Medical section above.

Allowed Amount: The maximum amount a health plan will recognize as payable for a covered service. The plan bases its payment and the patient's cost share on this amount, which may be less than the provider's charge.
Balance Billing: When an out of network provider bills a patient for the difference between the provider's charge and the amount the health plan allowed. Federal and state rules limit balance billing in certain emergency and facility based situations.
Charge: The dollar amount a provider lists for a service before any insurance discount or adjustment. The charge often differs from what a plan allows or a patient ultimately pays.
Chargemaster: A comprehensive list maintained by a hospital of the standard charge for every service, item, and procedure it provides. The chargemaster is the starting point for a bill before discounts and payer contracts are applied.
Claim: A request for payment that a provider or patient submits to a health plan, listing the services provided and the associated codes and charges.
Cost Estimate: A projection of what a service is expected to cost a patient before it is provided, based on the price, the patient's coverage, and expected cost sharing. An estimate is not a guarantee of the final bill.
CPT Code: A Current Procedural Terminology code, maintained by the American Medical Association, that identifies a specific medical service or procedure for billing and record keeping.
DRG: A Diagnosis Related Group, a classification that groups inpatient stays with similar diagnoses and resource use into a single category. Medicare and other payers use DRGs to set a fixed payment for an inpatient admission.
Explanation of Benefits (EOB): A statement a health plan sends after processing a claim that shows the charge, the allowed amount, what the plan paid, and what the patient owes. An EOB is not a bill.
Good Faith Estimate: A written estimate of expected charges that a provider must give an uninsured or self pay patient before scheduled care, as required by federal law. It lists the items and services and their expected costs.
ICD Code: An International Classification of Diseases code that identifies a diagnosis or health condition. Providers report ICD codes on claims to describe why a service was performed.
In-Network and Out-of-Network: In network providers have a contract with a health plan and accept its negotiated rates, which usually lowers patient cost. Out of network providers have no such contract, and using them typically increases what the patient pays.
Itemized Bill: A detailed statement that lists each individual service, item, and charge associated with a patient's care rather than a single summary total. Patients can request one to review charges line by line.
Out-of-Pocket Cost: The portion of health care expenses a patient pays directly, including deductibles, coinsurance, and copays. Most plans cap annual out of pocket costs for covered in network care.
Preauthorization: Approval a health plan requires before certain services, procedures, or equipment will be covered. It confirms the plan considers the service medically necessary, though it does not guarantee payment.
Self-Pay and Uninsured Discount: A reduced price a provider offers to patients who do not use insurance or who lack coverage and pay directly. Discounts and payment arrangements vary by provider.

Medicare, Medicaid and CMS Terms

Terms used in federal health coverage programs administered by the Centers for Medicare and Medicaid Services. The formulary term is defined in the Pharmacy and Medical section above.

Beneficiary: A person who is enrolled in and eligible to receive benefits from a health program such as Medicare or Medicaid.
Benefit Period: The way Medicare Part A measures a spell of inpatient care. It begins when a beneficiary is admitted and ends after 60 consecutive days without inpatient or skilled care, and it determines how deductibles and coverage limits apply.
Capitation: A payment method in which a provider or plan receives a fixed amount per enrolled person for a period, regardless of how many services the person uses. It contrasts with fee for service.
CHIP: The Children's Health Insurance Program, a joint federal and state program that provides low cost health coverage to children in families that earn too much to qualify for Medicaid but cannot readily afford private coverage.
CMS: The Centers for Medicare and Medicaid Services, the federal agency within the Department of Health and Human Services that administers Medicare, works with states on Medicaid and CHIP, and sets many national coverage and payment rules.
Dual Eligible: A person who qualifies for both Medicare and Medicaid. For these individuals Medicaid may help cover premiums, cost sharing, and services that Medicare does not.
Durable Medical Equipment (DME): Reusable medical equipment ordered by a provider for use in the home, for example wheelchairs, walkers, hospital beds, and oxygen equipment. Medicare Part B covers many items of durable medical equipment.
Fee-for-Service: A payment method in which providers are paid separately for each service delivered. Original Medicare operates largely on a fee for service basis.
Local Coverage Determination (LCD): A decision by a Medicare Administrative Contractor about whether a particular service is covered within its region. An LCD applies where no national determination exists or adds regional detail.
Medicaid: A joint federal and state program that provides health coverage to eligible low income individuals and families and to certain people with disabilities. Eligibility and benefits vary by state within federal rules.
Medicare: The federal health insurance program primarily for people age 65 and older and for certain younger people with disabilities or end stage renal disease.
Medicare Administrative Contractor (MAC): A private company that contracts with Medicare to process claims and administer payments for a defined geographic region and that issues local coverage determinations.
Medicare Advantage (Part C): A way to receive Medicare benefits through a private plan approved by Medicare that bundles Part A and Part B and often Part D. These plans may offer extra benefits and set their own networks and rules.
Medicare Part A: The hospital insurance part of Medicare that helps cover inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
Medicare Part B: The medical insurance part of Medicare that helps cover physician services, outpatient care, preventive services, and durable medical equipment.
Medicare Part D: The prescription drug coverage part of Medicare, offered through private plans approved by Medicare, that helps pay for outpatient prescription drugs.
Medigap: Private supplemental insurance that helps pay costs Original Medicare does not cover, such as certain deductibles and coinsurance. Medigap works alongside Original Medicare rather than replacing it.
National Coverage Determination (NCD): A nationwide decision by CMS about whether Medicare will cover a particular service, procedure, or item. An NCD applies across all regions.
Premium: The amount paid, often monthly, to maintain health coverage. Medicare, Medicaid managed care, and private plans may each involve premiums.
Skilled Nursing Facility (SNF): A facility that provides skilled nursing and rehabilitation care under the supervision of licensed health professionals. Medicare Part A may cover a limited skilled nursing facility stay after a qualifying hospital admission.