The glossary is designed to clarify terms and concepts presented on this website. We recognize that a brief definition may not be enough for someone who is new to health care financing. If you would like more help to understand terms or concepts, please contact us.
Select a letter to advance the page to terms beginning with that letter.
A Medicaid waiver that allows a state to restrict Medicaid recipients’ choice of providers by assigning recipients to a primary care case manager, managed care plan (MCO) or other health plan. Visit the Medicaid website to learn more about the 1915 (b) Waiver.
Also known as a Home and Community-based Services (HCBS) waiver, this type of Medicaid wavier allows states to provide Medicaid and additional support services that make it possible for individuals who require an institutional level of care to live at home and participate in community life. HCBS/1915 (c) waiver availability and eligibility vary by state. Visit the Medicaid website to learn more about the 1915(c) Waiver.
An Accountable Care Organization, often referred to as an ACO, is groups of doctors, hospitals, and/or health care providers, who come together to give coordinated high-quality care to patients enrolled in Medicaid to avoid duplication of services. The ACO receives payment for all care provided to the patient and is accountable for quality and cost of care. To learn more, visit the CMS.gov and Kaiser Family Foundation websites.
The Advancing Care for Exceptional Kids Act is designed to improve the care for children with medically complex conditions in Medicaid. The new law, signed into law in April 2019 and will take effect on October 1, 2022, will address existing challenges facing children with medically complex conditions by expanding access to patient-centered, pediatric focused, coordinated care models targeted for the child to collaboratively work across multiple providers and services, and by easing access to out-of-state care. To learn more, see the Children’s Hospital Association’s Summary of the Ace Kids Act.
In 1990, the Maternal and Child Health Bureau (MCHB) of the Health Services and Resources Administration (HRSA) and the Medicaid Bureau [currently known as the Centers for Medicare and Medicaid services (CMS)] convened a multidisciplinary group of experts in pediatric care and family representatives to envision a bright future for every child. This major initiative to improve the quality of health promotion and preventive services for infants, children, and adolescents resulted in the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. They address primary and preventive care such as immunization and vital screenings. They also provide a chart that includes screenings, assessments, physical examinations, procedures, and timing of anticipatory guidance recommended for each age-based visit. More information about Bright Futures can be found on their website.
The Children & Adolescent Health Measure Initiative (CAMHI) screener is a five-item screening tool used to identify CSHCN based on the Maternal and Child Health Bureau definition. More information about the CAHMI or Children with Special Health Care Needs (CSHCN) screener can be found on the CAHMI website.See also: Children and Youth with Special Health Care Needs (CYSHCN)
A fixed amount a provider receives per member per month (PMPM) from a payer regardless of the type and amount of services used. This is a shift from fee-for-service provider payments. See the Kaiser Family Foundation definition for more detail.
Services that promote the effective and efficient organization and utilization of resources among all health providers and services to ensure access to necessary comprehensive services for children with special health care needs and their families. The Care Coordination Conundrum and Children and Youth with Special Health Care Needs on Catalyst Center website.See also: Case Management
In some service delivery systems the functions of a case manager and a care coordinator are similar. In other systems case managers may function as gatekeepers, with authority to approve or deny access to benefits. Case Management description on Kaiser Family Foundation website.See also: Care Coordination
A fund established by a state or other payer through various public and private sources, that may pay expenses incurred by families for health or social support services that are not covered by an insurance plan or other benefit program. Independent commissions or Title V programs usually administer these funds. The term catastrophic refers to the impact on a family’s finances and not the child’s condition. See Relief Funds: A Safety Net for Children and Youth with Special Health Care Needs on the Catalyst Center website.
Formerly called the Health Care Financing Administration (HFCA), CMS is the federal agency that administers Medicare and oversees the states’ administration of Medicaid. For more information, visit the Centers for Medicare and Medicaid Services (CMS) section on the CMS website.
As defined by the MCHB, CYSHCN are those from birth to age 21 who have, or are at increased risk for, chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally. Also referred to as Children with Special Health Care Needs (CSHCN). For more details, see the CYSHCN description on MCHB website.
Other entities, including state Medicaid agencies or state legislatures, may define CYSHCN differently. To learn about definitions of CYSHCN, see the brief The Role of State Medicaid and Title V Program Definitions of Children with Special Health Care Needs in the Provision of Services and Supports.
The Children’s Health Insurance Program (CHIP) is an insurance program that is jointly financed by federal and state dollars, and is administered by each state. CHIP provides health care coverage to uninsured children up to age 19 whose family income is too high for Medicaid, but less than state-specific income eligibility limits. Within broad federal guidelines, each state determines the design of its program, eligibility groups, benefit packages, reimbursement rates, and administrative and operating procedures. Children began receiving coverage through CHIP in 1997 and the program has helped states expand health care coverage to more than 8 million children. To learn more, visit the Children’s Health Insurance Program description on Medicaid website.
The percent of the allowed amount for a covered service that the insured pays. For example, if a health insurance plan’s allowed amount for an office visit is $100 and your co-insurance is 20%, you would pay 20% of $100, and the insurance company would pay the remaining costs.
Providing the resources necessary to help education and provide accurate information to consumers who are making difficult health care decisions. Consumer assistance may be provided by state insurance departments, independent state consumer assistance agencies, or non-profit organizations. For more information, visit the CMS.gov website.
Care for a child or adult with disabilities that is directed by that individual or his or her family. The individual/family member can decide how funds, services, or other resources are used and who may hire or direct personal care staff. May also be called Family-Directed Care or self-directed care services. This use of the term consumer-directed should not be confused with its use to describe low-cost, high-deductible health plans.
A fixed dollar amount that an insured individual must pay out-of-pocket for covered services at the time they are rendered. Also called a copay. For more detail about Copayment, visit the Healthcare.gov website.
Providing the education and resources necessary for families and individuals to understand which health insurance programs they are eligible for, the pros and cons of different insurance programs and to weigh them, and how to apply for coverage.
The specified maximum dollar amount a health plan requires an insured individual to pay for covered services before the insurer begins to pay.
Used by private and public health plans, disease management programs are designed to identify and encourage individuals with chronic conditions to follow evidence-based recommendations for care. This includes taking medications, eating a healthy diet, and being physically active. Patient and family education are important elements in many disease management programs.
Health-related equipment that is not disposable, such as wheelchairs, walkers, or oxygen concentrators.
Developmental services provided to children birth to age 3 who have, or in states with broad eligibility, are at risk of developmental delay. State Early Intervention programs can receive federal education funds to subsidize these services. For more information about Early Intervention services and eligibility, visit the Parent Center Hub website.
EPSDT is a federally mandated Medicaid benefit that every state must provide to Medicaid-enrolled children and youth under 21. EPSDT ensures children receive comprehensive health services and supports that are tailored to their individual needs. EPSDT description on Medicaid website.
The ten categories of health services that the Affordable Care Act (ACA) requires all qualified health plans sold in the Marketplaces and new plans sold in the individual and small group market to provide. To learn more, visit the Essential Health Benefits description on Healthcare.gov website.
Federal legislation that gives states the option of providing Medicaid coverage to children who meet the disability standard used in the Supplemental Security Income (SSI) program, but whose family income is higher than the income limits for SSI or Medicaid but less than 300% federal poverty level (FPL). States may charge premiums for families who “buy in” to the Medicaid program for a child with a disability. See Frequently Asked Questions about the Family Opportunity Act’s Medicaid Buy-In Option on the Catalyst Center website.
Centers run by and for families of children and youth with special needs that provide assistance in navigating the systems of health care services and supports. F2F HICs share information and provide resources to help families access necessary medical care and supports, partner with professionals to make informed health care decisions, and have opportunities to participate in the development of health policies and programs. To learn more about how Family-to-Family Health Information Centers support families of CYSHCN, visit the Family Voices website.
The federal matching dollars that states receive for every dollar they spend to support their Medicaid program. FMAP is based on the state-specific multiplier that the federal government uses to determine the percentage of each state’s federal match. The FMAP ranges from 50% – 83%, with a higher federal match going to those states with a lower per capita income. Note: eFMAP is the enhanced Federal Medical Assistance Percentage that states receive for CHIP. The Affordable Care Act (ACA) included a 23 percentage point increase, which went into effect in October 2015. The eFMAP range is now 88% – 100%. The additional funding for CHIP frees up state funds that can still be used for CHIP, or redirected to Medicaid, or used in other parts of the state’s budget. Learn more about Federal Medical Assistance Percentage description on U.S. Department of Health and Human Services website.
The threshold used as a basis for determining eligibility for many public benefits programs, including Medicaid and CHIP. The limits are usually expressed as a percentage of the base federal poverty level. For example, in 2020 for a 4-person household, the base federal poverty guideline is $26,000, 200% of the FPL is $52,400. For more information about Federal Poverty Level and examples of how they are used to determine eligibility, visit the description on Healthcare.gov website. See the 2021 FPL guidelines.
Federally Qualified Health Centers are community-based health care providers that receive funding from HRSA Health Care Center Program to provide comprehensive primary care services in underserved areas. To learn more, visit the HRSA website.
A payment system in which an insurer pays the provider for each medical service provided, rather than paying a fixed amount for all services (capitation). See the Kaiser Family Foundation definition for more detail.
Global payments are a model of health care financing where fixed payments made to a group of providers or a health care system to cover all of a patient’s care in a specific time period. Global payments are normally paid monthly per patient over a year. To learn more, see the Global Payments to Health Providers – Health Cost Containment on the National Conference of State Legislatures website.
Created as part of the Affordable Care Act, the Marketplaces allow people to purchase insurance and be assessed for Medicaid and CHIP eligibility. This online resource allows individuals, families, and small businesses to compare and shop for health insurance. Depending on household income, purchasers may also be eligible for tax credits and other subsidies to make insurance more affordable. Some states operate a state-based Marketplace, while others have a federally supported, state partnership, or federally facilitated Marketplace. To learn about the Health Insurance Marketplace visit the Healthcare.gov website.
A type of health insurance plan where individuals (or employers) pay a fixed or capitated amount for all health services provided by a specific, contracted network of providers.
A reimbursement strategy that pays more per patient to health plans that serve patients with complex or intense medical needs, including individuals with disabilities. Provides an incentive for plans to provide good quality care to individuals with costly care needs, as opposed to limiting care to avoid financial risk.
An insurance program that allows people who have health problems or have trouble getting insurance to purchase health insurance, generally at higher than average premium rates
Home and Community-Based service (HCBS) waivers allow a state to offer Medicaid beneficiaries a wide array of services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted populations groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses. Learn more about the Home and Community Based Services description on the Medicaid website.
An individual or organization that is trained to be able to help consumers look for health coverage options through the Marketplace, including assisting with eligibility and enrollment. The services are free to consumers if accessed through the Marketplace. To learn more, visit the HealthCare.gov website.
Private or public health service programs, often led by a primary care team (and often developed for a specific target population) that who work together with patients and families to provide a full array of coordinated services, such as medical care, mental health care, family support services, or school-based services in a cost-effective way. Integrated care models may have alternative financing and reimbursement mechanisms such as capitation.
A long-term care facility that provides health and related services above the level of basic custodial care but below the level of care available in a hospital or skilled nursing facility. An Intermediate Care Facility for Individuals with Intellectual Disability (ICF/ID) is a particular type of ICF. This is an optional Medicaid benefit that states may use to provide services and supports that promote the independence of people with intellectual disabilities.
The Katie Beckett waiver allows children who would otherwise be institutionalized or hospitalized due to their complex needs to be cared for at home and still maintain Medicaid eligibility by waiving their parent’s income. It is named after the child whose mother successfully advocated for its creation in Iowa in 1982. This type of waiver has different names in different states; not every state has this waiver. See the Catalyst Center publication, The TEFRA Medicaid State Plan Option and Katie Beckett Waiver for Children, for more detail.
The person-driven services and supports provided by Medicaid to individuals with chronic conditions, disabilities, or mental illness. Services can be provided in community-based or institutional settings. For more information about Long Term Services and Supports, visit the Medicare website.
A health care delivery system that works to coordinate health services, while managing utilization of services, quality, and cost (generally through capitation). Managed care may rely on a primary care provider to provide referrals and document the medical necessity for other services. The capitation may be used to purchase services from a network of providers. For more detail, see the Managed Care description on the Medicaid.gov website.
A benefit, coverage group, or provider type that must be covered by certain types of health plans as a matter of state law. Self-insured and government health plans are exempt from such mandates. See the state-required benefits (another name for mandates) for each state at Centers for Medicare and Medicaid Services website (click on the state and scroll down to state-required mandates).
Part of the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services (HHS), the MCHB is responsible for promoting the health of mothers and children in the United States and its jurisdictions. MCHB administers the Title V program. For more information about MCHB , visit the HRSA website.
A public benefits program, jointly funded by state and federal dollars. The federal government oversees the program, but it is administered by the states. Medicaid provides coverage for health care and health-related services to low-income and other specific categories of individuals, such as children and youth with disabilities. To learn more about Medicaid and enrollment, visit the Medicaid website.
Medicaid buy-in programs allow families who meet certain eligibility criteria (often disability-related) but whose household income exceeds a state’s income eligibility limits to purchase Medicaid benefits.
An approach to providing primary care that emphasizes proactive identification of special health care needs, comprehensive care coordination, partnership between providers and families (or youth) around health decision-making, and collaboration with other community providers, including schools. The National Resource Center for Patient/Family-Centered Medical Home provides information about medical homes for families and caregivers, as well as information about state initiatives.
Equal health insurance coverage for the treatment of mental health, substance use disorder and medical/surgical health conditions. The Affordable Care Act requires all health plans, including grandfathered and self-funded plans, to provide mental health parity. For more detail about Mental Health Parity, see the Government Publishing Office publication.
The National Survey of Children’s Health (NSCH) is an annual, cross-sectional, address-based survey that collects information on the health and well-being of children ages 0-17, including health care, family, and community-level factors that can influence health. Data from NSCH reflect information collected from parents/caregivers and are the only source of both national and state-level estimates on key measures of child health.
Among other changes, the 2016 National Survey of Children’s Health started integrating two surveys: the previous NSCH and the National Survey of Children with Special Health Care Needs (NS-CSHCN)
Care that focuses on improving quality of life for patients with progressive, incurable illness, focused on quality of life. For more information, see the Catalyst Center publication Financing Pediatric Palliative and Hospice Care Programs.
P2P programs offer parent-to-parent support as a core resource for families with children who have special health care needs, disabilities, behavioral, or mental health issues. Through a one-to-one “match” experienced support parents provide emotional support to families and assist them in finding information and resources. To learn more, visit the Parent-to-Parent USA website.
Signed into law by President Obama on March 23, 2010, the Affordable Care Act (ACA) is federal health care reform legislation. The main goals are to create new pathways to affordable insurance and reduce the number of people without insurance, promote primary and preventive care, and decrease the growth of the cost of health care. To learn more, see the Patient Protection and Affordable Care Act (AVA) description on Healthcare.gov website.
A reimbursement strategy that pays health care providers according to how well they meet certain quality standards.
Services designed to help an individual with a disability perform activities of daily living at home or in the workplace. A Personal Care Attendant (PCA) provides these services.
The amount of money paid to a health plan to provide coverage for an individual or family over a specified time period. Payments are typically made monthly, but may be yearly.
The payment of all or part of an individual’s or family’s private health insurance premium, usually by a public program such as Title V, Medicaid, or CHIP. For more information, see the Premium Assistance description on the Department of Labor website.
A type of service delivery model where beneficiaries choose a primary care provider who will deliver primary care services, provide referrals to specialists, and coordinate care.
A contract in which an insurer is itself insured, wholly or in part, against financial risk. See the Kaiser Family Foundation definition for more detail.
Temporary, short-term care for a child or adult with disabilities, chronic health conditions, and/or complex health conditions that provides relief for a family caregiver. Respite care may be provided by another family member, a friend, or a paid employee. Respite care can be provided on a temporary basis, emergencies, or long-term, in a variety of settings including the family home, respite centers, or residential care facilities. To learn more about standards for systems of care for respite care for children and youth with special health care needs, visit the AMCHP website.
Statistical or economic adjustment of premiums to compensate health plans or providers for the increased financial risks associated with providing health services to subgroups of patients who share demographic or health need attributes (e.g., age or special health care needs of their clients). See the Risk Adjustment and Other Financial Protections for Children with Special Health Care Needs in Our Evolving Health Care System on the Catalyst Center website.
Coverage offered by a company, typically a large employer, that chooses to pay employees’ health care costs directly, instead of purchasing health insurance coverage.
Diagnosable mental health disorder in a child or adolescent that severely disrupts daily functioning in the home, school, or community. Learn more about Serious Emotional Disturbance on the SAMHSA website.
A state’s Medicaid program plan, federally approved under Title XIX of the Social Security Act. A state may submit amendments to modify its plan. The state plan defines which services will be covered and the terms of eligibility for those services. While state Medicaid programs must include certain basic services and eligibility standards, the state plan or SPA often refers to other, and/or new optional standards and services. State Plan/State Plan Amendment (SPA) description on Medicaid website.
A federal program established under Title XVI of the Social Security Act that provides monetary benefits to eligible recipients to offset income loss due to long-term disability. It is administered by the Social Security Administration. In many states, individuals eligible for SSI automatically receive Medicaid coverage. For more information about Supplemental Security Income, visit the Social Security website.
The provision of case management services to specific groups of Medicaid clients, which are designed to provide “targeted” individuals with needed services while promoting the cost-effective use of community resources.
The Tax Equity and Fiscal Responsibility Act (TEFRA) is a state plan option that creates a pathway to Medicaid for certain children under age 19 with complex disabilities or special health care needs to be cared for at home instead of an institution even if family income exceeds state Medicaid eligibility limits. A TEFRA state plan option, while different from a Katie Beckett waiver, has the same goals: to honor a family’s wish to care for a child with complex health needs at home instead of in an institutional setting. The Catalyst Center publication The TEFRA Medicaid State Plan Option and Katie Beckett Waiver for Children provides more detail.
The provision of health care and/or health education using telecommunications technology, rather than in person encounters.
Care provided by foster parents who have received specialized training in the care of children with complex health needs. It is also referred to as treatment foster care. To learn more, visit the Child Welfare Information Gateway.
A voluntary program in which qualified SSI recipients can obtain vocational rehabilitation, employment or other support services from an approved provider to help them go to work and achieve employment goals. Ticket to Work is part of the Work Incentives Improvement Act of 1999, which also expands Medicaid and Medicare coverage to more people with disabilities who work. For more detail, see the Ticket to Work description on the Social Security website.
Title IV of the Social Security Act provides federal block grants to states for Temporary Assistance for Needy Families (TANF) and for child and family services. To learn more about Title IV, visit the Social Security website.
Title IV-E is a subpart of Title IV. This program provides federal reimbursement to states for the costs of children receiving care in foster homes. To learn more about Title IV-E, visit the Social Security website.
Title V of the Social Security Act provides federal block grants to states to support Maternal and Child Health (MCH) and Children with Special Health Care Needs (CSHCN) programs. These programs may provide direct care, but generally focus on provision of wrap-around and population-based services (e.g. immunization) and on assuring capacity for maternal and child health care. The Maternal and Child Health Bureau (MCHB) administers Title V nationally. Learn more about Title V on the Social Security website.
The Title V Block grant is a fixed amount of federal funds that the 59 states and jurisdictions receive to promote the health of all mothers and children, including CYSHCN. The three Block Grant components are Formula Block Grants, Special Projects of Regional and National Significance (SPRANS), and Community Integrated Service Systems (CISS) Grants. At least 30% of funds must be spent on preventive and primary care for children. Another 30% must be used to ensure CYSHCN and their families have access to family-centered, coordinated, community-based systems of care. Other services include pre- and post-natal care for low-income and at-risk women, and toll-free hotlines families can call for information and referral to other needed services and supports. Title V Block Grant description on HRSA website.
Generally used in reference to supports and services required by youth with special health care needs as they go from pediatric to adult services, programs, or settings. Visit the Got Transition website to learn more about transition.
Describes health insurance that does not cover all the medically necessary services an individual requires, and/or does not provide access to all needed services, and/or the out-of-pocket expenses are not affordable. Underinsurance (also called inadequate insurance) is a cause of family financial hardship and medical debt.
A model of health care financing that pays providers for quality and value of services, not just the volume of services provided. Sometimes referred to as “pay-for-performance”. To learn more, see the definition on the HealthCare.gov website.
See also: Pay-for-Performance (P4P)