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Health Reform Terminology
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A
Auto Enrollment: The automatic assignment of a person to a health insurance plan, typically done under Medicaid plans.
B
Benefit Mandates: Benefits that health plans are required by law to provide.
C
Community Rating: Setting insurance rates based on the average cost of providing health services to all people in a geographic area, without adjusting for each individual's medical history or likelihood of using medical services. With community rating, premiums do not vary for different groups of subscribers or with such variables as the group's claims experience, age, sex or health status. The intent of community rating is to spread the cost of illness evenly over all subscribers.
Comprehensive Reform: Health insurance reform that incorporates multiple reform interventions with the goal of significantly increasing access to insurance for a segment of the population.
Crowd Out: A phenomenon that occurs when the government increases access to health insurance through public programs, decreasing enrollment in, or "crowding out" private health insurance. Crowd out occurs because public insurance becomes cheaper than private insurance for some people.
D
Defined Contribution Plan: Employer-sponsored health insurance plans that involve employer funding of a fixed (as opposed to variable) dollar amount for health benefits, which employees may then use to purchase benefits from an employer arranged funding mechanism. The benefits could either be group benefits packaged and arranged by the employer, or purchased individually by the employees.
E
ERISA: The Employee Retirement and Income Security Act (1974) provided options for employers to self-fund health benefits and supersedes any states laws that relate to employee benefit plans. Therefore, there is no state authority for self-insured plans.
I
Insurance Connector/Exchange: A purchasing mechanism connecting individuals and employers with affordable insurance products. Typically, connectors target small businesses and individuals with the goals of simplyfing administrative functions for employers, pooling risk over a broader group, ensuring that insurance coverage is portable across jobs, and allowing individuals working multiple jobs to pool employer contributions to purchase one plan. If paired with a Section 125 or "cafeteria plan", individuals can purchase coverage through a connector with tax free dollars.
M
Mandates: State law requiring offer or purchase of health insurance. Mandates may be employer mandates to offer coverage or individual mandates. Hawaii is the only state with employer mandate and an official ERISA exemption. Massachusetts is the first state to have an individual mandate requiring all citizens (except for children) to have coverage. The mandate is enforced through a tax penalty for not having certified coverage.
P
Premium Assistance: Premium assistance programs use public funding to subsidize the purchase of private health insurance (typically employer-sponsored insurance).
Public Program Expansions: Expansion of Medicaid/SCHIP through Section 1115 Waivers and Health Insurance Flexibility and Accountability (HIFA) waivers, etc.
Public Reinsurance: Reinsurance refers to insurance for the insurer, or the entity that assumes the risk of health expenses for the insured. In this case, private insurers/carriers cede some of their risk to the state, thereby reducing the need for reserves and surpluses to be built into the premiums, resulting in potentially lower premiums and increased access.
Purchasing Pools: Purchasing pools aggregate a large number of otherwise single or small group purchasers with the goal of decreasing costs, spreading risk and increasing access by realizing economies of scale. Most state initiated purchasing pools focus on small employers or high risk individuals.
R
Rate Bands: The allowable variation in insurance premiums as defined in state regulations. Acceptable variation may be expressed as a ratio from highest to lowest (eg, 3:1) or as a percent from the community rate (eg, +/-20%). Rate bands are usually based on risk factors such as age, gender, occupation or residence.
Reform: To put into a better form or condition by improving, altering, correcting error, or removing defects.
- The principle focus of SHARE will be current or recent state health reform initiatives that seek to enhance access to health insurance coverage
- Unique and innovative reform approaches that address health care cost and access may also be considered
- Broad health care access reform initiatives will be considered but the components of the reform and their evaluation must be clearly delineated in the grant proposal
S
Section 125 or "cafeteria plan": An employee benefit arrangement allowed by Internal Revenue Code Section 125, under which employees are allowed to pay for certain employee benefits, such as health insurance and some medical spending, on a pre-tax rather than an after-tax basis.
T
Tax Credits: Health insurance tax credits come in the form of a tax credit or refund for individuals who purchase health insurance on their own and are not eligible for public programs and not offered or eligible for employer sponsored insurance. Tax credits can also be given to businesses (typically small businesses) that provide and contribute towards health insurance for their employees.
Three-Share Programs/Multi-Share Programs: Financing arrangements in which employers and employees each pay 30 percent of the cost of the program, and the community pays the remainder. In "multi-share" programs, there may be more than three financial contributors, and each may contribute a different amount. Three-share and multi-share programs are aimed at employers with low-wage work forces that do not currently provide health benefits to employees. The scope of benefits under three share programs is typically limited and involves a closed, local provider network. However, the plans are often more comprehensive than some "bare bones" plans, and include an inpatient benefit as well as coverage for ambulatory services and prescription drugs. By dividing the financial responsibility, this program offers affordable premiums for all parties involved. States currently using three-share programs include: Illinois, Michigan, New Mexico and Oklahoma.
U
Universal Coverage: most states define universal coverage as health insurance coverage for all residents. Some define universal coverage as universal access to coverage or universal access to affordable coverage. Many states use a defined threshold (Massachusetts: 95%; Minnesota: 96% (Minnesota Statute 62Q.165); Vermont: 96%). Other states define target populations (Rhode Island:100% of citizens under 65 years of age; universal coverage for kids).
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