06-05-2020 Healthcare

Health Insurance and Medicaid Terms and Abbreviations

Health Insurance and Medicaid Terms and Abbreviations | America’s Pharmacy

Health Insurance Terms

Use this glossary for easy reference of common health insurance and Medicaid terms and abbreviations. 

Allowed Amount  

This is the maximum amount on which payment is based for all covered health care services. This might also be called an “eligible expense,” or a “payment allowance" or a "negotiated rate."


This is a request you make to your health insurer or health plan to review a decision has made or a grievance you have again.

Balance Billing

This is when a provider invoices you for the difference between a provider’s charge and an allowed amount. As an example, if a provider’s charge is $200 and the allowed amount is $170, the provider will bill you for the remaining $130.


This is your portion of the costs of a covered health care service, usually presented as a percent (for example, 18%) of the allowed amount for a service. You then pay the co-insurance plus any deductibles. As an example, if a health insurance allowed amount for a doctor’s office visit is $150 and you have already met your deductible, your co-insurance payment of 18% would be $27. Your health insurance will pay the rest of the allowed amount.


A fixed dollar amount ((an example might be $25) which you would pay for a covered health care service, generally at the time you receive the service. This amount can vary a lot by the type of covered health care service.


The dollar amount that you will need to pay for health care services that your health insurance or health plan covers before your health insurance or health plan begins to pay for services. As an example, if your deductible is $3,000, your health plan will not pay anything until you have spent your $3000 deductible for any covered health care services that are subject to the deductible. Please remember that the deductible might not apply to all services.

Durable Medical Equipment (DME)

This refers to equipment and supplies that are ordered by a health care provider to be used every day or for an extended period of time. These might include wheelchairs, oxygen equipment, testing strips for diabetics, or crutches.

Emergency Medical Condition

This is an illness, injury, symptom or existing condition that is so serious that a reasonable person will seek care right away to avoid harm.

Emergency Medical Transportation

Any ambulance service for an emergency medical condition.

Emergency Room Care

Emergency services one receives in an emergency room.

Emergency Services

This is evaluation of an emergency medical condition as well as treatment provided in an effort to prevent the condition from getting worse.

Excluded Services

Health care services that your health insurance or health plan does not cover or pay for.

Health Insurance

This is the name for a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium that you pay to them.

Home Health Care

Specifically, health care services that a person receives at home.

Hospice Services

A range of Services that is provided to comfort and support people (and their families) during the last stages of a terminal illness.

Hospital Outpatient Care

Care on received from a hospital that that does not require an overnight stay.

In-network Co-insurance

This is the percent (as an example, 25%) that you will pay of the allowed amount for covered health care services to providers who have contracts with your health insurance or health plan. As a rule of thumb, in-network co-insurance is more likely to cost you less than out-of-network co-insurance.

In-network Co-payment

This is a fixed amount (as an example, $20) that you will pay for covered health care services to providers who have contracts with your health insurance or health plan. As a rule of thumb, In-network co-payments are more likely to be less than out-of-network co-payments.

Medically Necessary

These are health care services or supplies that are needed to prevent, diagnose, or treat illnesses, injuries, diseases, conditions and their symptoms. They also must meet accepted standards of medicine.


All the facilities, providers and suppliers with which your health insurer or health plan has contracted to provide health care services.

Non-Preferred Provider

This is a provider who does not have a contract with your health insurer or health plan. With a non-preferred provider you typically will pay more. Remember to check your policy to make sure you can go to all providers who have contracted with your health insurance or health plan. Many health insurance companies or health plans have a “tiered” network that require you pay extra to see some providers.

Out-of-network Co-insurance

This is the percent (as an example, 35%) that you pay of the allowed amount for health care services that are covered to providers who do not currently have a contract with your health insurance or health plan. Out-of-network co-insurance will usually costs you more than in-network co-insurance. Out-of-network Co-payment This is a fixed amount (as an example, $35) that you pay for health care services that are covered from providers who do not contract with your health insurance or health plan. Out-of-network copayments are generally higher than in-network co-payments.

Out-of-Pocket Limit

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Physician Services Plan

This is a benefit that your employer, union or some other sponsoring group provides to you in order to pay for your health care services.


This is a decision made by your health insurer or health plan about the medical necessity of a health care service, a prescription drug, a treatment plan, or durable medical equipment. It is sometimes called prior authorization, precertification, or prior approval. Your health insurance or health plan might require this preauthorization for specific services before you are able to receive them, with the exception of emergences. Please remember, getting preauthorization is not a promise that your health insurance or plan will cover the cost.

Preferred Provider

This is a provider who has a contracted with your health insurer or plan to provide you with services at a discount. You can check your policy to see if you can see all the preferred providers or if your health insurance or health plan are on a “tiered” network and if you must pay more to see certain providers. Your health insurance or health plan may have preferred providers designated as “participating” providers. Participating providers also have contracts with your health insurer or health plan, but the discount may not be as big, so you may have to pay more.


The amount you must pay for your health insurance or health plan. This is usually paid monthly, quarterly, or yearly.

Prescription Drug Coverage

This is the part of your health insurance or health plan that helps pay for prescription drugs. Please note that this is not always a part of every health insurance or health plan offering.

Primary Care Physician

A physician -- whether an M.D. (Medical Doctor) or a D.O. (Doctor of Osteopathic Medicine) -- who directly provides to the patient or coordinates a wide range of health care services.

Primary Care Provider

A physician -- whether an M.D. (Medical Doctor) or a D.O. (Doctor of Osteopathic Medicine), a nurse practitioner, a clinical nurse specialist, or a physician assistant (as allowed under your state law) who provides, coordinates or helps a patient with accessing a wide range of health care services.


A physician -- whether an M.D. (Medical Doctor) or a D.O. (Doctor of Osteopathic Medicine), a health care professional, or a health care facility that is licensed, certified, or accredited as required by your state law.

Reconstructive Surgery 

This is Surgery and follow-up treatments needed to correct or improve any part of the body due to of birth defects, injuries, accidents, or other medical conditions.

Rehabilitation Services

These are health care services that help a patient keep, retrieve, or improve skills and functioning that have been impaired or lost due to sickness, injury, or disability. These services could include physical and occupational therapy, psychiatric rehabilitation services, or speech-language pathology in a variety of inpatient or outpatient settings.

Skilled Care Services

These are services provided by technicians and therapists in your own home or in a nursing home. Skilled Nursing Care These are services provided by licensed nurses that you receive in your own home or in a nursing home.


Physician specialists focus on a specific area of medicine or a specific group of patients. They diagnose, manage, prevent or treat certain types of symptoms and/or conditions. A non-physician specialist is a provider with additional training in a specific part of health care.

UCR (Usual, Customary and Reasonable)

The cost of medical service in a geographic area is based on what providers in the area typically charge for the same or similar medical service. UCR is how is often used to determine the allowed cost.

Urgent Care

This is care for an illness, condition, or injury that is serious enough for a reasonable person to seek care immediately, but not so severe as to require a visit to the emergency room.


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Common Medicaid Acronyms


AAC actual acquisition cost

AAP American Academy of Pediatrics

AAPD American Academy of Pediatric Dentistry

ABA applied behavioral analysis

ABP alternative benefit plan

ACA Patient Protection and Affordable Care Act

ACAP Association for Community Affiliated Plans

ACC accountable care collaborative

ACF Administration for Children and Families

ACIP Advisory Committee on Immunization Practices

ACO accountable care organization

ACS American Community Survey

ADA Americans with Disabilities Act

ADD attention deficit disorder

ADHD attention deficit hyperactivity disorder

ADLs activities of daily living

ADT admission, discharge, transfer

AFCARS Adoption and Foster Care Analysis Reporting System

AFDC Aid to Families with Dependent Children

AHA American Hospital Association

AHCA American Health Care Association

AHCCCS Arizona Health Care Cost Containment System Administration (Arizona’s Medicaid Agency)

AHRQ Agency for Health Care Research and Quality

AIDS acquired immune deficiency syndrome

AMA American Medical Association

AMP average manufacturer price

APC ambulatory payment classification

APRN advanced practice registered nurse

APS annual person summary

ARTS addiction and recovery treatment services

ASAM American Society of Addiction Medicine

ASC ambulatory surgical center

ASP average sales price

ASPE Assistant Secretary for Planning and Evaluation

AWP average wholesale price

BBA 97 Balanced Budget Act of 1997

BHH behavioral health homes

BHO behavioral health organization

BHP basic health program

BIP Balancing Incentive Payments Program

BMI body mass index

BOE basis of eligibility

BRFSS Behavioral Risk Factor Surveillance System

CAH critical access hospital

CAHMI Child and Adolescent Health Measurement Initiative

CAHPS Consumer Assessment of Health Care Providers and Systems

CAPD continuous ambulatory peritoneal dialysis

CARF Commission on Accreditation of Rehabilitation Facilities

CARTS CHIP Annual Reporting Template System

CBO Congressional Budget Office

CBT cognitive-behavioral therapy

CCC Community Care Collaborative

CCCESUN children with chronic conditions and elevated service use or need

CCIIO Center for Consumer Information and Insurance Oversight

CCN CMS certification number

CCO coordinated care organization

CCPD continuous cycling peritoneal dialysis

CCR cost-to-charge ratio

CCW Chronic Condition Data Warehouse

CDC U.S. Centers for Disease Control and Prevention

CDL clinical diagnostic laboratory

CDPS Chronic Illness and Disability Payment System

CDT Current Dental Terminology

CF conversion factor

CHAMP-VA Civilian Health and Medical Program of the Department of Veterans Affairs

CHIP State Children’s Health Insurance Program

CHIPRA Children’s Health Insurance Program Re-Authorization Act

CHNA community health needs assessment CIN client identification number

CLIA Clinical Laboratory Improvement Amendments of 1988

CMC comprehensive managed care

CMCS Center for Medicaid and CHIP Services

CMHC community mental health center

CMIP comprehensive Medicaid integrity plan

CMS Centers for Medicare & Medicaid Services

CNM certified nurse-midwife

CNOM costs not otherwise match-able

CNS clinical nurse specialist

COA Council on Accreditation of Services for Families and Children

COBRA Consolidated Omnibus Budget Reconciliation Act of 1985

CORD The Childhood Obesity Research Demonstration

CPE certified public expenditure

CPI Center for Program Integrity

CPI-U consumer price index for all urban consumers

CPNP certified pediatric nurse practitioners

CPS Current Population Survey

CPT Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association

CRNA certified registered nurse anesthetists

CRNP certified registered nurse practitioner

CRNW certified registered nurse-midwife

CSHCN children with special health care needs

CSR cost-sharing reduction

CT computerized tomography

CTA computerized tomography angiography

CY calendar year

DHCF Department of Health Care Finance

DHCS Department of Health Care Services

DHR Department of Human Resources

DHRM DSH Health Reform Methodology

DHSS Department of Health and Social Services

DHW Department of Health and Welfare

DMAP Division of Medical Assistance Programs

DMAP Delaware Medical Assistance Programs

DMAS Department of Medical Assistance Services

DME durable medical equipment

DOH Department of Health

DOJ U.S. Department of Justice

DRA Deficit Reduction Act

DRG diagnosis-related group

DSH disproportionate share hospital

DSM Diagnostic and Statistical Manual of Mental Disorders

D-SNP dual-eligible special needs plan

DSRIP delivery system reform incentive payment

DSRIP PPS delivery system reform incentive payment performing provider system

DUR drug utilization review

DVHA Department of Vermont Health Access

DxCG diagnostic cost group risk adjustment model

DYS Department of Youth Services

E/M evaluation and management

EAC estimated acquisition cost

EAPG enhanced ambulatory patient group

ECP essential community provider

ED emergency department

EDZ economically disadvantaged zone

E-FMAP enhanced federal medical assistance percentage

EHB essential health benefit

EHR electronic health record

EKG electrocardiogram

ELE express lane eligibility

EMTALA Emergency Medical Treatment and Active Labor Act

EPSDT early and periodic screening, diagnostic, and treatment

EQR external quality review

EQRO external quality review organization

ESI employer-sponsored insurance

ESRD end-stage renal disease

FACS Family and Children’s Services

FCA False Claims Act

FCHCO Federal Coordinated Health Care Office

FDA Food and Drug Administration

FERA Fraud Enforcement and Recovery Act

FFP federal financial participation

FFS fee for service

FHIAP Family Health Insurance Assistance Program

FIDE SNP fully integrated dual-eligible special needs plan

FMAP federal medical assistance percentage

FMR financial management report

FOA Family Opportunity Act

FPG federal poverty guidelines

FPL federal poverty level

FQHC federally qualified health center

FSSA Family and Social Services Administration

FUL federal upper limit

FY fiscal year (October 1–September 30)

FYE full-year equivalent

GAO U.S. Government Accountability Office

GDP gross domestic product

GME graduate medical education

GPP global payment program

HAN health access network

HBO hyperbaric oxygen therapy

HCA health care authority

HCAC health care-acquired condition

HCBS home- and community-based services

HCC hierarchical condition category

HCERA Health Care and Education Reconciliation Act

HCFA Health Care Financing Administration

HCFAC Health Care Fraud and Abuse Control Program

HCPCS Health Care Common Procedure Coding System

HCPF health care policy and financing

HCRIS Health Care Cost Report Information System

HCRP high-cost risk pool

HCUP Health Care Cost and Utilization Project

HEAT Health Care Fraud Prevention and Enforcement Action Team

HEDIS Health Care Effectiveness Data and Information Set

HHS U.S. Department of Health and Human Services

HHSC Health and Human Services Commission

HIE health information exchange

HIO health insuring organization

HIP Healthy Indiana Program

HIPAA Health Insurance Portability and Accountability Act

HIT health information technology

HIU health insurance unit

HMO health maintenance organization

HMOA Health Maintenance Organization Act

HOPD hospital outpatient department

HP20 Healthy People 2020

HPSA health professional shortage area

HRA health risk assessment

HRET Health Research and Educational Trust

HRMS Health Reform Monitoring Survey

HRSA Health Resources and Services Administration

IBNRS Incurred But Not Reported Survey

ICD International Classification of Diseases

ICD-10 International Classification of Diseases, 10th Edition

ICF intermediate care facility ICF/ID intermediate care facility for people with intellectual disabilities

ICT integrated care team ID/DD intellectual or developmental disabilities

IDALs instrumental activities of daily living IDR integrated data repository

IGT intergovernmental transfer

IHCP Indiana Health Coverage Program

HI Institute for Health Care Improvement

IHS Indian Health Service

IMD Institutions for Mental Diseases

IME indirect medical education

IMU Index of Medical Underservice

IOM Institute of Medicine

IOP intensive outpatient program

IPPS inpatient prospective payment system

IPUMS Integrated Public Use Microdata Series

IRC Internal Revenue Code

IRS Internal Revenue Service

KCMU Kaiser Commission on Medicaid and the Uninsured

KDHE Kansas Department of Health and Environment

KFF Kaiser Family Foundation

LADC licensed alcohol and drug counselor

LEA local education agency LIHP low-income health program

LINKS Louisiana Immunization Network for Kids Statewide

LIS low-income subsidy

LM licensed midwife

LOC level of care

LPR legal permanent resident

LTSS long-term services and supports

MA Medicare Advantage

MACBIS Medicaid and CHIP Business Information Solutions

MACPAC Medicaid and CHIP Payment and Access Commission

MACRA Medicare and CHIP Reauthorization Act

MAGI modified adjusted gross income

MAP Measure Applications Partnership

MAS maintenance assistance status

MAT medication assisted treatment

MAX Medicaid Analytic Extract

MBES/CBES Medicaid and CHIP Budget Expenditure System

MBI Medicaid buy-in

MCCA Medicare Catastrophic Coverage Act

MCE Medicaid coverage expansion (or managed care entity)

MCH maternal and child health

MCHA maternal and child health access

MCHB Maternal and Child Health Bureau

MCO managed care organization

MDCH Michigan Department of Community Health

MDHHS Michigan Department of Health and Human Services

MEC minimum essential coverage Medi-Medi Program Medicare-Medicaid Data Match Program MedPAC Medicare Payment Advisory Commission

MEMA member enrollment mix adjustment

MEPS Medical Expenditure Panel Survey

MEPS-HC Medical Expenditure Panel Survey–Household Component

MEPS-IC Medical Expenditure Panel Survey–Insurance Component

MEQS Medicaid Eligibility Quality Control System

MFCU Medicaid Fraud Control Unit

MFP Money Follows the Person

MFSDB Medicare fee schedule database

MH/SUD mental health/substance use disorder

MHCP Minnesota Health Care Program

MHPA Mental Health Parity Act of 1996

MHPAEA Mental Health Parity and Addiction Equity Act of 2008

MIC Medicaid integrity contractor

MIG Medicaid integrity group

MIHMS Maine Integrated Health Management Solution

MII Medicaid Integrity Institute

MIP Medicaid Integrity Program

MIPPA Medicare Improvements for Patients and Providers Act

MITA Medicaid Information Technology Architecture

MLR medical loss ratio

MLTSS managed long-term services and supports

MMA Medicare Modernization Act

MMCDCS Medicaid Managed Care Data Collection System

MMCO Medicare-Medicaid Coordination Office

MMIS Medicaid Management Information Systems

MMLR minimum medical loss ratio

MMNA monthly maintenance of need allowance

MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007

MOE maintenance of effort

MOMS Maternal Opiate Medicine Support Project

MOU memorandum of understanding

MOUD medications to treat opioid use disorder

MRA magnetic resonance angiogram

MRCP magnetic resonance cholangiopancreatography

MRI magnetic resonance imaging

MRS magnetic resonance spectroscopy

MSA metropolitan statistical area

MSHO Minnesota Senior Health Options

MSIS Medicaid Statistical Information System

MSP Medicare Savings Program

MSTAT Medicaid State Technical Assistance Teams

MUA medically underserved area

MUP medically underserved population

NADAC National Average Drug Acquisition Cost Survey

NAMCS National Ambulatory Medical Care Survey

NAMD National Association of Medicaid Directors

NASBO National Association of State Budget Officers

NASHP National Academy of State Health Policy

NASUAD National Association of States United for Aging and Disabilities

NCANDS National Child Abuse and Neglect Data System

NCCI National Correct Coding Initiative

NCHC North Carolina Health Choice

NCHS National Center for Health Statistics

NCQA National Committee for Quality Assurance

NCSL National Conference of State Legislatures

NDC National Drug Code

NDDoH North Dakota Department of Health

NEDS Nationwide Emergency Department Sample

NEHRS National Electronic Health Records Survey

NEMT non-emergency medical transportation

NESCO New England States Consortium Systems Organization

NF nursing facility

NFIB National Federation of Independent Business

NFLOC nursing facility level of care

NGA National Governors Association

NHAMCS National Hospital Ambulatory Care Survey

NHCM New Hampshire certified midwives

NHE national health expenditures

NHIS National Health Interview Survey

NHPF National Health Policy Forum

NHRA Nursing Home Reform Act

NHSC National Health Service Corps

NICU neonatal intensive care unit

NIDA National Institute on Drug Abuse

NIPT Non-Institutional Provider Team

NIRT National Institutional Reimbursement Team

NIS nationwide inpatient sample

NPI national provider identifier

NPPES National Plan and Provider Enumeration System

NPR net patient revenue

NQF National Quality Forum

NSCAW National Survey of Child and Adolescent Well-Being

NSCH National Survey of Children’s Health

NSCLC National Senior Citizens Law Center

NSCSHCN National Survey of Children with Special Health Care Needs

NSDUH National Survey on Drug Use and Health

NSLP National School Lunch Program

OACT Office of the Actuary

OASI Old-Age and Survivors Insurance Trust Fund

OB-GYN obstetrician-gynecologist

OBRA Omnibus Budget Reconciliation Act

ODWCC outpatient departmental weight cost-to-charge

OE operating expenses

OFM Office of Financial Management

OHA Oregon Health Authority

OHCA Oklahoma Health Care Authority O

HP Oregon Health Plan

OIG Office of Inspector General

OMB Office of Management and Budget

OPD outpatient department

OPFS outpatient prospective fee schedule

OPM U.S. Office of Personnel Management

OPPC other provider preventable conditions

OPPS outpatient prospective payment system

OT occupational therapy

OTC over-the-counter

OTP opioid treatment program

P4P pay for performance

PA physician assistant

PAAS Physician Assured Access System

PACE Program of All-inclusive Care for the Elderly

PAHP prepaid ambulatory health plans

PAPE payment amount per episode

PBFQHC provider-based federally qualified health center

PBM pharmacy benefit manager

PBRHC provider-based rural health clinic

PCA personal care attendant

PCC primary care clinician

PCCM primary care case management

PCMH patient-centered medical home

PCP primary care provider

PCPCH patient-centered primary care home

PCPCP primary care partial capitation provider

PCRI primary care rate increase

PDL preferred drug list

PDMP prescription drug monitoring program

PERM Payment Error Rate Measurement Program

PET positron emission tomography

PHAB Public Health Accreditation Board

PHP prepaid health plan

PHUP Partial Hospitalization Units Program

PI program integrity

PIHP prepaid inpatient health plan

PMH pregnancy medical home

PMP primary medical provider

PMPM per member per month

PMPY per member per year

PNA personal needs allowance

POPS Pharmacy On-Line Processing System

POS point of service

PPAC Preferred Physicians and Children Program

PPC provider preventable conditions

PPO preferred provider organization

PPS prospective payment system

PQMP Pediatric Quality Measures Program

ProPAC Prospective Payment Access Commission

PRR patient review and restriction programs

PT physical therapy

QDWI qualifying disabled and working individual

QHP qualified health plan

QI qualifying individual

QMB qualified Medicare beneficiary

RAC recovery audit contract

RBRVS resource-based relative value scale

RBRVU resource-based relative value units

RCCO regional care collaborative organizations

RDU renal dialysis units

RFI request for information

RFP request for proposal

RHC rural health clinic

RNFA registered nurse first assistants

RPICC regional perinatal intensive care centers

RVU relative value unit

SAMHSA Substance Abuse and Mental Health Services Administration

SBHC school-based health center

SBIRT screening, brief intervention and referral to treatment

SCDHHS South Carolina Department of Health and Human Services

SCH sole community hospital

SCO senior care options

SDMI severe disabling mental illness

SED severe (or serious) emotional disturbance

SEDD state emergency department database

SEDS Statistical Enrollment Data System

SFY state fiscal year (July 1–June 30)

SGA substantial gainful activity

SHADAC State Health Access Data Assistance Center

SHIP State Health Insurance Assistance Programs

SHOPP Supplemental Hospital Offset Payment Program

SI status indicator

SIL special income level

SIM state innovation models

SIPP Survey of Income and Program Participation

SLMB specified low-income Medicare beneficiary

SLP speech and language pathology

SMAC state maximum allowable cost

SMD state Medicaid director 

SMI serious mental illness

SNAP Supplemental Nutrition Assistance Program

SNF skilled nursing facility

SNP special needs plan

SOTA State Operations and Technical Assistance Initiative

SPA state plan amendment

SPMI serious persistent mental illness

SPRY state plan rate year

SSA Social Security Administration

SSBG Social Services Block Grant

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

ST speech therapy

SUD substance use disorder

TANF Temporary Assistance for Needy Families

TAR treatment authorization request

TBI/SCI traumatic brain or spinal cord injury

TEACH Training and Education for the Advancement of Children’s Health Program

TEFRA Tax Equity and Fiscal Responsibility Act

TEFT Testing Experiences and Functional Tools Demonstration

TMA transitional medical assistance

TMPPM Texas Medicaid Provider Procedures Manual

T-MSIS Transformed Medicaid Statistical Information System

TPL third party liability

TTWIIA Ticket to Work and Work Incentives Improvement Act

U&C usual and customary

UC uncompensated care

UCC uncompensated care cost

UCR usual and customary rate

UDS uniform data system

UPL upper payment limit

URA unit rebate amount

USC usual source of care

USPSTF U.S. Preventive Services Task Force

VA U.S. Department of Veterans Affairs

VFC Vaccines for Children program

WAC wholesale acquisition cost

WCC weighted cost-to-charge

WDI working disabled individual

WIC Special Supplemental Nutrition Program for Women, Infants, and Children

ZPIC Zone Program Integrity Contractor