Glossary of Key Health Reform Terms

 

Annual Benefit Limit: Insurers place a ceiling on the amount of claims they will pay in a given year for an individual.   Individuals would then have to pay the full cost for any claims incurred above this ceiling during the course of year. Beginning in 2010, annual benefit limits will be restricted and will be prohibited in 2014 under health reform.

 

Case Management: The process of coordinating medical care provided to patients with specific diagnoses or those with high health care needs. These functions are performed by case managers who can be physicians, nurses or social workers

 

Chronic Care Management: The coordination of both health care and supportive services to improve the health status of patients with chronic conditions such as diabetes and asthma. These programs focus on evidence-based interventions and rely on patient education to improve patients’ self-management skills. The goals of these programs are to improve the quality of health care provided to these patients and to reduce costs.

 

Community Living Assistance Services and Supports (CLASS) program: The CLASS program establishes a national voluntary insurance program for purchasing non-medical services and supports necessary for individuals with functional limitations to maintain community residence. Enrollment will begin Jan 1, 2011 and will target working adults who will be able to make voluntary premium contributions either through payroll deductions through their employer or directly.

 

Employer Health Care Tax Credit: An incentive mechanism designed to encourage employers to offer health insurance to their employees. The tax credit enables employers to deduct an amount, usually a percentage of the contribution they make toward their employees premiums, from the federal taxes they owe.

 

Grandfathered Plan: A health plan that was in place on March 23, 2010 when the health reform law was enacted is exempt from complying with some parts of the health reform law.

 

Health Care Cooperative (CO-OP): A non profit member-run health insurance organization, governed by a board of directors elected by its members. Co-ops provide insurance coverage to individuals and small business and can operate at state, regional and national levels.

 

Health Insurance Exchange/Connector: An arrangement through which insurers offer smaller employers and individuals health insurance plans for purchase. Individuals and small employers will be able to select their coverage within this organized arrangement.

 

Health insurance Portability and Accountability Act of 1996 (HIPAA): Through the HIPPAA, individuals can maintain coverage while changing jobs or for a temporary period of unemployment without a waiting period. Individuals in many states who lose group health coverage after a loss of employment have access to coverage through high risk pools with no-preexisting condition exclusion periods. HIPAA also sets standards that address these security and privacy of personal health data

 

High Risk Pool: State programs designed to provide health insurance to residents who are considered medically uninsurable and are unable to buy coverage in individual markets. The health reform law creates temporary high risk pools in each state (referred to the as the Pre-existing Condition Insurance Plan) to provide coverage for those with pre-existing conditions who are uninsured. These temporary pools will provide coverage until 2014.

 

Lifetime Benefit Maximum: A cap on the amount of money insurers will pay toward the cost of health care services over the lifetime of insurance policy. Lifetime benefit maximums are prohibited under health reform.

 

Pre-existing Condition Exclusions: It is an exclusion from coverage of an illness or medical condition for which a person had received a diagnosis or treatment within a specified period of time, prior to becoming insured. Health care providers can exclude benefits for a defined period of time for the treatment of medical conditions that they determine to have existed within a specific period prior to the beginning of coverage. Pre-existing condition exclusions are prohibited by the health reform law beginning 2010 for children and 2014 for adults.

 

Credits: This list was compiled from Kaiser Family Foundation

 

Websites

National Government Website

Family Voices

Kaiser Family Foundation

Georgia Health Policy

Spinal Cord Advocates  

 

Families USA