All-Payer Claims Database: A state-based database of all claims filed by public and private patients. They help consumers understand prices and quality information for their state. https://www.ahrq.gov/data/apcd/index.html

 

Claim: When a patient gets a service that should be covered by their insurer, they or their health care provider submit a a request for payment to the insurer. This request is called a claim.

 

Coinsurance: after meeting the deductible, coinsurance is the percentage of cost that the patient pays. 

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Copayment: a set amount patients are charged for an appointment, usually the day of.

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Cost Sharing: The out-of-pocket costs that the patient themselves pays for their care. This includes deductibles, coinsurance, and copayments, but excludes most out-of-network costs, such as the portion of a bill paid for a non-network provider or the cost of services that aren't covered. 

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Deductible: an amount that the patient has to pay before the insurance pays for covered services. Some preventive services are covered before the deductible is met. 

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Health Maintenance Organization (HMO): A network of doctors and providers, usually restricted to a specific area of residency/employment. Typically, HMOs don't cover providers outside of the network, except for in cases of emergency. 

HMOs are a kind of Managed Care. The main distinction of HMOs is that they are limited to a network, rather than paying partial costs for out of network services.

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Health Savings Account (HSA): Available only for people with a HDHP. Allows consumers to set aside funds in a tax-free account that can be used to pay deductibles and other health costs. They are ideal for patients that want the lower premiums HDHPs offer, but still need more frequent care.

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High Deductible Health Plans (HDHP): Plans with lower premiums, but higher deductibles. These can be helpful for people who don't typically require much health care, since they won't have to pay as much every month but are still covered for extremely large bills.

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Managed Care Organization (MCO): Managed Care Organizations or Managed Care plans are a kind of health insurance, where the organization forms contracts with a network of providers and facilities in order to supply care at reduced costs. Health Maintenance Organizations (HMOs) are a kind of Managed Care Organization.

In Arizona, all Medicaid enrollees are part of a Managed Care Organization, except for American Indians.

 

Premium: A premium is the monthly cost of health insurance. It does not include other costs, such as copayments, coinsurance, or deductibles.

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Reinsurance: Provides protection for insurance companies. If their claims exceed a specified high amount, third-party groups will reimburse them and pay part of the claims.

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Subsidized Coverage: Coverage available at partial or no cost depending on an individual/family's income. Sometimes, this comes in the form of premium tax credits that can be used to reduce the monthly premium cost.

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Value-Based Payment: In value-based systems, providers get paid based on their performance and how it improves. This is an alternative to fee-for-service systems, where providers are paid for each service (for example, each visit or test would cost a fee)

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