CMS Presentations

• Overview of the Health Insurance Marketplace (October 2014)
  • Video Presentation
    
    
• American Indians and Alaska Natives in the Marketplace (March 2015)
  • Presenter Slides
    
    
• Overview of the SHOP Marketplace (January 2015)
  • Video Presentation
    
    

IHS 2013 Partnerships Conference (August 13 - 15)

• ACA and the AIAN Provisions 101
  • Presenter Slides
    
    
• ACA Enrollment and the Patient Experience on October 1, 2013
  • Presenter Slides
    
    
• ACA IHS Business Plan Template and Best Practices
  • Presenter Slides
    
    
• ACA Major Changes – Preparing the National, Area, and SUs
  • Presenter Slides
    
    
• Benefits Coordination – ACA Medicaid Expansion and Enrollment
  • Presenter Slides
    
    
• IPC – Medical Home Model Initiative ACA and Medicaid Expansion
  • Presenter Slides
    
    
• Network Provider Contracts Pricing Negotiation QHP Addendum Decision Making
  • Presenter Slides
    
    
• Third Party Billing Updates
  • Presenter Slides
    

• Report Examines the Role of Medicare and the Indian Health Service for American Indians and Alaska Natives
  • Article
    
    
• American Indian and Alaska Native Health Disparities Compared to Non-Hispanic Whites
  • Article
    
    

• To Access List of Common Acronyms Used in IHS, click here

This glossary aims to provide a brief explanation of a few commonly used health coverage terms. While this glossary is by no means comprehensive, we invite you to view HealthCare.Gov’s Glossary, and CMS’ Glossary of Health Coverage and Medical Terms for more information. There is an in-depth example showing how co-insurance, deductibles, and out-of-pocket limits work together in a real situation.

Please note that the definition of these terms may not have the exact meaning as when they are used in your health plan/policy and that the health plan/policy governs.

• Affordable Coverage (related to Advanced Premium Tax Credit): If an employee’s share of the annual premium for self-only coverage is no greater than 9.5% of the annual household income, employer coverage is considered affordable. Beginning in 2014, individuals offered coverage from their employer is affordable and provides minimum value will not be eligible for the Advanced Premium Tax Credit.
  
  
• Allowed Amount: Maximum amount that payment is based for covered health care services. This may also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
  
  
• Annual Deductible Combined:Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
  
  
• Annual Limit: A cap on the benefits your insurance company will pay in a year while you are enrolled in a specific health insurance plan. These caps are sometimes place on particular services such as hospitalizations or prescriptions. Annual limits may be placed as a dollar amount or as the number of visits that will be covered for a particular service. After an annual limit is reached, you are required to pay all associated health costs for the rest of that year.
  
  
• Benefits:The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
  
  
• Brand Name (Drugs):A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.
  
  
• Broker: A business or individual that can help you apply for paying for coverage and enroll in a health plan through the Marketplace. Brokers and agents can make specific recommendations about which plan you should enroll in. Brokers are licensed and regulated by states.
  
  
• Catastrophic Health Plan: To qualify for a catastrophic plan, you must be under 30 or have a hardship exemption. Catastrophic plans meet all requirements applicable to other QHPs (Qualified Health Plans) but do not cover any benefits other than three primary care visits annually before the plan’s deductible is met.
  
  
• Children’s Health Insurance Program (CHIP): Insurance program funded jointly by state/federal government that provides health coverage to low-income children and in some states, pregnant women in families that earn too much to qualify for Medicaid but cannot afford private health insurance coverage.
  
  
• Co-insurance: Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
  
  
• Co-payment: A fixed amount you pay for a covered health care service, usually when you receive the service. The amount varies by the type of covered health care service.
  
  
• Cost Sharing : The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
  
  
• Cost Sharing Reduction: A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. If you're a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits. If you're a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.
  
  
• Deductible: The amount you owe for health care services that your health insurance/plan cover before your health insurance or plan begins to pay. Example: If your deductible is $1,000, your plan will not pay anything until you’ve met your deductible for covered health services subject to the deductible. It may not apply to all services. 
  
  
• Dependent: A child or other individual that a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act (ACA), individuals may be able to claim a premium tax credit to help cover the coverage costs for themselves and their dependents.
  
  
• Eligibility Assessment:In certain states, the Marketplace doesn't provide the final decision on Medicaid eligibility. Instead, the Marketplace conducts an assessment and passes the application to the State Medicaid agency to conduct a final eligibility determination.
  
  
• Emergency Room Care: Emergency services you get in an emergency room.
  
  
• Employer Shared Responsibility Payment:The Affordable Care Act requires certain employers with at least 50 full-time employees (or equivalents) to offer health insurance coverage to its full-time employees (and their dependents) that meets certain minimum standards set by the Affordable Care Act or to make a tax payment called the ESRP.
  
  
• Essential Health Benefits: The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and facilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.
  
  
• Excluded Services: Health care services that your health insurance/plan does not cover or pay for.
  
  
• Federally Qualified Health Center (FQHC): Federally funded nonprofit health centers and clinics that serve medically underserved areas and populations. These health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on the ability to pay.
  
  
• Federally Recognized Tribe: Any Indian or Alaska Native tribe, band, nation, pueblo, village, or community that the Department of the Interior acknowledges to exist as an Indian tribe.
  
  • View the current list of federally recognized tribes click federally recognized tribes
    
    
• Generic Drug:A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
  
  
• Grandfathered: Exempt from certain provisions in the Affordable Care Act.
  
  
• Limited cost sharing plan: A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is above 300% of the federal poverty level. People enrolled in this type of plan: don’t pay co-payments, deductibles, or coinsurance when getting care through an Indian health care provider or when getting essential health benefits through a Marketplace plan; do need a referral from an I/T/U when getting essential health benefits through a Marketplace plan to avoid paying co-payments, deductibles, or co-insurance; can get limited cost sharing with a plan at any metal level on the Marketplace.
  
  
• Medicaid: A state-administered health insurance program for low-income families and children, the elderly, pregnant women, individuals with disabilities, and in some states, other adults. The Federal government provides part of the funding for Medicaid and sets overall guidelines for the program. States are able to design their program and as a result, it varies state by state.
  
  
• Medicare: A federal health insurance program for people who are 65 or older and younger people with disabilities.
  
  
• Minimum Value: A health plan meets this standard if it is designed to pay at least 60% of the total cost of medical services for a standard population.
  
  
• Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
  
  
• Non-Preferred Provider:  A provider that doesn’t have a contract with your health insurer/plan to provide you services. You’ll pay more to see a non-preferred provider.
  
  
• Open Enrollment Period: The period of time that eligible individuals can enroll in a Qualified Health Plan through the Marketplace.
  
  
• Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
  
  
• Out-of-Pocket Limit:The most you pay during a policy period (typically a year) before your insurance/plan begin to pay 100% of the allowed amount. This limit never includes your balance-billed charges, your premium, or health care that they do not cover.
  
  
• Plan: A benefit your employer, union, or other group sponsor provides to you to pay for your health care services.
  
  
• Pre-Existing Condition:A health problem you had before the date that new health coverage starts.
  
  
• Premium: The amount that must be paid for your health insurance/plan. Your and/or your employer usually pay it monthly, quarterly, or yearly.
  
  
• Prevention: Activities to prevent illness such as routine check-ups, patient counseling, screenings, and immunizations.
  
  
• Primary Care:Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advice and treat you on a range of health related issues. They may also coordinate your care with specialists.
  
  
• Primary Care Physician:A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
  
  
• Special Enrollment Period: A time outside of the open enrollment period during which you have the right to sign up for health coverage.
  
  
• UCR (Usual, Customary, and Reasonable):The amount for a medical service in a geographic area based on what providers in the area typically charge for the same or similar medical service. The UCR amount is sometimes used to determine the allowed amount.
  
  
• Zero Cost Sharing Plan:A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is at or below 300% of the federal poverty level. People enrolled in this type of plan: don’t pay co-payments, deductibles, or coinsurance when getting care from an Indian health care provider or when getting essential health benefits through a Marketplace plan; don’t need a referral from an Indian health care provider when getting essential health benefits through a Marketplace plan; can get zero costs sharing with a plan at any metal level on the Marketplace.