Understanding Healthcare Reform

Understanding Healthcare Reform
Basic Terms and Definitions
payerfusion.com/ceos-blog

A Access to Health Services A persons or populations ability to engage in healthcare services and coverage, which are a) geographically proximate, b) physically accessible (for people with limited mobility), c) temporally (timing) appropriate d) socioculturally consistent, and e) without financial barriers. Accountable Care Organization (ACO) A care-delivery model in which physicians, specialists, and hospitals are aligned in providing efficient and effective care for a patient population. Instead of the present fragmented, fee-for-service delivery of care, this model emphasizes collaboration of providers accountable for the health status and outcomes of care provided to their panel of patients. Accreditation Certification that an organization meets the reviewing organizations standards. Examples: National Committee on Quality Assurance (NCQA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO). Actuarial Justification The demonstration by an insurer that the premiums collected are reasonable, given the benefits provided under the plan or that the distribution of premiums among policyholders are proportional to the distribution of their expected costs, subject to limitations of state and federal law. PPACA requires insurers to publicly disclose the actuarial justifications behind unreasonable premium increases. Adjudication The administrative procedure used to process a claim for service according to the covered benefit. Adjusted Community Rating A way of pricing insurance where premiums are not based upon a policyholders health status, but may be based upon other factors, such as age and geographic location. PPACA requires the use of adjusted community rating, with maximum variation for age of 3:1 and for tobacco use of 1.5:1. Administrative Services Only (ASO) An arrangement in which a licensed insurer provides administrative services to an employers health benefits plan (such as processing claims), but doesnt insure the risk of paying benefits to enrollees. In an ASO arrangement, the employer pays for the health benefits. Annual Limit Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. PPACA prohibits annual limits for essential benefits for plan years beginning after Sept. 23, 2010.
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B Balance billing When you receive services from a health care provider that does not participate in your insurers network, the health care provider is not obligated to accept the insurers payment as payment in full and may bill you for unpaid amount. This is known as balance billing. Benchmarking A way for hospitals and doctors to analyze quality data, both internally and against data from other hospitals and doctors, to identify best practices of care and improve quality. Bending the Curve Healthcare cost trends in the United States are two to three times greater than inflation and are therefore unsustainable. This popular phrase describes current efforts to promote health and wellbeing as well as a more effective and efficient healthcare delivery system that will thereby slow the growth in healthcare spending. Bundled Payments/Episodic Payments A bundled payment is a single, standardized comprehensive payment that covers all services provided to a patient during an episode of care for a procedure or an acute or chronic condition. C Cadillac Tax The Cadillac Tax is a 40 percent excise tax on healthcare premiums (employer + employee) that is placed on employers for premiums that exceed $10,200 for individual coverage and $27,500 for family coverage. The Cadillac Tax is part of the Patient Protection and Affordable Care Act and is slated to go into effect on January 1 in 2018. Care Continuum The care continuum describes the full range of services that a patient may encounter from prenatal care prior to birth to palliative services at end of life. This term also recognizes that care is provided across the full spectrum of healthcare delivery including outpatient, inpatient, home care, rehabilitation, nursing, virtual, and pre- and post-acute care settings. Center for Medicare and Medicaid Innovation (CMMI) The CMMI was established to test new healthcare delivery and payment models. The threefold focus of the CMMI is to help find better ways to care for individuals, better overall health and reduced costs. The initial focus will be on patient-centered medical homes, advanced primary care practice within community health centers, and comprehensive treatment practices for dual (Medicare and Medicaid) eligibles. CHIP The Childrens Health Insurance Program (CHIP) provides coverage to low- and moderate-income children. Like Medicaid, it is jointly funded and administered by the states and the federal government. It was originally called the State Childrens Health Insurance Program (SCHIP).

Clinical Decision Support These are computerized tools that incorporate informationgathering, as well as monitoring and delivery systems, to ensure optimal decision-making on the part of the treating clinician. They assist physicians and other providers at the point of care to follow evidence-based guidelines and improve healthcare outcomes. COBRA Coverage Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The law generally covers health plans maintained by privatesector employers with 20 or more employees, employee organizations, or state or local governments. Many states have mini-COBRA laws that apply to the employees of employers with less than 20 employees. Coinsurance A percentage of a health care providers charge for which the patient is financially responsible under the terms of the policy. Community Rating A way of pricing insurance, where every policyholder pays the same premium, regardless of health status, age or other factors. Comparative Effectiveness Research Presently most research compares a treatment or intervention to a placebo or doing nothing. There are few studies that compare multiple approaches to medical concerns. Comparative Effectiveness Research addresses this problem. According to the Department of Health and Human Services, Comparative effectiveness research is the conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions. The purpose of comparative effectiveness research is to inform patients, providers, and decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances. Computerized Physician Order Entry Computerized Physician Order Entry (CPOE) is the electronic entry of medical practitioner instructions for services, tests, and treatments of patients into a computerized system that relays the orders to the appropriate party such as a hospital pharmacists or blood-draw lab. These systems can be used for care orders, prescriptions, lab tests, and radiological orders. Consumer-Driven (or Directed) Care A form of health insurance that combines a highdeductible health plan with a tax-favored Health Savings Account, Flexible Spending Account or Health Reimbursement Account to cover out-of-pocket expenses. These accounts are consumer-driven in that they give participants greater control over their own health care, allowing individuals to determine on a personal basis how they choose to spend their health care account funds. Co-Op Plan A health insurance plan that will be sold by member-owned and operated non-profit organizations through Exchanges when they open in 2014. PPACA provides grants and loans to help Co-Op plans enter the marketplace.

Co-payment A flat-dollar amount which a patient must pay when visiting a health care provider. Cost-sharing Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance and co-payments. Balance-billed charges from out-ofnetwork physicians are not considered costsharing. PPACA prohibits total cost-sharing exceed $5,950 for an individual and $11,900 for a family. These amounts will be adjusted annually to reflect the growth of premiums. Coverage Limits A health insurance plan has been able dictate the maximum number of dollars spent on benefits per individual/family/policy, and these restrictions come in two forms annual and lifetime. Culture of Health This is an ideological transformation of an organizations culture that passively accepts rising, unsustainable healthcare costs to a proactive entity that encourages the holistic wellbeing of each of its employees. Such organizations integrate the health status of their workforce into their mission and vision statements and require all of their employees to be accountable for their health. D Deductible The amount of money a patient must pay for health care services before an insurance company will make a payment. This amount is predetermined by your insurance company based on your policy and usually due every calendar year. Demonstration Projects These are federally funded efforts to test and evaluate care delivery, cost reduction, health improvement, and payment reform models. The goal of these projects is to develop new, effective methodologies for care and payment, which can be expanded to a broader, perhaps national, scope. The Affordable Care Act has several funded pilots dealing with innovations such as the bundled payment model and programs for chronically ill Medicare beneficiaries using home-based teams. Note that demonstration project opportunities have been ongoing for years and are not solely tied to recent legislation. Department of Health and Human Services The U.S. governments principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. Disease Management Disease management programs address the needs of population cohorts affected by chronic illnesses to reduce their medical costs and the deleterious effects of these conditions. A successful effort involves an effective way to identify worthy patients and engage them to fully participate in evidence-based interventions that produce measurable improvements in care, reduced costs, and perceived value.

E Early Retiree Reinsurance Program The Early Retiree Reinsurance Program (ERRP) is a temporary $5 billion program established by the Patient Protection and Affordable Care Act. Its purpose is to help businesses and unions cover the healthcare costs of Medicare-ineligible early retirees, their spouses, and other dependents. It provides 80 percent of claims costs for benefits between $15,000 and $90,000 starting with the 2010 calendar year. Electronic Medical Record/Electronic Health Record Electronic medical records (EMRs) and electronic health records (EHRs) are computerized records maintained centrally by a medical practice or health center to keep track of patient care. EMRs are electronic versions of a patients paper medical chart and maintain a patients medical history over time, including patient demographics, clinical notes, prescriptions and registries, web applications, and connection to personal health records kept by patients. They are usually constructed so the data can be part of other systems such as clinical workflow and decision support and possess the ability to safely exchange health information between entities such as collaborating providers. Employer Mandate/Pay or Play This Patient Protection and Affordable Care Act mandate requires employers to either offer minimal levels of health insurance coverage to their employees or pay a fine, which in turn will subsidize health insurance for those without access. This part of the health reform law will go into effect for plan years beginning on or after 1/1/2014 and for employers with 50 or more full-time employees who choose not to provide group coverage and have at least one employee obtaining federally subsidized coverage through a health insurance exchange. EOB (Explanation of Benefits) Explanation of payments sent to the provider and policyholder by the insurance company. E-prescribing According to the Centers for Medicare and Medicaid, e-prescribing is, a prescribers ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care. Studies have demonstrated that replacing handwritten prescriptions with this electronic transmission greatly reduces medication errors. ERISA The Employee Retirement Income Security Act of 1974 (ERISA) is a comprehensive and complex statute that federalizes the law of employee benefits. ERISA applies to most kinds of employee benefit plans, including plans covering health care benefits, which are called employee welfare benefit plans. Essential Benefits PPACA requires all health insurance plans sold after 2014 to include a basic package of benefits including hospitalization, outpatient services, maternity care, prescription drugs, emergency care and preventive services among other benefits. It also places restrictions on the amount of cost-sharing that patients must pay for these services.

Evidence-Based Medicine Much of the care delivered today has been simply based on expert opinion. Evidence-Based Medicines (EBM)s charge is to deliver care that has strong scientific validation. Ideally this term refers to the synthesis of individual, first-hand clinical experience with evidence garnered by external systematic research to create best practices in care delivery. It involves the interested clinician or organization asking a specific care question and then proceeding to systematically review published research to find practices backed by concrete data. Exchange PPACA creates new American Health Benefit Exchanges in each state to assist individuals and small businesses in comparing and purchasing qualified health insurance plans. Exchanges will also determine who qualifies for subsidies and make subsidy payments to insurers on behalf of individuals receiving them. They will also accept applications for other health coverage programs such as Medicaid and CHIP. Expanded Coverage A significant goal of the Affordable Care Act is near universal coverage. To accomplish this, a mandate requiring most U.S. citizens and legal residents to have health insurance is included. There are individual regulations that support this initiative by: Expanding Medicaid coverage Removing bans on coverage of individuals with pre-existing conditions Setting required groundwork for the formation of state-based health insurance exchanges Supplying assistance for individuals to procure insurance Expanding coverage of dependents up to age 26 External Review The review of a health plans determination that a requested or provided health care service or treatment is not or was not medically necessary by a person or entity with no affiliation or connection to the health plan. PPACA requires all health plans to provide an external review process that meets minimum standards. F Formulary The list of drugs covered fully or in part by a health plan. G Global Payments (Global Capitation) Global payments (global capitation) are fixed payments for which providers are given a pre-specified amount per patient (dependent on demographic data and other considerations) for a time period such as a month or a year. This payment schema places the burden of risk on the provider who will be responsible for delivering comprehensive acute, chronic, and preventive care during that time period for that all-inclusive payment.

Grandfathered Plan A health plan that an individual was enrolled in prior to March 23, 2010. Grandfathered plans are exempted from most changes required by PPACA. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans. Group Health Plan An employee welfare benefit plan that is established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement or otherwise. Guaranteed Issue A requirement that health insurers sell a health insurance policy to any person who requests coverage. PPACA requires that all health insurance be sold on a guaranteed-issue basis beginning in 2014. Guaranteed Renewability A requirement that health insurers renew coverage under a health plan except for failure to pay premium or fraud. HIPAA requires that all health insurance be guaranteed renewable. H Health Information Exchange and Interoperability A Health Information Exchange (HIE) is an initiative focused on the electronic exchange of healthcare data between healthcare stakeholders. The exchange typically includes clinical, administrative, and financial data across a medical care and coverage area. Interoperability refers to the ability to connect to two or more disparate systems, for example, a disease registry and a payer claims database, for the sharing of permissible secure information via standardized protocols and exchanges. Health Maintenance Organization (HMO) A type of managed care organization (health plan) that provides health care coverage through a network of hospitals, doctors and other health care providers. Typically, the HMO only pays for care that is provided from an innetwork provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan. Health Savings Account (HSA) The Medicare bill signed by President Bush on Dec. 8, 2003 created HSAs. Individuals covered by a qualified high deductible health plan (HDHP) (and have no other first dollar coverage) are able to open an HSA on a tax preferred basis to save for future qualified medical and retiree health expenses. High Deductible Health Plan (HDHP) A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower. In 2010, an HSAqualifying HDHP must have a deductible of at least $1,200 for single coverage and $2,400 for family coverage. The plan must also limit the total amount of out-of-pocket costsharing for covered benefits each year to $5,950 for single coverage and $11,900 for families.

High Risk Pool A state-subsidized health plan that provides coverage for individuals with pre-existing health care conditions who cannot purchase it in the private market. PPACA creates a temporary federal high risk pool program, which may be administered by the states, to provide coverage to individuals with pre-existing conditions who have been uninsured for at least 6 months. HIPAA (Health Insurance Portability and Accountability Act of 1996) The federal law enacted in 1996 which eased the job lock problem by making it easier for individuals to move from job to job without the risk of being unable to obtain health insurance or having to wait for coverage due to pre-existing medical conditions. Hospital Value-Based Purchasing/Pay for Performance These programs are established to reward providers of care for better results. They require the care-providing organizations have a system of accurate measurements to gauge performance (i.e., a hospital measuring readmission rates). If the organization achieves established goals set by a program sponsor, the organization receives an incentive payment. Organizations can also receive lower remunerations for poor outcomes. I Individual Coverage Market For people unable to receive health coverage through their employer or the government, the Affordable Care Act legislation will create a competitive marketplace for buying coverage from insurers at the state-specific level. Individual Mandate A requirement that everyone maintain health insurance coverage. PPACA requires that everyone who can purchase health insurance for less than 8% of their household income do so or pay a tax penalty. Individual Market The market for health insurance coverage offered to individuals other than in connection with a group health plan. PPACA makes numerous changes to the rules governing insurers in the individual market. In-Network Provider A health care provider (such as a hospital or doctor) that is contracted to be part of the network for a managed care organization (such as an HMO or PPO). The provider agrees to the managed care organizations rules and fee schedules in order to be part of the network and agrees not to balance bill patients for amounts beyond the agreed upon fee. Integrated Healthcare Delivery System An integrated delivery system (IDS) is a network of healthcare providers and organizations that provide or arrange to provide a coordinated continuum of services. Services provided by an IDS can include a fully equipped community and/or tertiary hospital, home healthcare and hospice services, primary and specialty outpatient care and surgery, social services, rehabilitation, preventive care, and health education.

Internal Review The review of the health plans determination that a requested or provided health care service or treatment health care service is not or was not medically necessary by an individual(s) associated with the health plan. PPACA requires all plans to conduct an internal review upon request of the patient or the patients representative. Interstate Compact An agreement between two or more states. PPACA provides guidelines for states to enter into interstate compacts to allow health insurance policies to be sold in multiple states. J Job Lock The situation where individuals remain in their current job because they have an illness or condition that may make them unable to obtain health insurance coverage if they leave that job. PPACA would eliminate job lock by prohibiting insurers from refusing to cover individuals due to health status. L Lifetime Limit Many health insurance plans place dollar limits upon the claims that the insurer will pay over the course of an individuals life. PPACA prohibits lifetime limits on benefits beginning with on Sept. 23, 2010. Limited Benefits Plan A type of health plan that provides coverage for only certain specified health care services or treatments or provides coverage for health care services or treatments for a certain amount during a specified period. M Mandated Benefit A requirement in state or federal law that all health insurance policies provide coverage for a specific health care service. Meaningful Use The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH Act) is part of the American Recovery and Reinvestment Act (ARRA) which included funding for Medicare and Medicaid incentives for the Meaningful Use (MU) of certified electronic health records (EHRs). The intent of the legislation is to promote the use of EHR technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their healthcare Enhance care coordination Support population and public health

Medicaid A joint state and federal program that provides health care coverage to eligible categories of lowincome individuals. Rules for eligible categories (such as children, pregnant women, people with disabilities, etc), and for income and asset requirements, vary by state. Coverage is generally available to all individuals who meet these state eligibility requirements. Medicaid often pays for long-term care (such as nursing home care). PPACA extends eligibility for Medicaid to all individuals earning up to $29,326 for a family of four. Medical Loss Ratio This is the fraction of the collected insurance premium revenue dedicated to providing health services and improving the quality of care compared to the total revenue that includes expenditure for business administration, marketing, and profit. Medicare A federal government program that provides health care coverage for all eligible individuals age 65 or older or under age 65 with a disability, regardless of income or assets. Eligible individuals can receive coverage for hospital services (Medicare Part A), medical services (Medicare Part B), and prescription drugs (Medicare Part D). Together, Medicare Part A and B are known as Original Medicare. Benefits can also be provided through a Medicare Advantage plan (Medicare Part C). Medicare Advantage An option Medicare beneficiaries can choose to receive most or all of their Medicare benefits through a private insurance company. Also known as Medicare Part C. Plans contract with the federal government and are required to offer at least the same benefits as original Medicare, but may follow different rules and may offer additional benefits. Unlike original Medicare, enrollees may not be covered at any health care provider that accepts Medicare, and may be required to pay higher costs if they choose an out-ofnetwork provider or one outside of the plans service area. Medicare Drug Coverage Gap/Donut Hole This is a voluntary medication benefit program that started in 2006. Participants with a standard plan have 75 percent of their drug costs covered until they reach a cost of $2,830. Any expense higher than this is paid out of pocket until the cost reaches $4,550. Once costs reach this amount, 95 percent of costs are covered by Medicare. O Open Enrollment Period A specified period during which individuals may enroll in a health insurance plan each year. In certain situations, such as if one has had a birth, death or divorce in their family, individuals may be allowed to enroll in a plan outside of the open enrollment period. Out-of-Network Provider A health care provider (such as a hospital or doctor) that is not contracted to be part of a managed care organizations network (such as an HMO or PPO). Depending on the managed care organizations rules, an individual may not be covered at all or may be required to pay a higher portion of the total costs when he/she seeks care from an out-of-network provider.
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Out-of-Pocket Limit An annual limitation on all costsharing for which patients are responsible under a health insurance plan. This limit does not apply to premiums, balancebilled charges from out of network health care providers or services that are not covered by the plan. PPACA requires out-of-pocket limits of $5,950 per individual and $11,900 per family, beginning in 2014. These amounts will be adjusted annually to account for the growth of health insurance premiums. P Patient Protection and Affordable Care Act (PPACA) Legislation (Public Law 111-148) signed by President Obama on March 23, 2010. Commonly referred to as the health reform law. Patient Registry To deliver the most appropriate care to specific cohorts within a population, providers are encouraged to keep lists of patients who have common conditions or concerns. These registries can be paper-based or preferably computerized. With these lists, physicians and other providers can institute disease or condition management programs for patients with illness burdens or track others for their completion of appropriate screenings, for example. Patient Safety The domain dedicated to preventing and reducing the harm that may be caused during a patients interaction with the medical system. This can help improve healthcare outcomes while reducing costs. Payment Integrity Payment integrity is the process by which the correct payments for the correct covered lives, for the correct services are paid to the correct provider(s). This process involves detecting and minimizing fraud, waste, abuse, and misuse of healthcare dollars. Personal Health Record A personal health record (PHR) is a patients healthcare profile. Unlike an electronic medical record or electronic health record, these data are collected and maintained by the individual. In the future, PHRs will be electronically connected to provider EHRs for secure and private exchange of approved information. Pre-existing Condition Exclusion The period of time that an individual receives no benefits under a health benefit plan for an illness or medical condition for which an individual received medical advice, diagnosis, care or treatment within a specified period of time prior to the date of enrollment in the health benefit plan. PPACA prohibits pre-existing condition exclusions for all plans beginning January 2014. Preferred Provider Organization (PPO) A type of managed care organization (health plan) that provides health care coverage through a network of providers. Typically the PPO requires the policyholder to pay higher costs when they seek care from an out-of-network provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan.
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Premium The periodic payment required to keep a policy in force. Preventive Benefits Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. PPACA requires insurers to provide coverage for preventive benefits without deductibles, copayments or coinsurance. Price Transparency The process of collecting and reporting health care cost, performance and quality data in a format that can be accessed by consumers to make a decision based on quality and cost of health care services at a variety of outlets and is intended to improve the delivery of services and ultimately improve the health care system as a whole. R Rate Review Review by insurance regulators of proposed premiums and premium increases. During the rate review process, regulators will examine proposed premiums to ensure that they are sufficient to pay all claims, that they are not unreasonably high in relation to the benefits being provided, and that they are not unfairly discriminatory to any individual or group of individuals. Reinsurance Insurance purchased by insurers from other insurers to limit the total loss an insurer would experience in case of a disaster or unexpectedly high claims. PPACA directs states to create temporary reinsurance programs to stabilize their individual markets during the implementation of health reform. Rescission The process of voiding a health plan from its inception usually based on the grounds of material misrepresentation or omission on the application for insurance coverage that would have resulted in a different decision by the health insurer with respect to issuing coverage. PPACA prohibits rescissions except in cases of fraud or intentional misrepresentation of a relevant fact. Risk Adjustment A process through which insurance plans that enroll a disproportionate number of sick individuals are reimbursed for that risk by other plans who enroll a disproportionate number of healthy individuals. PPACA requires states to conduct risk adjustment for all non-grandfathered health insurance plans. Risk Corridor A temporary provision in PPACA that requires plans whose costs are lower than anticipated to make payments into a fund that reimburses plans whose costs are higher than expected. Risk Pool If individuals had to pay for their healthcare costs each year without insurance, some families would become bankrupt when faced with a catastrophic illness and a very large medical bill. The insurance industry was born to help large groups of people share the risk burden each year. Each participant bears only a fraction of the total risks and costs through premium insurance payments by joining the risk pool.
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S Self-Insured Group health plans may be self-insured or fully insured. A plan is self-insured (or self-funded), when the employer assumes the financial risk for providing health care benefits to its employees. A plan is fully insured when all benefits are guaranteed under a contract of insurance that transfers that risk to an insurer. Small Group Market The market for health insurance coverage offered to small businesses those with between 2 and 50 employees in most states. PPACA will broaden the market to those with between 1 and 100 employees. Solvency The ability of a health insurance plan to meet all of its financial obligations. State insurance regulators carefully monitor the solvency of all health insurance plans and require corrective action if a plans financial situation becomes hazardous. In extreme circumstances, a state may seize control of a plan that is in danger of insolvency. T Telehealth Telehealth is the practice of using electronic information systems with telecommunications technology to support the long-distance delivery of care. The practice of telehealth gives care providers the ability to diagnose, receive, and transfer appropriate health data, address questions, provide information, and oversee treatments and therapies for patients who are difficult to care for face to face (i.e., location). The Patient-Centered Medical Home A Patient-Centered Medical Home (PCMH) is a model of care by which a personal primary care physician, who has an ongoing trusted relationship with a patient, provides comprehensive and continuous care with care coordination to meet the patients multiple care needs including: wellness, risk reduction, preventive services, as well as acute, chronic, and end-of-life care. This model focuses on improving accessibility, comprehensiveness, collaboration, record-keeping, patient safety, and the quality of care for the patients treated within them. U Usual, Customary and Reasonable Charge (UCR) The cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic area. Reimbursement for out-of-network providers is often set at a percentage of the usual, customary and reasonable charge, which may differ from what the provider actually charges for a service.
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V Value-Based Insurance Design Recent studies demonstrate that health outcomes can be influenced by a patients insurance coverage and benefit policy. Therefore it is possible to design insurance packages that improve outcomes and add value. An example of this involves identifying effective clinical practices and reducing the financial barriers associated with those treatments and services encouraging greater adherence with care protocols. W Waiting Period A period of time that an individual must wait either after becoming employed or submitting an application for a health insurance plan before coverage becomes effective and claims may be paid. Premiums are not collected during this period.
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Understanding Healthcare Reform - Basic Terms & Definitions

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