AHIP PHIAS key terms

The maximum dollar figure a health plan will recognize as payment for a covered service, set by its fee schedule or negotiated contract. Cost sharing is calculated from this figure, not from the provider's billed charge.

A provider's practice of charging a patient the difference between the billed charge and the amount the insurer allows. Network providers typically agree not to do this; out-of-network providers often may.

A reimbursement benchmark built from the prevailing charges for a service in a geographic area, used by many indemnity and preferred provider plans to set the allowed amount for out-of-network care.

A managed care plan that generally covers care only from its contracted network and requires members to choose a primary care physician who coordinates care and issues referrals to specialists.

The network physician in an HMO or similar plan who manages a member's overall care and must authorize specialist visits and certain services before the plan will pay for them.

A plan that contracts with a network of providers at negotiated rates but still pays benefits for out-of-network care, usually with higher deductibles, coinsurance, and a separate out-of-network maximum.

A hybrid arrangement in which members may use an in-network gatekeeper for the richest benefits or self-refer to out-of-network providers at a reduced benefit level, often after meeting a separate deductible.

A physician, hospital, or other clinician who has signed a contract with a plan to accept its negotiated rates and abide by its administrative rules, such as prior authorization and non-discrimination requirements.

The process a plan uses to verify a provider's license, training, malpractice history, and other qualifications before admitting the provider to its network and periodically thereafter.

A requirement that the plan approve a service in advance before it will be covered, used to confirm medical necessity and steer care toward appropriate settings and providers.

The set of review techniques a plan uses to evaluate whether care is medically necessary and appropriate, including pre-service review, concurrent review during a hospital stay, and retrospective claims review.

A coordinated approach in which a nurse or social worker helps members with complex or high-cost conditions navigate care, arrange services, and follow treatment plans to improve outcomes and control spending.

A population-based program that identifies members with chronic conditions and provides education, monitoring, and coaching intended to prevent complications and reduce avoidable hospital use.

A network-based plan that pays for care only from contracted providers, like an HMO, but typically does not require a gatekeeper or referrals for specialist care.

Rules that determine which of two or more health plans pays first when a person is covered by more than one, preventing duplicate payment and limiting total reimbursement to the covered expense.

The hospital insurance portion of original Medicare, covering inpatient hospital stays, skilled nursing facility care after a qualifying stay, hospice, and some home health services, subject to benefit periods and cost sharing.

The medical insurance portion of original Medicare, covering physician services, outpatient care, durable medical equipment, and preventive services, financed largely by premiums and general revenue.

The unit of time Medicare Part A uses to measure inpatient hospital coverage, beginning with admission and ending after a set number of days without inpatient care; a new period resets the deductible.

A private plan option under Medicare Part C that delivers Part A and Part B benefits, and often Part D, through a contracted network in exchange for a fixed monthly payment per enrollee.

A Medicare Advantage plan limited to specific eligible groups, such as people dually eligible for Medicare and Medicaid, institutionalized individuals, or those with certain severe chronic conditions.

A person enrolled in both Medicare and Medicaid, for whom Medicaid may pay Medicare premiums and cost sharing and may cover services Medicare does not, depending on the person's eligibility category.

Quality scores Medicare assigns to Medicare Advantage and Part D plans based on clinical, member experience, and administrative measures; high ratings can earn bonuses and influence enrollment choices.

The yearly window, generally in the fall, when Medicare beneficiaries may enroll in, switch, or disenroll from Medicare Advantage and Part D plans, with coverage typically starting the following January.

The statutory rules that make Medicare the secondary payer when another plan, such as employer group coverage based on current employment, is primary for a beneficiary's care.

A set of state-administered programs that help low-income Medicare beneficiaries pay Part B premiums and, in some categories, deductibles and coinsurance.

A tax-advantaged account available to people enrolled in a qualifying high-deductible health plan, funded with employee or employer contributions and used for qualified medical expenses; unused balances roll over.

A plan meeting statutory minimum deductible and maximum out-of-pocket limits, which is a prerequisite for making or receiving health savings account contributions.

An employer-funded account that reimburses employees for qualified medical expenses; it is owned by the employer, and unused funds generally may be carried forward at the employer's discretion.

An employer-sponsored account funded with pre-tax employee salary reductions for qualified expenses; it is subject to use-it-or-lose-it rules unless the employer adopts a carryover or grace period.

Individually purchased private coverage that pays some or all of original Medicare's deductibles, coinsurance, and copayments; it cannot be combined with a Medicare Advantage plan.

A protected window in which an insurer must sell a Medigap policy regardless of the applicant's health history, such as the six months after a person first enrolls in Part B at age 65 or later.

The insurer's evaluation of an applicant's health status, history, and risk factors to decide whether to issue coverage and at what premium, used in most Medigap sales outside protected periods.

A temporary policy with a fixed maximum term that is not required to meet all Affordable Care Act market rules, so it may exclude pre-existing conditions and offer narrower benefits.

Traditional fee-for-service coverage that pays a set share of covered charges without a provider network or gatekeeper, leaving the member responsible for charges above the allowed amount.

The waiting period at the start of a disability or long-term care claim during which no benefits are payable; it functions like a time deductible before the benefit stream begins.

A disability policy standard that pays benefits when the insured cannot perform the material duties of their own specific occupation, even if they could work in another field; it is the most favorable definition for claimants.

A stricter disability standard that pays only when the insured cannot perform the duties of any occupation for which they are reasonably suited by training, education, or experience.

A partial benefit paid when an insured returns to work at reduced hours or income because of a covered disability, typically calculated in proportion to the lost earnings.

Basic self-care tasks such as bathing, dressing, eating, toileting, transferring, and continence, used as triggers for long-term care benefits when a person cannot perform a specified number of them.

A long-term care benefit trigger based on a diagnosed deterioration or loss of intellectual capacity, such as dementia, that requires substantial supervision to protect the person from threats to health and safety.

Coverage that pays for custodial and personal care services, such as nursing home, assisted living, or home care, when the insured meets benefit triggers and the elimination period.