Insurance & Benefits Glossary

A federal program requiring drug manufacturers to provide outpatient drugs at reduced prices to eligible healthcare organizations serving low-income and uninsured patients. Organizations can use savings to expand services but program has faced controversy over its scope and use.

Traditional compounding pharmacy operating under state pharmacy board authority and section 503A of FDCA. Compounds patient-specific prescriptions using FDA-approved ingredients. Limited to preparing small quantities and cannot distribute across state lines like manufacturers.

Large-scale compounding facility registered with FDA under section 503B of FDCA. Can compound without patient-specific prescriptions and distribute across state lines. Subject to current good manufacturing practices and FDA oversight. Fills gap between compounding and manufacturing.

Federal law expanding health insurance and creating online marketplaces where individuals shop for coverage. Provides premium tax credits and cost-sharing reductions based on income, prohibits denial for pre-existing conditions.

Supplemental insurance that pays benefits if the policyholder is injured in a covered accident. Pays a lump sum or scheduled benefits for accidents resulting in emergency room visits, hospitalization, fractures, or other specified injuries.

Basic self-care tasks used to assess functional ability and determine need for assistance. Six standard ADLs: bathing, dressing, toileting, transferring, continence, feeding. Inability to perform ADLs independently triggers long-term care needs. Used for insurance eligibility, facility placement, care planning.

The percentage of total average costs for covered benefits that a health plan pays. Bronze plans have 60% actuarial value, Silver 70%, Gold 80%, and Platinum 90%. The remaining percentage is what consumers pay through deductibles, copayments, and coinsurance.

Rare disorder where adrenal glands do not produce enough cortisol and often aldosterone. Symptoms develop slowly: fatigue, muscle weakness, weight loss, low blood pressure, skin darkening. Life-threatening adrenal crisis can occur with stress. Requires lifelong hormone replacement therapy.

Neurodevelopmental disorder with persistent patterns of inattention, hyperactivity, and impulsivity affecting functioning. Three presentations: predominantly inattentive, predominantly hyperactive-impulsive, or combined. Affects children and adults, impacting academic, occupational, and social functioning.

Supervised program providing social activities, meals, recreation, some health services during daytime hours. Allows caregivers to work or get respite while participants receive care and socialization. May be social model or medical model. Often private pay, sometimes Medicaid or Veterans benefits. Not covered by Medicare.

Under the employer mandate, coverage is considered affordable if the employee s share of self-only premium for the lowest-cost plan does not exceed 9.12% (2023) of household income. If coverage is unaffordable, the employee may qualify for marketplace premium tax credits.

The practice of charging different premiums based on age. Under the ACA, insurers can charge older adults up to 3 times more than younger adults (3:1 ratio). Some states impose stricter limits on age rating.

A family plan structure where the entire family deductible must be met before insurance begins cost-sharing for any family member. All family members' expenses count toward the single family deductible amount.

Concept of remaining in one's own home and community as one ages, using services to maintain independence. May involve home modifications, assistive technology, home care services, meal delivery, transportation. More affordable than facility care. Requires adequate housing and support network. Goal of many seniors and long-term care planning.

Physician specializing in diagnosing and treating allergies and immune system disorders. Treats allergic rhinitis, asthma, food allergies, drug allergies, eczema, anaphylaxis. Performs allergy testing, administers immunotherapy (allergy shots). Often called allergist-immunologist. Requires internal medicine or pediatrics training plus allergy fellowship.

The maximum payment your insurance plan negotiates with providers for specific services. In-network providers agree to accept this rate as full payment. If a provider charges more than the allowed amount and is out-of-network, you may face balance billing for the difference.

Most common cause of dementia, progressive brain disorder destroying memory and thinking skills. Symptoms worsen over time: memory loss, confusion, difficulty with familiar tasks, personality changes. Usually begins after 60. Exact cause unknown but involves abnormal protein buildup in brain. No cure.

Progressive brain disorder destroying memory and cognitive function due to brain cell death. Most common cause of dementia. Begins with mild memory loss, progresses to inability to carry on conversation or respond to environment. No cure. Current medications temporarily improve symptoms. Eventually requires full-time care.

Secured unit within nursing facility designed specifically for dementia patients. Provides specialized environment, staff training, structured activities, safety features. Higher staff-to-resident ratio. More expensive than standard nursing home care. May be separate facility or dedicated wing. Also called memory care unit.

Payment system for Medicare outpatient services including hospital clinics, emergency departments, same-day surgeries. Groups services with similar clinical characteristics and costs. Updated quarterly. Used instead of DRGs for outpatient settings. Determines Medicare reimbursement.

Progressive neurodegenerative disease affecting nerve cells controlling voluntary muscles. Causes muscle weakness, difficulty speaking, swallowing, breathing. No cure. Riluzole may slow progression. Eventually requires feeding tube and ventilator. Average survival 3-5 years from diagnosis. Also called Lou Gehrig's disease.

Procedure widening narrowed or blocked blood vessels, typically arteries. Balloon-tipped catheter inserted and inflated to compress plaque and stretch vessel. Often combined with stent placement. Can be done on coronary, carotid, or peripheral arteries. Improves blood flow, reduces symptoms.

Maximum amount dental insurance pays for covered services per year (typically $1,000-2,000). After reaching maximum, patient pays 100% until next calendar year. Doesn't include premiums.

Medications affecting dopamine and serotonin used for schizophrenia, bipolar disorder, and treatment-resistant depression. Examples include risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify). Require regular metabolic monitoring.

Mental health condition characterized by excessive worry and fear. Types include generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobias. Physical symptoms include rapid heartbeat, sweating, trembling, shortness of breath. Treatable with therapy and/or medication.

Emergency surgery removing inflamed appendix (appendicitis). Done laparoscopically or through small incision. Prevents rupture which can cause life-threatening peritonitis. Short hospital stay. Quick recovery. Untreated appendicitis can be fatal. One of most common emergency surgeries.

Surgery connecting artery to vein, usually in arm, creating access point for hemodialysis. Takes weeks to months to mature before use. Preferred type of dialysis access with lowest infection risk and best long-term outcomes. Requires care to prevent clotting or infection.

Minimally invasive surgery using small camera (arthroscope) inserted through small incision to view and treat joint problems. Most commonly done on knee, shoulder, ankle, wrist, hip. Can repair torn cartilage or ligaments, remove loose bodies, smooth arthritic surfaces. Faster recovery than open surgery.

Residential setting providing housing, meals, personal care assistance for people who need help with daily activities but not full-time nursing care. Provides medication management, housekeeping, activities, transportation. Not medical care. Private pay, not typically covered by Medicare or most insurance. Medicaid may cover in some states.

Chronic condition causing airways to narrow and swell, producing extra mucus, making breathing difficult. Triggered by allergens, exercise, cold air, stress. Symptoms include shortness of breath, wheezing, coughing, chest tightness. Controlled with inhaled corticosteroids and quick-relief inhalers. Can be life-threatening if severe.

Irregular curvature of cornea or lens causing blurred or distorted vision at all distances. Often occurs with myopia or hyperopia. Corrected with special cylinder lenses. Very common.

Irregular and often rapid heart rhythm (arrhythmia) causing poor blood flow and increasing stroke risk. Symptoms include heart palpitations, fatigue, shortness of breath, dizziness. May be episodic or persistent. Treated with medications to control rate and rhythm, blood thinners to prevent stroke, sometimes procedures or surgery.

Neurological condition causing persistent pattern of inattention and/or hyperactivity-impulsivity interfering with functioning. Common in children but often continues into adulthood. Symptoms include difficulty focusing, disorganization, impulsivity, restlessness. Treated with stimulant medications and behavioral therapy.

Neurodevelopmental condition affecting social communication and interaction, with restricted, repetitive patterns of behavior or interests. "Spectrum" reflects wide variation in challenges and strengths. Early intervention improves outcomes.

A benchmark used in pricing prescription drugs, representing a published price suggesting what wholesalers charge pharmacies. Not actual transaction prices and often criticized as inflated. Being replaced by more transparent pricing benchmarks.

The American Rescue Plan Act of 2021 was a $1.9 trillion federal stimulus package that included enhanced premium tax credits for health insurance purchased through ACA marketplaces. These enhanced subsidies removed the 400% FPL income cap and capped premiums at 8.5% of income. The ARPA enhancements were extended through the Inflation Reduction Act until December 31, 2025, after which they expired.

When out-of-network providers bill patient for difference between their charges and insurance allowed amount. In-network providers cannot balance bill for covered services. Federal law protects against surprise balance billing in emergencies and certain situations.

The most recent four completed calendar quarters before the effective date of an application for Minnesota PFML benefits. Used to determine wage credits and financial eligibility for benefits.

A 52-week period starting from the effective date of leave, during which an eligible employee can take up to 12 weeks of family leave, 12 weeks of medical leave, or a combined maximum of 20 weeks of leave under Minnesota's Paid Family and Medical Leave program.

Fast-acting anti-anxiety medications that enhance GABA (calming neurotransmitter) activity. Used for short-term anxiety relief, panic attacks, and insomnia. Examples include alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin). Habit-forming with potential for dependence.

Medication made from living organism or its products. Examples include vaccines, gene therapies, blood products, antibodies. Larger and more complex than traditional small-molecule drugs. Cannot be exactly replicated (biosimilars are similar but not identical). Often require special storage and handling. Typically expensive. Growing segment of new drugs.

Removal of small tissue sample for microscopic examination to diagnose disease, especially cancer. Types include needle biopsy, punch biopsy, excisional biopsy, endoscopic biopsy. Usually done with local anesthesia or sedation.

A biological product highly similar to an already-approved biological product (reference product) with no clinically meaningful differences in safety, purity, or potency. Less expensive than the reference biologic but not identical like generic drugs are to brand drugs.

Mental health condition causing extreme mood swings including emotional highs (mania or hypomania) and lows (depression). Episodes can affect sleep, energy, activity, judgment, behavior, ability to think clearly. Lifelong condition requiring ongoing treatment. Medications (mood stabilizers, antipsychotics) and therapy essential.

A method used to determine which parent s health insurance is primary for dependent children covered by both parents. The plan of the parent whose birthday comes first in the calendar year is primary. If birthdays are the same, the plan covering the parent longer is primary.

Images showing upper and lower teeth in one area. Detect cavities between teeth and bone loss. Typically covered annually.

Strongest safety warning FDA can require on prescription drug labeling. Boxed in black border on package insert and prescribing information. Indicates serious or life-threatening risks. Does not prevent prescribing but alerts prescribers and patients. Examples include antidepressants and suicide risk, NSAIDs and cardiovascular risk. Also called boxed warning.

Drawing blood from vein for laboratory analysis. Tests many things: blood cell counts, glucose, cholesterol, organ function, infections, hormones, drug levels. Most common medical test. Results help diagnose diseases, monitor conditions, assess treatment effectiveness.

Time spent by a parent with a biological, adopted, or foster child in connection with the child's birth, adoption, or placement. Must be taken within 12 months of the event. Employees can take up to 12 weeks of bonding leave under Minnesota PFML.

X-ray test measuring bone mineral density to diagnose osteoporosis and assess fracture risk. Uses very low radiation dose. Patient lies on table while scanner passes over body, typically measuring spine and hip. Quick and painless. Recommended for women over 65, men over 70, or earlier if risk factors present. Results given as T-score.

Procedure replacing damaged or destroyed bone marrow with healthy blood-forming stem cells. Treats leukemia, lymphoma, multiple myeloma, other blood cancers. Can be autologous (patient s own cells) or allogeneic (donor cells). Requires high-dose chemotherapy or radiation first. Weeks hospitalization, months recovery.

Orthodontic appliance using brackets bonded to teeth connected by wires, gradually moving teeth into correct positions. Traditional metal braces most common. Ceramic braces tooth-colored and less visible.

Medication sold under proprietary trademark name by company that originally discovered and developed it. Protected by patent for typically 20 years from patent filing. More expensive than generic equivalent. After patent expires, generic versions can be manufactured. May be preferred by some patients or medically necessary in certain cases.

Cancer forming in breast tissue, most commonly in ducts (ductal carcinoma) or lobules (lobular carcinoma). Most common cancer in women. Detected through mammography or physical exam. Treatment depends on stage and type, may include surgery, chemotherapy, radiation, hormone therapy, targeted therapy. Outcomes vary widely by stage.

Fixed dental appliance replacing one or more missing teeth using adjacent teeth as anchors. Types include traditional (crowns on adjacent teeth), cantilever (anchored to one side), and Maryland (framework bonded to backs of adjacent teeth). Typically 50% covered.

Payment methodology where multiple related services are paid under single comprehensive code rather than separately. National Correct Coding Initiative (NCCI) defines bundling rules. Prevents fragmentation of services. Common in surgical procedures where anesthesia, supplies bundled with primary procedure.

Open-heart surgery creating new route around blocked coronary arteries using blood vessel from elsewhere in body. "Bypass" refers to grafted vessel bypassing blockage. Major surgery requiring heart-lung machine. Hospital stay 5-7 days, recovery 6-12 weeks.

Group of diseases involving abnormal cell growth with potential to invade or spread to other parts of body. Many types depending on where it starts: lung, breast, prostate, colorectal, melanoma, leukemia, lymphoma. Treatment may include surgery, chemotherapy, radiation, immunotherapy, targeted therapy.

Procedure destroying small areas of heart tissue causing abnormal heart rhythms (arrhythmias). Catheter inserted through blood vessel to heart, energy (radiofrequency or cryotherapy) delivered to ablate tissue. Treats atrial fibrillation, supraventricular tachycardia, other arrhythmias. Success rates vary by condition.

Procedure threading thin tube through blood vessel to heart to diagnose or treat heart conditions. Can measure pressures, inject dye for imaging, take tissue samples, perform interventions. Done in special lab under local anesthesia. Diagnostic or therapeutic. Relatively low risk.

Physician specializing in diagnosing and treating heart and blood vessel diseases. Treats conditions including coronary artery disease, heart failure, arrhythmias, hypertension, heart valve disease. Performs procedures like echocardiograms, stress tests, cardiac catheterizations. May require referral from primary care.

Disease of heart muscle making it harder for heart to pump blood. Types include dilated, hypertrophic, restrictive. Causes include genetics, infections, autoimmune diseases, alcohol abuse, medications. Symptoms include shortness of breath, fatigue, swelling. Can lead to heart failure, arrhythmias. Treated with medications, devices, sometimes transplant.

Process of organizing and managing healthcare services across multiple providers and settings to ensure appropriate, efficient care. Particularly important for elderly, chronically ill, post-hospitalization. Helps navigate complex healthcare system. Reduces hospitalizations, improves outcomes. May be provided by case managers, social workers, nurses.

Minimally invasive procedure placing stent in narrowed carotid artery to improve blood flow to brain and prevent stroke. Catheter with balloon and stent inserted through leg artery. Filter catches debris during procedure. Alternative to endarterectomy, especially for high-surgical-risk patients.

Surgery removing plaque buildup from carotid artery in neck to prevent stroke. Artery opened, plaque removed, artery closed. Done under general or local anesthesia. For patients with significant carotid stenosis. Alternative to stenting in some patients. Reduces stroke risk.

Surgery removing cloudy lens from eye and replacing with artificial lens. Most common surgery in US, very safe and effective. Usually outpatient with local anesthesia. Quick procedure (15-30 minutes), rapid recovery. Vastly improves vision in most patients.

Clouding of eye's natural lens causing blurry vision, like looking through foggy window. Very common with aging—most people over 70 have some degree. Only treatment is surgery replacing cloudy lens with artificial lens. Most common surgery in US, very safe and effective.

Immune reaction to eating gluten causing damage to small intestine lining. Symptoms include diarrhea, bloating, gas, fatigue, weight loss, anemia. Can lead to serious complications including malnutrition, osteoporosis, infertility. Requires strict lifelong gluten-free diet. Hereditary autoimmune disease.

Surgical delivery of baby through incisions in mother s abdomen and uterus. Done when vaginal delivery risky for mother or baby. Can be planned or emergency. Requires longer recovery than vaginal birth. Most common major surgery in US. May impact future pregnancies.

Comprehensive list of hospital's prices for all services, procedures, supplies. Used to generate patient bills. Charges typically higher than actual payment from insurance. Negotiated rates lower than chargemaster. Uninsured patients may be charged full chargemaster rates. Must be publicly available.

Treatment using drugs to kill cancer cells or stop growth and division. Works systemically throughout body. Given intravenously, orally, or by injection in cycles. Side effects include nausea, hair loss, fatigue, increased infection risk.

Cancer treatment using drugs

Cancer treatment using drugs to kill rapidly dividing cancer cells. Given intravenously, orally, or other routes. Usually in cycles allowing recovery between treatments. Causes various side effects including nausea, hair loss, fatigue, infection risk. Can be curative, control cancer, or palliate symptoms.

Provides low-cost coverage to children in families earning too much for Medicaid but unable to afford private insurance. Some states also cover pregnant women.

Healthcare professional focusing on neuromuscular disorders, primarily through manual adjustment or manipulation of spine. Treats back pain, neck pain, headaches, joint problems. Requires doctoral degree (DC). Uses hands-on treatments, exercise, lifestyle counseling. Coverage varies by insurance plan.

Surgery removing gallbladder, typically for gallstones causing symptoms. Usually done laparoscopically through small incisions. May be open surgery if complications. Outpatient or short stay. Quick recovery. Most people adapt well without gallbladder. May cause temporary digestive changes.

Progressive loss of kidney function over months to years. Measured in five stages from mild damage to kidney failure. Caused by diabetes, high blood pressure, or other kidney diseases. Eventually may require dialysis or transplant. Requires careful management of blood pressure, blood sugar, diet, medications.

Progressive lung disease causing obstructed airflow and breathing difficulties. Includes emphysema and chronic bronchitis. Often caused by smoking. Symptoms include shortness of breath, chronic cough, wheezing. No cure but treatment can slow progression. Requires ongoing medication and pulmonary rehabilitation.

Late-stage liver scarring (fibrosis) from many forms of liver diseases including hepatitis and chronic alcoholism. Liver cannot function properly. Often symptom-free until extensive damage. Complications include portal hypertension, bleeding, ascites, jaundice, liver cancer, liver failure. Irreversible but treatment can slow progression. May require transplant.

Formal payment request submitted by provider to insurance for services rendered. Includes medical codes describing diagnoses and procedures, patient information, charges.

The process by which an insurance company reviews a submitted claim, determines coverage and payment according to the benefit plan, and issues payment or denial. This involves verifying eligibility, checking coverage, applying cost-sharing, and coordinating benefits.

When an insurance company refuses to pay for a submitted claim. Denials may be due to lack of coverage, services not being medically necessary, providers being out-of-network, claims not being filed timely, or incomplete documentation. Denials can often be appealed.

When claim not accepted for processing due to errors—wrong patient ID, incomplete information, formatting issues. Must be corrected and resubmitted. Different from denial.

A claim submitted with all required information and proper documentation that can be processed without additional information from the provider. Clean claims are typically paid faster than claims requiring additional review.

Series of custom clear plastic trays worn sequentially, gradually moving teeth. Removable for eating and cleaning. More aesthetic than braces but requires compliance. Not suitable for all cases.

Mental health professional with doctoral degree (PhD or PsyD) providing psychotherapy and psychological testing. Treats depression, anxiety, trauma, relationship issues, behavioral problems. Cannot prescribe medications (except in few states with additional training). Focuses on talk therapy and behavioral interventions.

Standard paper claim form for billing professional services from physicians, suppliers, other non-institutional providers. Used for Medicare, Medicaid, private insurance. Also called HCFA-1500. Contains patient demographics, diagnosis codes, procedure codes, charges. Most claims now submitted electronically.

Consolidated Omnibus Budget Reconciliation Act. A federal law requiring employers with 20+ employees to offer continued health coverage to employees and dependents who lose group coverage due to qualifying events like job loss or divorce. Coverage typically lasts 18-36 months and beneficiaries pay the full premium plus 2% administrative fee.

A structured, goal-oriented therapy focusing on the relationship between thoughts, feelings, and behaviors. CBT helps identify and change negative thought patterns and behaviors, teaching practical coping skills. Highly effective for anxiety, depression, OCD, PTSD, and many other conditions.

Your percentage share of costs for covered services after meeting your deductible. With 20% coinsurance, you pay $20 of a $100 office visit while insurance covers $80. Unlike fixed copays, coinsurance means your costs vary based on the service price, making expensive procedures more costly until you reach your out-of-pocket maximum.

Procedure examining inside of colon using flexible tube with camera. Screens for colon cancer, investigates symptoms like bleeding or pain. Can remove polyps and take biopsies during procedure. Requires bowel preparation day before. Done under sedation. Key preventive procedure, recommended at age 45-50.

Cancer of colon or rectum, usually beginning as polyps. Regular screening can detect and remove polyps before they become cancer. Symptoms include blood in stool, abdominal pain, weight loss, fatigue. Treatment depends on stage: surgery, chemotherapy, radiation. Highly treatable when caught early.

An insurance pricing method where premiums for the same plan are the same for all enrollees in a geographic area, regardless of health status. Under the ACA, premiums can only vary based on age, tobacco use, geographic rating area, and family size.

Custom-made medication prepared by pharmacist mixing individual ingredients to meet specific patient needs. Used when commercial product unavailable or unsuitable (allergy to inactive ingredient, different strength needed, different dosage form). More expensive. Not FDA-approved. Quality depends on compounding pharmacy practices.

Thorough evaluation of eye health and vision including visual acuity test, refraction (prescription determination), eye muscle test, peripheral vision test, eye pressure measurement, and dilated eye examination. Recommended every 1-2 years depending on age and risk factors.

Ongoing monitoring and approval process during extended treatments or hospital stays to ensure continued medical necessity. Insurance reviews progress periodically to determine if ongoing care remains appropriate and covered.

Chronic condition where heart cannot pump enough blood to meet body needs. Causes fluid buildup in lungs and tissues, shortness of breath, fatigue, swelling. Results from coronary disease, high blood pressure, heart valve problems, or cardiomyopathy. Requires lifelong management with medications, diet, monitoring.

Maximum amount plan pays for contact lenses instead of eyeglasses, usually per year. Typically $100-150. You choose between eyeglasses or contacts each benefit period, not both.

Small corrective lenses placed directly on eye surface. Types include soft (flexible, comfortable, most popular) and rigid gas permeable (harder, sharper vision, more durable). Require proper cleaning and replacement schedule.

Residential community offering continuum of care from independent living through assisted living to skilled nursing on one campus. Residents can age in place, moving to higher care levels as needed. Typically requires large upfront entrance fee plus monthly charges. Provides long-term care security.

Drugs regulated by DEA due to abuse potential, categorized in schedules I-V. Schedule II includes medications with accepted uses but high abuse potential (opioid pain relievers, stimulants like Adderall). Require special prescribing and dispensing procedures.

DEA classification system for drugs based on medical use and abuse potential. Schedule I (highest abuse potential, no accepted medical use) through Schedule V (lowest abuse potential). Schedules II-V are available by prescription with varying restrictions.

Dollar amount multiplied by total RVUs to calculate Medicare payment. Single conversion factor for most physician services. Adjusted annually by Congress or formula. 2023 factor is about $33. Geographic practice cost indices adjust for local costs. Final payment = RVU × CF × GPCI.

The process of determining which insurance plan pays first when a person has coverage from multiple sources. The primary plan pays first, then the secondary plan pays some or all of the remaining costs, up to the total charge.

A fixed dollar amount paid at the time of service for specific healthcare visits or prescriptions. You might pay $30 for a doctor's visit or $15 for a generic prescription. The predictability of copays helps budget for routine care, though they typically don't count toward your deductible.

Umbrella term for chronic lung diseases including emphysema and chronic bronchitis. Progressive condition making breathing difficult. Primary cause is smoking. Symptoms include persistent cough, phlegm production, shortness of breath, wheezing. No cure but treatments can slow progression.

Open-heart surgery creating new route around blocked coronary arteries using blood vessel from another body part. Restores blood flow to heart muscle. Major surgery requiring several days hospitalization and months recovery. Improves symptoms and prolongs life in appropriate patients.

Most common heart disease, occurring when arteries supplying heart become damaged or diseased, usually by cholesterol deposits (plaque). Reduced blood flow can cause chest pain (angina), heart attack. Risk factors include high cholesterol, high blood pressure, smoking, diabetes. Treated with lifestyle changes, medications, procedures, surgery.

Procedure inserting small mesh tube (stent) into coronary artery during angioplasty to keep artery open after balloon dilation. Stents can be bare metal or drug-eluting (releasing medication to prevent re-narrowing). Requires blood thinners afterward. May need multiple stents.

Employment that qualifies for Minnesota PFML benefits. Includes full-time, part-time, and seasonal workers. Excludes federal employees, independent contractors (unless opted in), and self-employed individuals (unless opted in).

Five-digit standardized codes describing medical procedures, services, treatments. Maintained by American Medical Association. Used for billing—each code determines reimbursement. Examples: 99213 (office visit), 99285 (emergency visit), 70450 (CT head).

Surgery opening skull to access brain. Bone flap temporarily removed, brain surgery performed, bone replaced. Treats brain tumors, aneurysms, blood clots, epilepsy, other brain conditions. Major surgery requiring intensive care. Recovery depends on reason for surgery. Risks include infection, bleeding, neurological deficits.

Supplemental insurance that pays a lump sum benefit if the policyholder is diagnosed with a covered critical illness such as cancer, heart attack, stroke, or organ transplant. The benefit can be used for any purpose, including medical expenses, lost income, or non-medical costs.

Chronic inflammatory bowel disease causing inflammation anywhere in digestive tract from mouth to anus, most commonly in small intestine. Symptoms include diarrhea, abdominal pain, weight loss, fatigue. Requires ongoing medication, sometimes biologics or immunosuppressants. May require surgery for complications.

Tooth-shaped covering placed over damaged tooth, restoring shape, size, strength, and appearance. Made of porcelain, ceramic, metal, or combination. Typically 50% covered. Major restorative service requiring multiple visits. Lasts 10-15 years with care.

Computed Tomography uses X-rays to create detailed cross-sectional images of body. Faster than MRI. Good for detecting bone injuries, lung disease, cancer, internal injuries. Uses radiation. May require contrast dye. Takes 10-30 minutes.

Five-digit numeric codes describing medical, surgical, diagnostic procedures and services. Published by American Medical Association. Used universally for billing and reporting. Updated annually. Different codes for office visits (99xxx), surgery (10xxx-69xxx), imaging, lab work. Determines reimbursement.

Condition caused by prolonged exposure to high cortisol levels from body producing too much or from corticosteroid medications. Causes weight gain (especially face and upper back), purple stretch marks, thin skin, muscle weakness, osteoporosis. Treatment depends on cause: surgery, radiation, medication reduction.

Non-medical care assisting with ADLs—help with bathing, dressing, eating, toileting, walking, supervision. Distinguished from skilled care (requires medical professionals). Most long-term care is custodial. Medicare doesn't cover custodial care; Medicaid does for eligible individuals.

Inherited disorder causing severe lung and digestive problems. Thick, sticky mucus clogs airways causing infections and respiratory failure, blocks pancreatic ducts affecting digestion. Diagnosed by genetic testing or sweat test. Requires daily treatments including airway clearance, enzyme supplements, antibiotics. Median survival age increasing with new treatments.

Procedure examining inside of bladder and urethra using thin tube with camera inserted through urethra. Investigates blood in urine, frequent UTIs, bladder problems. Can take biopsies, remove small tumors or stones. Done under local anesthesia or sedation. May cause temporary discomfort urinating.

The number of days a dispensed medication is expected to last based on the prescribed directions. Used to calculate when a refill is due and to measure adherence. Some plans limit days supply or require mail-order for 90-day supplies.

The amount you must pay out-of-pocket for covered services before your insurance begins sharing costs. If your deductible is $2,000, you pay 100% of covered services until reaching that threshold, then cost-sharing through copays or coinsurance begins. Deductibles reset annually, typically on January 1. Plans with higher deductibles usually have lower monthly premiums.

Surgery implanting electrodes in specific brain areas connected to pulse generator under skin near collarbone. Treats Parkinson s disease, essential tremor, dystonia, obsessive-compulsive disorder. Electrodes deliver electrical impulses modulating brain activity. Programmable. Improves symptoms but not curative.

Blood clot in deep vein, usually in legs. Can cause leg pain and swelling. Dangerous because clot can break loose and travel to lungs causing pulmonary embolism. Risk factors include prolonged sitting, surgery, pregnancy, certain medications, smoking. Treated with blood thinners. Can be life-threatening.

General term for loss of memory and other thinking abilities severe enough to interfere with daily life. Alzheimer's disease causes 60-80% of cases. Other causes include vascular dementia, Lewy body dementia, frontotemporal dementia. Not a normal part of aging. Progressive and currently irreversible.

Comprehensive or periodic evaluation of oral health. Includes checking teeth, gums, bite, and oral cancer screening. Typically covered 100% once or twice yearly.

Titanium post surgically placed in jawbone acting as artificial tooth root. Topped with crown, bridge, or denture. Most natural-looking and functional replacement. Very expensive ($3,000-6,000 per tooth). Often not covered or limited coverage.

Coverage for oral healthcare services separate from medical insurance. Three main types: dental HMO (limited to network, requires primary dentist), dental PPO (flexibility to see any dentist, lower costs in-network), and dental indemnity (traditional fee-for-service).

Removable replacement for missing teeth and surrounding tissues. Complete dentures replace all teeth; partial dentures replace some teeth when natural teeth remain. Made of acrylic, metal, or combination. Typically 50% covered. Require adjustment period.

A pre-tax account for childcare or adult dependent care expenses that enable you to work. Can cover daycare, preschool, before/after school programs, and adult day care for qualifying dependents.

Mental health disorder causing persistent feelings of sadness and loss of interest. Affects thinking, feeling, and ability to function. Symptoms include depressed mood, loss of pleasure, sleep/appetite changes, fatigue, difficulty concentrating. Treatable with therapy, medication, or both.

Physician specializing in skin, hair, nail disorders. Treats acne, eczema, psoriasis, skin cancer, rashes, hair loss. Performs skin biopsies, excisions, cosmetic procedures. Important for skin cancer screening and chronic skin conditions. May require referral depending on insurance.

Diabetes complication damaging blood vessels in retina, leading cause of blindness in working-age adults. Can progress without symptoms until advanced. All diabetics at risk. Requires regular dilated eye exams. Treated with laser, injections, or surgery.

Classification system grouping hospital inpatient stays into categories for payment purposes. Based on diagnosis, procedures, age, sex, discharge status. Medicare and many insurers pay fixed amount per DRG regardless of actual costs. Incentivizes efficient care. Approximately 750 DRGs.

Originally developed for borderline personality disorder, DBT combines CBT with mindfulness practices. Teaches four core skills: mindfulness (staying present), distress tolerance (coping with crisis), emotion regulation (managing intense feelings), and interpersonal effectiveness (healthy relationships).

Treatment removing waste and excess fluid from blood when kidneys cannot. Hemodialysis uses machine and filter, typically 3 times weekly in center for 3-4 hours. Peritoneal dialysis uses catheter and abdominal lining as filter, done at home daily. Lifesaving but demanding, awaiting transplant.

Food and nutrition expert with bachelor's or master's degree helping people make healthy dietary choices. Provides medical nutrition therapy for diabetes, kidney disease, heart disease, weight management, eating disorders. Registered Dietitian Nutritionist (RDN) is credentialed professional. May require referral.

Examination of retina and optic nerve after dilating pupils with eye drops. Allows doctor to see back of eye more completely, detecting problems like diabetic retinopathy, macular degeneration, retinal detachment. Causes temporary light sensitivity and blurred near vision lasting several hours.

An instruction from a prescriber requiring the pharmacist to dispense the brand-name drug as written and not substitute a generic equivalent. Increases patient cost-sharing on most plans. Sometimes abbreviated as DAW with numeric codes indicating reason.

Inflammation or infection of pouches (diverticula) that develop in intestinal wall, usually colon. Causes abdominal pain, fever, nausea, change in bowel habits. Can lead to complications including abscess, perforation, fistula. Treated with antibiotics, liquid diet, sometimes surgery. More common with age.

Health insurance coverage extended to employee's domestic partner (same-sex or opposite-sex partner in committed relationship but not married). Not all employers offer this. Tax treatment may differ from spousal coverage. Some states recognize domestic partnerships differently. Increasingly being replaced by same-sex marriage coverage.

When payer changes submitted code to lower-level code, reducing reimbursement. Can happen if documentation insufficient to support level billed, bundling rules apply, or codes inconsistent. Not always fraud - sometimes necessary. Provider can appeal with better documentation.

Illegal transfer of controlled substances from legitimate distribution channels to illicit market. Includes theft, doctor shopping, prescription fraud, employee pilferage. Major concern with opioids. Pharmacies and prescribers must monitor and report suspicious activity. DEA investigates and prosecutes. Can result in loss of DEA license, criminal charges.

A unique identifier assigned by the DEA to healthcare providers authorized to prescribe controlled substances. Required on prescriptions for scheduled drugs. Format includes two letters, six digits, and one check digit.

When two or more medications, supplements, or foods affect each other's effectiveness or safety. Can increase side effects, reduce effectiveness, or create new problems. Pharmacists screen for interactions when dispensing. Can be minor to life-threatening.

Payments from drug manufacturers to PBMs or health plans, typically based on formulary placement or market share. Rebates lower net drug costs but are not transparent to patients and may increase list prices. Subject to increasing regulatory scrutiny.

Manufacturer or FDA-requested removal of a drug from the market due to safety issues or defects. Class I (dangerous or potentially fatal), Class II (temporary health problem or slight threat), or Class III (unlikely to cause adverse effects). Pharmacies must notify patients.

A systematic review of prescribing, dispensing, and patient use of medications to ensure appropriate drug therapy. Includes prospective review before dispensing, concurrent review during therapy, and retrospective review of past use patterns.

Serious mental health conditions involving persistent disturbance of eating behaviors. Types include anorexia nervosa (restriction and fear of weight gain), bulimia nervosa (binge eating with compensatory behaviors), and binge eating disorder (recurrent binge episodes without purging).

Ultrasound of heart showing structure and function. Visualizes chambers, valves, blood flow. Detects heart disease, valve problems, congenital defects, blood clots, fluid around heart. Types include transthoracic (through chest wall), transesophageal (through esophagus), stress echo. Non-invasive, no radiation. Key cardiac diagnostic test.

Philosophy and approach to long-term care focusing on creating vibrant, human-centered environments rather than institutional settings. Emphasizes companionship, meaningful activities, spontaneity, variety. Brings plants, animals, children into care settings. Reduces loneliness, helplessness, boredom. Alternative model to traditional nursing home care. Requires cultural transformation of facility.

The first day of absence associated with an approved Minnesota PFML leave, which determines when the benefit year begins and when leave duration is calculated.

Non-invasive test recording heart's electrical activity. Small electrodes placed on chest, arms, legs detect electrical signals. Shows heart rhythm, rate, abnormalities suggesting heart attack, arrhythmia, or other problems. Quick, painless, done in office.

Test recording electrical activity of heart using electrodes on chest, arms, legs. Detects heart rhythm abnormalities, heart attacks, heart disease. Quick, painless, non-invasive. Standard test in emergency departments, pre-operative evaluation, routine physicals. Can be routine (resting ECG) or during exercise (stress test). Essential cardiac diagnostic tool.

Test recording electrical activity of brain using electrodes attached to scalp. Detects abnormalities in brain waves. Used to diagnose epilepsy, sleep disorders, brain tumors, brain injury, encephalitis. Can be routine (30-60 minutes) or prolonged (24 hours or more). Non-invasive and painless. Patient may be asked to sleep or receive stimulation during test.

Electronic exchange of healthcare information in standardized format between computer systems. Used for claims submission (837 transactions), eligibility verification (270/271), remittance advice (835), prior authorization. Faster and more accurate than paper. HIPAA mandates standard transactions.

A family deductible structure where each family member has an individual deductible that applies to their own care. Once an individual deductible is met, that person gets cost-sharing benefits even if the family deductible is not met.

A specialized therapy primarily for trauma and PTSD involving guided eye movements while recalling traumatic memories. Helps the brain reprocess traumatic experiences, reducing their emotional intensity. Uses bilateral stimulation (eye movements, sounds, or tapping) to facilitate healing.

Final stage of chronic kidney disease where kidneys have lost nearly all ability to function. Requires dialysis or kidney transplant to sustain life. Patients qualify for Medicare regardless of age. Requires intensive ongoing treatment and medical management.

Physician specializing in hormone disorders and diseases of endocrine glands. Treats diabetes, thyroid disorders, metabolic disorders, pituitary problems, adrenal diseases, bone metabolism disorders, reproductive hormone issues. Orders specialized tests and manages complex medication regimens.

Specialist in diagnosing and treating tooth pain, performing root canals and other procedures involving tooth interior. Expert in saving natural teeth.

Condition where tissue similar to uterine lining grows outside uterus, causing pelvic pain, painful periods, pain during intercourse, infertility. Estrogen-dependent. Diagnosed by laparoscopy. Treated with pain medications, hormonal therapy, surgery. No cure. Symptoms often improve after menopause.

Procedure examining inside of upper digestive tract using flexible tube with camera inserted through mouth. Visualizes esophagus, stomach, duodenum. Investigates symptoms, takes biopsies, treats bleeding, removes foreign objects. Done under sedation. Low-risk diagnostic and therapeutic procedure.

Neurological disorder causing recurrent seizures due to abnormal electrical activity in brain. Seizures vary from brief lapses of attention to severe convulsions. Causes include genetics, head trauma, brain infections, stroke. Controlled with anti-seizure medications in most patients. Some may benefit from surgery or devices.

Ten categories of services health insurance plans must cover under the ACA: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, and pediatric services.

Plans covering services only within the provider network (except emergencies), but not requiring primary care physicians or specialist referrals. EPOs balance cost and flexibility—lower premiums than PPOs but more freedom than HMOs.

Health insurance designed for people living or working outside their home country for extended periods. Provides international coverage, emergency evacuation, and may include repatriation benefits. Different from travel insurance in duration and comprehensiveness.

Statement from insurer (NOT a bill) explaining what was paid for services, insurance covered, and patient owes. Shows charges, allowed amounts, insurance payments, patient responsibility.

Independent review of denied claim/service by third party outside insurance company. Available after exhausting internal appeals or for certain urgent denials. Reviewer's decision usually binding. Patients have right to external review under ACA.

Corrective lenses mounted in frames worn on face. Most common vision correction. Types include single-vision (one prescription), bifocals (two prescriptions), and progressives (gradual transition between prescriptions).

Enhanced premium tax credits were temporary improvements to ACA subsidies provided by ARPA (2021-2025). They removed the 400% FPL income cap (allowing higher earners to qualify), increased subsidy amounts for lower-income enrollees, and capped premiums at 8.5% of household income regardless of income level. These enhancements expired December 31, 2025.

Leave taken to care for a family member with a serious health condition under Minnesota PFML. This includes caring for a spouse, domestic partner, child, parent, sibling, grandparent, grandchild, or other close relations.

Primary care specialty treating patients of all ages from newborns to elderly. Broad training covering many areas—pediatrics, adult medicine, women's health, some procedures. Can be sole physician for entire family. Emphasizes preventive care and chronic disease management.

Treatment involving family members to improve communication, resolve conflicts, and address family dynamics contributing to mental health issues. Helps families understand how their interactions affect individual members.

Chronic disorder causing widespread musculoskeletal pain, fatigue, sleep problems, cognitive difficulties (fibro fog). Pain amplification due to abnormal pain processing. No cure but symptoms managed with medications (pain relievers, antidepressants), exercise, stress management, cognitive behavioral therapy. More common in women.

Material placed in tooth to repair cavity (tooth decay). Types include amalgam (silver-colored, durable, less expensive), composite (tooth-colored, more aesthetic), and gold or porcelain (most expensive). Typically 50-80% covered.

Insurance that pays a predetermined amount for specific medical events regardless of actual costs. For example, paying $500 per day for hospitalization. This supplements but does not replace comprehensive health insurance since it does not cover all medical expenses.

An employer-owned account funded with pre-tax dollars for eligible healthcare expenses. Unlike HSAs, FSAs are "use-it-or-lose-it"—unused funds generally don't roll over at year's end, though some plans allow small carryovers or grace periods.

Application of concentrated fluoride to teeth preventing decay. Typically covered for children; adult coverage varies. Can be foam, gel, varnish, or rinse.

A tiered list of prescription drugs covered by your plan. Tier 1 typically includes generic drugs with lowest copays, while higher tiers include brand-name and specialty drugs with higher costs. Formularies also indicate which drugs require prior authorization or step therapy.

Maximum amount vision plan pays toward eyeglass frames, typically $100-200 every 1-2 years. Exceeding allowance means paying difference out-of-pocket. Some plans offer higher allowances for in-network providers.

The Federal Poverty Level is an income measure issued annually by the Department of Health and Human Services used to determine eligibility for various government programs including ACA premium tax credits. For 2026 coverage, 100% FPL is $15,650 for an individual and $32,150 for a family of four. ACA subsidies are available for those between 100-400% FPL (up to $62,600 individual / $128,600 family of four).

Hardened deposits forming in gallbladder from bile. Can cause sudden intense pain in upper right abdomen, nausea, vomiting. Many people have gallstones without symptoms. Complications include cholecystitis (gallbladder inflammation), pancreatitis, bile duct blockage. Symptomatic gallstones treated with gallbladder removal surgery.

Gap health insurance is short-term coverage designed to bridge periods without comprehensive health insurance, such as between jobs, after aging off a parent's plan at 26, or while waiting for employer coverage to begin. Gap plans typically last 1-12 months and may not cover pre-existing conditions or essential health benefits required under the ACA. Common alternatives include COBRA continuation coverage (expensive but comprehensive), short-term limited duration insurance (affordable but limited), or special enrollment in an ACA marketplace plan if you qualify due to a life event like job loss. In Minnesota, residents losing coverage may qualify for MinnesotaCare or Medical Assistance depending on income, or can enroll in MNsure marketplace plans during a 60-day special enrollment period.

Physician specializing in digestive system and liver diseases. Treats conditions including GERD, IBS, IBD, liver disease, pancreatitis, gallbladder disease. Performs endoscopy, colonoscopy, other procedures. Key for colon cancer screening and chronic digestive problems. Usually requires referral.

Chronic condition where stomach acid frequently flows back into esophagus, irritating lining. Causes heartburn, regurgitation, difficulty swallowing. Can damage esophagus over time. Risk factors include obesity, pregnancy, smoking. Treated with lifestyle changes, antacids, PPIs, H2 blockers. Severe cases may need surgery.

Primary dental care provider for patients of all ages. Performs examinations, cleanings, fillings, crowns, extractions, and other routine procedures. Refers to specialists for complex cases.

Mental health disorder causing persistent excessive worry about various aspects of life disproportionate to actual circumstances. Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance. Treated with therapy, anti-anxiety medications, or antidepressants.

Medication with same active ingredients, dosage, strength, route of administration, and intended use as brand-name counterpart. FDA-approved as therapeutically equivalent. Typically costs 80-85% less than brand-name versions. Must meet same quality and safety standards.

Professional (often nurse or social worker) specializing in assisting elderly and families with long-term care planning. Assesses needs, develops care plans, coordinates services, monitors care, communicates with family. Private pay service. Helps families navigate complex long-term care system. Not covered by insurance.

Early stage gum disease with inflammation, redness, and bleeding. Reversible with proper oral hygiene and professional cleaning. No bone loss yet.

Group of eye diseases damaging optic nerve, usually from high intraocular pressure. Leading cause of irreversible blindness. Often no early symptoms (silent thief of sight). Detected by comprehensive eye exam. Treated with eye drops, laser therapy, surgery to lower pressure. Vision loss is permanent but progression can be slowed.

Form of inflammatory arthritis caused by excess uric acid forming sharp crystals in joints. Causes sudden severe pain, swelling, redness, typically in big toe. Attacks come and go. Can lead to permanent joint damage if untreated. Managed with medications to reduce uric acid, anti-inflammatory drugs during attacks, dietary changes.

Additional time after a premium payment due date during which coverage continues and the policyholder can pay the premium without losing coverage. For marketplace plans with advance premium tax credits, the grace period is 90 days. For other plans, it varies.

A health insurance plan that was in place when the ACA became law on March 23, 2010, and has maintained continuous coverage. These plans are exempt from certain ACA requirements but must still comply with some consumer protections.

Therapy involving multiple people (typically 6-12) working through similar challenges together under a therapist's guidance. Provides peer support, reduces isolation, allows practice of social skills, and offers multiple perspectives.

An exemption from the ACA individual mandate penalty available to people facing financial or other hardships that make obtaining insurance difficult. Examples include homelessness, eviction, bankruptcy, domestic violence, or death of a close family member.

An organization where members with common ethical or religious beliefs share medical expenses. These are not insurance and are not regulated like insurance. Members pay a monthly share amount, and the ministry facilitates sharing of eligible medical expenses among members.

Insurance plans requiring you to select a primary care physician who coordinates all care and provides referrals to specialists. Coverage is limited to in-network providers except for emergencies. HMOs typically offer the lowest premiums and out-of-pocket costs but provide the least flexibility in choosing providers.

An employer-funded account that reimburses employees for qualified medical expenses. Your employer owns the account, determines covered expenses, and contributes all funds. HRAs can often roll over year to year at employer discretion but typically aren't portable if you leave your job.

A personal savings account for medical expenses that you own and control, offering triple tax advantages: pre-tax contributions, tax-free growth, and tax-free withdrawals for qualified expenses. Only available with HDHPs. Funds roll over indefinitely, stay with you if you change jobs, and can be invested for growth.

Coding system for products, supplies, services not included in CPT codes. Level I is CPT codes. Level II (HCPCS codes) covers ambulance services, durable medical equipment, prosthetics, orthotics, supplies. Five-character alphanumeric. Used primarily for Medicare billing.

Occurs when blood flow to part of heart muscle blocked, usually by blood clot in coronary artery. Heart muscle begins dying without oxygen. Symptoms include chest pain/pressure, shortness of breath, nausea, cold sweat. Medical emergency requiring immediate treatment.

Chronic condition where heart's pumping ability weakened, unable to meet body's needs. Blood may back up into lungs and other organs. Causes include coronary artery disease, high blood pressure, heart attack damage. Symptoms include shortness of breath, fatigue, swelling in legs/feet.

Damage to one or more heart valves preventing valves from opening fully or closing completely, disrupting blood flow. Can be present from birth or develop over time. Symptoms include fatigue, shortness of breath, irregular heartbeat, chest pain. Treatment ranges from monitoring to medications to valve repair or replacement surgery.

Physician specializing in blood disorders and diseases. Treats anemia, bleeding disorders, blood clots, leukemia, lymphoma, sickle cell disease. Often combined with oncology training. Performs bone marrow biopsies, interprets blood tests. May manage patients requiring blood transfusions or anticoagulation.

Viral infection attacking liver causing acute or chronic disease. Spread through body fluids. Can lead to cirrhosis, liver cancer, liver failure. Preventable with vaccine. Chronic infection treated with antiviral medications but not cured. Requires lifelong monitoring and treatment.

Viral infection causing liver inflammation and damage. Spread through blood-to-blood contact. Often chronic infection leading to serious liver problems including cirrhosis and liver cancer. Many people unaware they are infected. Now curable with direct-acting antiviral medications taken for 8-12 weeks.

Surgery repairing weakness in abdominal wall where tissue or organ pushes through. Types include inguinal, umbilical, hiatal, incisional. Can be open or laparoscopic. Often uses mesh to strengthen area. Outpatient or short stay. Quick recovery. Hernias do not heal on their own and can become strangulated.

Plans with lower monthly premiums but higher deductibles ($1,600+ for individuals, $3,200+ for families in 2024). HDHPs qualify you to open a Health Savings Account (HSA), making them attractive for healthy individuals who want to build tax-advantaged healthcare savings.

Medications that carry increased risk of adverse effects, especially in elderly patients. The Beers Criteria lists potentially inappropriate medications for older adults. Plans may require additional monitoring or impose quantity limits on high-risk drugs.

Surgery replacing damaged hip joint with artificial joint (prosthesis). Usually due to arthritis or fracture. Relieves pain, improves mobility. Hospital stay 1-4 days, recovery 3-6 months. Implant typically lasts 15-20 years.

Portable device that continuously records heart rhythm for 24-48 hours (or longer) while patient goes about normal activities. Used to detect irregular heart rhythms not captured on standard ECG. Patient wears electrodes on chest connected to small recording device. Keeps diary of symptoms and activities. Non-invasive. Results analyzed by cardiologist.

Personal care worker helping with daily activities like bathing, dressing, meal preparation, light housekeeping, medication reminders. Not medical care - that is skilled nursing. Can be private pay or through home health agency. May be covered by Medicaid or long-term care insurance. Not typically covered by Medicare alone.

Medical care provided at home by healthcare professionals. Includes skilled nursing, physical therapy, occupational therapy, speech therapy, aide services. Medicare covers if homebound, under physician's care, need skilled services. Intermittent care only. Helps people recover at home or manage chronic conditions.

Non-medical assistance with household tasks like cleaning, laundry, shopping, meal preparation. Helps people remain independent at home. Private pay or sometimes Medicaid waiver programs. Not covered by Medicare. Part of comprehensive home care services. Less expensive than institutional care.

Specialized care for people in final stages of terminal illness focusing on comfort and quality of life rather than cure. Interdisciplinary team provides medical care, pain management, emotional and spiritual support. Can be provided at home, hospital, nursing home, or hospice facility. Medicare Hospice Benefit covers when prognosis is six months or less.

Supplemental insurance that pays a fixed daily, weekly, or monthly benefit for hospital stays. Benefits are paid directly to the policyholder regardless of other insurance and can be used to help cover deductibles, copayments, or non-medical expenses.

Physician specializing in care of hospitalized patients. Coordinates all aspects of inpatient care including consultations, procedures, medications, discharge planning. Available 24/7 in hospital. Improves efficiency and communication. Does not see patients in outpatient setting. Growing specialty replacing traditional inpatient care by primary doctors.

Virus attacking immune system, specifically CD4 cells (T cells), weakening ability to fight infections. Without treatment progresses to AIDS. Spread through body fluids. Now managed as chronic condition with antiretroviral therapy, allowing near-normal lifespan. Prevention includes PrEP medications and safe practices.

Condition where distant objects clearer than close objects. Light focuses behind retina. Can cause eye strain and headaches. Corrected with convex (plus) lenses. Young people may compensate through focusing.

High blood pressure condition

Condition where blood pressure consistently elevated (≥130/80 mm Hg). Often called "silent killer" because usually no symptoms until serious damage occurs. Major risk factor for heart disease, stroke, kidney disease. Treated with lifestyle modifications and medications.

Overactive thyroid gland producing excessive thyroid hormone, speeding metabolism. Symptoms include unintentional weight loss, rapid heartbeat, anxiety, tremor, sweating, heat sensitivity. Caused by Graves disease, thyroid nodules, or thyroiditis. Treated with anti-thyroid medications, radioactive iodine, or surgery.

Underactive thyroid gland producing insufficient thyroid hormone, slowing metabolism. Symptoms include fatigue, weight gain, cold sensitivity, constipation, dry skin, depression, muscle weakness. Most commonly caused by autoimmune disease (Hashimoto's). Treated with daily thyroid hormone replacement medication, typically levothyroxine.

Alphanumeric codes identifying diagnoses, diseases, injuries, conditions. Currently ICD-10. Used to explain why services were necessary. Insurers use to determine medical necessity and coverage. Example: E11.9 (Type 2 diabetes).

Device implanted under skin monitoring heart rhythm and delivering electric shock if life-threatening fast rhythm detected. Treats ventricular arrhythmias that can cause sudden cardiac death. Similar to pacemaker but can deliver stronger shock. Requires regular monitoring and eventual battery replacement.

Inability to perform regular work, attend school, or conduct daily activities due to a serious health condition, treatment, or recovery. Required for Minnesota PFML medical leave eligibility.

Medicaid coverage gap where individuals earning slightly above Medicaid eligibility limits may face unaffordable marketplace premiums despite premium subsidies, especially in non-expansion states. Creates a disincentive to earn additional income.

Senior housing providing apartment-style living with amenities like meals, housekeeping, activities, transportation. No medical care or assistance with daily activities provided. For active seniors who can live independently. Private pay, not covered by insurance. May offer continuum of care if health declines.

Physician specializing in infections caused by bacteria, viruses, fungi, parasites. Treats HIV/AIDS, hepatitis, tuberculosis, difficult infections, tropical diseases. Consults on antibiotic selection and resistance. Important for immunocompromised patients. Requires internal medicine training plus infectious disease fellowship.

The first seven days of Minnesota PFML leave, which must be paid retroactively after the employee meets the seven-day qualifying event requirement. For intermittent leave, this means seven total days (consecutive or non-consecutive) from the effective date.

24-hour care in locked psychiatric unit for people in acute crisis posing danger to themselves or others, or unable to care for themselves. Typical stay 5-10 days focused on stabilization through medication adjustment, safety, and discharge planning.

Complex daily activities required for independent living. Includes managing finances, shopping, meal preparation, housework, medication management, using phone, transportation. More complex than basic ADLs. Inability indicates need for assistance but may not require facility care. Important for independent living assessment.

Structured treatment program requiring multiple therapy sessions per week (typically 9-15 hours total) while living at home. More intensive than outpatient therapy but less restrictive than hospitalization. Often includes group therapy, individual therapy, and skills training.

Physician specializing in care of critically ill patients in intensive care unit (ICU). Manages ventilators, medications for unstable conditions, procedures. Available for emergencies. Board certified in critical care medicine. Often has training in internal medicine, anesthesiology, or surgery plus critical care fellowship.

A biosimilar that meets additional FDA standards showing it can be expected to produce the same clinical result as the reference product and can be safely switched. Can be automatically substituted by pharmacists in states allowing biosimilar substitution.

Facility providing less intensive care than skilled nursing facility but more than residential care. Serves people with mental retardation, developmental disabilities, or chronic conditions needing regular medical supervision but not continuous nursing. Primarily Medicaid-funded. Less common than SNFs.

Minnesota PFML leave taken in separate blocks of time rather than one continuous period. Can be as short as one minute up to one day per occurrence. Employees can take up to 480 hours (12 weeks) intermittently per benefit year.

Patient or provider request for insurance to reconsider denied claim or service authorization. First level of appeal reviewed by different reviewer than initial decision. Must be filed within specified timeframe (typically 180 days).

Primary care physicians for adults (18+). Training focused on prevention, diagnosis, treatment of adult diseases. Often manage complex, chronic conditions. Some internists subspecialize in areas like cardiology, gastroenterology, endocrinology.

Alphanumeric codes describing diagnoses and diseases. Used globally for health statistics and billing. ICD-10 is current version in US with over 70,000 codes. More specific than ICD-9. Required on claims to justify medical necessity. Updated annually. Determines coverage decisions.

Common disorder affecting large intestine causing cramping, abdominal pain, bloating, gas, diarrhea, constipation. Chronic condition requiring long-term management. Triggers include certain foods, stress, hormones. No cure but symptoms managed through diet, stress management, medications.

Detailed bill listing every charge separately with description, code, quantity, individual cost. More detailed than summary bill. Patients have right to request itemized bill to review charges for errors or duplicates.

Procedures removing or breaking up kidney stones. Methods include shock wave lithotripsy (sound waves), ureteroscopy (scope through urethra), percutaneous nephrolithotomy (scope through back). Choice depends on stone size and location. Most are minimally invasive. May require stent temporarily.

Surgery placing healthy donor kidney in person with kidney failure. Donor can be deceased or living. New kidney placed in lower abdomen, diseased kidneys usually left in place. Requires lifelong immunosuppression. Excellent outcomes when successful. Better than dialysis for quality and length of life.

Surgery replacing damaged knee joint with artificial joint. Most commonly due to osteoarthritis. Relieves pain, improves function. Hospital stay 1-3 days, intensive physical therapy, recovery 3-6 months.

Surgery removing portion of vertebral bone (lamina) to relieve pressure on spinal cord or nerves. Treats spinal stenosis, herniated disc causing nerve compression. Creates more space in spinal canal. Can be done as outpatient or short stay. Recovery several weeks. May be combined with fusion.

The health insurance market for businesses with typically more than 50 employees. These employers are subject to different regulations than small group and individual markets, including the employer mandate under the ACA.

Most common laser vision correction surgery. Reshapes cornea using laser to correct myopia, hyperopia, or astigmatism. Quick procedure (minutes per eye) with fast recovery. Results usually permanent. Expensive ($2,000-3,000 per eye), rarely covered by insurance.

A leave of absence (LOA) is an approved period of time away from work during which an employee maintains their job status but is not actively working. Leave can be paid or unpaid depending on the type, employer policy, and state law. Common types include medical leave for your own health condition, family leave to care for a relative, parental leave for bonding with a new child, military leave, and personal leave. Under the federal Family and Medical Leave Act (FMLA), eligible employees can take up to 12 weeks of unpaid, job-protected leave annually. Minnesota's Paid Family and Medical Leave (PFML) program, launching in 2026, provides partial wage replacement of up to $1,473 per week for up to 20 weeks of combined family and medical leave. Employees typically must provide advance notice and documentation, such as medical certification from a healthcare provider, to qualify for protected leave.

Cancer of blood-forming tissues including bone marrow and lymphatic system, causing production of abnormal white blood cells. Many types: acute vs chronic, lymphocytic vs myeloid. Symptoms include fatigue, frequent infections, easy bleeding, weight loss. Treatment includes chemotherapy, targeted therapy, stem cell transplant.

Mental health professional with master's degree providing psychotherapy and case management. Helps with mental health, substance abuse, life transitions, trauma. Works in agencies, hospitals, private practice. Cannot prescribe medications. Often covered by insurance with mental health benefits.

Retirement community offering continuum of care including independent living, assisted living, skilled nursing on one campus. Resident can transition between levels as needs change. Typically requires large entrance fee plus monthly fees. Provides housing and healthcare for life. Financially complex. Also called continuing care retirement community.

Health plan with restricted coverage and low benefit maximums. May only cover certain services or have annual or lifetime limits. Less expensive than comprehensive coverage but leaves significant gaps. Not ACA-compliant. Examples include mini-med plans, specified disease policies. Not adequate as sole health insurance.

An FSA that can be used alongside an HSA, covering only dental and vision expenses until you meet your HDHP deductible, then covering all qualified medical expenses.

Procedure removing small sample of liver tissue for laboratory analysis. Diagnoses liver disease, stages fibrosis, evaluates treatment response. Usually done with needle through skin (percutaneous) or through vein (transjugular). Done under local anesthesia or sedation. Brief recovery period. Generally low-risk.

State program where special long-term care insurance policies provide asset protection if purchaser eventually needs Medicaid. Dollar-for-dollar or total asset protection available. Policy must meet state requirements. Purchaser can keep assets equal to insurance benefits received even after qualifying for Medicaid. Available in participating states only.

Procedure inserting needle into lower spine to collect cerebrospinal fluid for testing or measure pressure. Diagnoses infections, bleeding, multiple sclerosis, cancer, other conditions. Can deliver medications. Done under local anesthesia. Temporary headache is common side effect. Low-risk diagnostic test.

Cancer beginning in lungs, most commonly caused by smoking but also occurs in never-smokers. Two main types: small cell and non-small cell. Often detected late due to lack of early symptoms. Treatment may include surgery, chemotherapy, radiation, targeted therapy, immunotherapy. Leading cause of cancer death.

Chronic autoimmune disease where immune system attacks own tissues, causing widespread inflammation and damage to joints, skin, kidneys, blood cells, brain, heart, lungs. Symptoms vary greatly. Often includes characteristic facial rash. Requires immunosuppressive medications. Lifelong condition with unpredictable flares.

Cancer of lymphatic system (part of immune system), beginning in lymphocytes. Two main types: Hodgkin lymphoma and non-Hodgkin lymphoma, each with many subtypes. Causes swollen lymph nodes, fever, weight loss, fatigue. Treated with chemotherapy, radiation, immunotherapy, stem cell transplant. Prognosis varies by type.

Eye disease causing central vision loss due to deterioration of macula (center of retina). Two types: dry (more common, gradual) and wet (rapid, severe). Leading cause of vision loss in older adults. No cure for dry type. Wet type treated with injections into eye. Risk factors include age, smoking, genetics.

A pharmacy that dispenses medications by mail, typically for maintenance medications taken regularly. Often offers 90-day supplies at lower cost-sharing than retail pharmacies. Required by some plans for certain medications after initial fills.

Mental health disorder causing persistent feelings of sadness, hopelessness, loss of interest in activities, affecting daily functioning. Symptoms include sleep changes, fatigue, difficulty concentrating, thoughts of death or suicide. Treated with antidepressants, psychotherapy, or combination. Can be chronic or episodic.

Surgery removing breast tissue, typically to treat or prevent breast cancer. Types include partial (lumpectomy), simple (all breast tissue), modified radical (breast and lymph nodes), radical (breast, lymph nodes, chest muscles). May be followed by reconstruction. Can be bilateral for prevention.

Obstetrician specializing in high-risk pregnancies. Manages complications like preeclampsia, gestational diabetes, multiple gestations, fetal abnormalities. Performs specialized ultrasounds and prenatal testing. Coordinates care with other specialists. Also called perinatologist. Requires obstetrics training plus MFM fellowship.

Maternity leave in Minnesota refers to time off work for pregnancy, childbirth, and bonding with a new child. Minnesota provides leave under multiple laws: the federal Family and Medical Leave Act (FMLA) offers up to 12 weeks of unpaid, job-protected leave for eligible employees at companies with 50+ workers. Minnesota's Paid Family and Medical Leave (PFML) program, launching in 2026, provides up to 12 weeks of paid bonding leave with partial wage replacement up to $1,473 per week. Pregnant employees may also qualify for PFML medical leave for pregnancy-related health conditions. Additionally, Minnesota's Parenting Leave Act requires employers with 21+ employees to provide up to 12 weeks of unpaid leave for birth or adoption. Employees can use Minnesota Earned Sick and Safe Time (ESST) for prenatal appointments and recovery.

The highest weekly benefit payment available under Minnesota PFML, set at the state's average weekly wage. For 2026, this amount is $1,423 per week.

Joint federal-state program providing free or low-cost coverage for low-income individuals, families with children, pregnant women, the elderly, and people with disabilities. Each state runs its own program within federal guidelines.

Medical Assistance is Minnesota's Medicaid program, providing free or low-cost health coverage to eligible low-income individuals and families. For 2026, single adults qualify with income up to $20,783 annually (138% FPL), while a family of four qualifies with income up to $42,662. Medical Assistance covers doctor visits, hospital care, prescriptions, mental health services, dental, vision, and long-term care. Unlike marketplace plans, there are no premiums, deductibles, or enrollment periods—Minnesotans can apply year-round through MNsure or county offices. Medical Assistance is a critical safety net for those who lose marketplace subsidies due to the 2026 subsidy cliff.

State program allowing Medicaid funding for home and community-based services as alternative to institutional care. Provides services like home care, adult day care, respite, personal care. Eligibility requirements vary by state. Must meet nursing home level of care. Limited funding, often waiting lists. Cost-effective alternative.

Healthcare services for pregnancy, prenatal care, incapacity due to pregnancy, childbirth, stillbirth, miscarriage, or related health conditions. Qualifies for Minnesota PFML medical leave.

The percentage of premium dollars an insurer spends on medical care and quality improvement versus administrative costs and profit. Under the ACA, insurers must spend at least 80% (individual/small group) or 85% (large group) on medical care or issue rebates to policyholders.

Requirement that services must be reasonable and necessary for diagnosis or treatment of illness or injury. Payers will not cover services deemed not medically necessary. Determined by diagnosis codes, clinical guidelines, coverage policies. Provider documentation must support medical necessity.

The process of evaluating an applicant s health status to determine eligibility and premium rates. Prohibited for ACA-compliant plans but still used for some non-ACA plans like short-term insurance and in some states for grandfathered plans.

Federal health insurance for people 65 and older, plus certain younger individuals with disabilities or specific conditions. Medicare divides into parts covering different services, and beneficiaries must actively enroll.

Private health insurance plans that provide Medicare Part A and Part B benefits and usually Part D prescription drug coverage. Also called Medicare Part C. Plans may offer extra benefits like dental, vision, and hearing coverage. Enrollees must have both Part A and Part B.

October 15 - December 7 each year when Medicare beneficiaries can change their coverage for the following year. Can switch between Original Medicare and Medicare Advantage, change Part D plans, or join/drop Medigap (if eligible).

The coverage gap in Medicare Part D where beneficiaries paid full price for drugs after initial coverage ended and before catastrophic coverage began. The Affordable Care Act gradually closed this gap, with 25% coinsurance in 2020 and beyond for both brand and generic drugs.

List of approved amounts Medicare pays for services and procedures. Different schedules for physicians, clinical lab, ambulance, durable medical equipment. Based on resource costs, practice expenses, malpractice costs. Updated annually. Geographic adjustments. Basis for many commercial insurance payments.

Covers inpatient hospital stays, skilled nursing facility care (following hospitalization), hospice care, and some home health services. Most people don't pay premiums if they worked at least 10 years, though deductibles and coinsurance for extended stays apply.

Covers doctor visits, outpatient care, preventive services, durable medical equipment, lab tests, and many vaccines. Requires a monthly premium and typically includes 20% coinsurance after meeting the annual deductible.

Private insurance plans bundling Parts A and B (usually with Part D) into one plan with potential extra benefits like dental, vision, and wellness programs. Plans typically require using network providers.

Prescription drug coverage provided by private insurers approved by Medicare. Beneficiaries pay a monthly premium plus cost-sharing for medications. Plans have formularies, tiers, and may require prior authorization or step therapy for certain drugs.

Any preventable event causing inappropriate medication use or patient harm while medication is in the control of healthcare professional, patient, or consumer. Includes prescribing, transcribing, dispensing, administering, and monitoring errors.

A measure of medication adherence calculated as the proportion of days a patient has medication available. An MPR of 80% or higher is generally considered adherent. Used by health plans to identify non-adherent patients and measure quality.

Process of creating accurate list of all medications patient is taking and comparing it to medications ordered during care transition (admission, transfer, discharge). Prevents errors including omissions, duplications, dosing errors, drug interactions. Required by Joint Commission. Critical patient safety practice. Should be done at every care transition.

A service provided by pharmacists to optimize drug therapy outcomes for patients with multiple medications or chronic conditions. Includes comprehensive medication review, personal medication record, medication action plan, intervention and referral, and documentation.

Supplemental insurance sold by private insurers to help cover out-of-pocket costs not paid by Original Medicare, such as copayments, coinsurance, and deductibles. Also called Medicare Supplement Insurance. Standardized plans labeled A through N with different coverage levels.

Most serious type of skin cancer developing in melanocytes (pigment-producing cells). Caused primarily by UV radiation exposure. Can spread to other organs if not caught early. Detected through skin exams looking for abnormal moles. Treatment includes surgical excision, immunotherapy, targeted therapy. Highly curable when caught early.

Specialized residential setting for people with dementia (Alzheimer's, other types). Provides 24-hour supervision in secure environment preventing wandering. Staff trained in dementia care. Activities designed for cognitive impairment. May be standalone facility or unit within assisted living/nursing home.

Specialized assisted living or skilled nursing facility for people with Alzheimer's disease or other dementia. Provides secure environment, specialized staff training, structured activities, monitoring. Higher level of supervision than standard assisted living. Typically private pay. May accept long-term care insurance.

Cluster of conditions occurring together increasing risk of heart disease, stroke, diabetes. Conditions include high blood pressure, high blood sugar, excess abdominal fat, abnormal cholesterol levels. Having three or more defines syndrome. Treated with lifestyle changes and medications for individual components.

Health insurance that meets ACA standards, protecting individuals from the individual mandate penalty. Includes employer-sponsored plans, individual market plans, Medicare, Medicaid, CHIP, and certain other coverage types.

A requirement that employer-sponsored health plans cover at least 60% of the total allowed costs of benefits (actuarial value) and provide substantial coverage for inpatient and physician services. Plans meeting this standard satisfy the employer mandate.

Two-character code added to CPT or HCPCS code providing additional information about service performed. Indicates service was altered but not changed in definition. Examples: -50 (bilateral procedure), -25 (significant separately identifiable service), -59 (distinct procedural service). Affects reimbursement. Proper use prevents claim denial. Can be alpha, numeric, or alphanumeric.

Medications that even out mood swings in bipolar disorder. Lithium is the gold standard mood stabilizer. Anticonvulsants also used include valproic acid (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol).

Magnetic Resonance Imaging uses powerful magnets and radio waves to create detailed images of organs and tissues. Non-invasive, no radiation. Used to diagnose wide range of conditions: brain/spine problems, joint injuries, tumors, heart disease. Requires lying still in narrow tube for 15-90 minutes.

Health insurance plan offered through ACA marketplaces in multiple states. Administered by Office of Personnel Management (same agency managing federal employee health benefits). Must meet specific requirements including offering same benefits in all states. Provides option for people who move frequently or have homes in multiple states.

Autoimmune disease where immune system attacks protective covering of nerve fibers, causing communication problems between brain and body. Symptoms vary widely: numbness, weakness, vision problems, difficulty walking, fatigue, cognitive issues. No cure but disease-modifying therapies can slow progression and manage symptoms.

Autoimmune disorder causing muscle weakness that worsens with activity and improves with rest. Affects eye muscles, facial muscles, swallowing, breathing. Caused by antibodies blocking nerve-muscle communication. Treated with medications to improve nerve-muscle transmission, immunosuppressants, thymectomy. Can cause life-threatening myasthenic crisis.

Condition where close objects appear clear but distant objects blurry. Light focuses in front of retina instead of on it. Very common, affecting about 40% of Americans. Corrected with concave (minus) lenses.

Also known as the Minnesota Premium Security Plan, this state-funded reinsurance program reimburses insurers for high-cost claims, reducing the need to charge higher premiums to all enrollees. The program was extended through 2027 with $335.6 million allocated for 2026. It keeps individual market premiums approximately 20-25% lower than they would otherwise be.

MinnesotaCare is Minnesota's public health insurance program for residents who earn too much for Medical Assistance (Medicaid) but need affordable coverage. For 2026, single adults qualify with income between $20,784 and $31,300 annually (138-200% of the Federal Poverty Level). A family of four qualifies with income between $42,663 and $64,300. MinnesotaCare requires small monthly premiums based on income, typically $0-$80 per month, with no deductibles for most services. Coverage includes doctor visits, hospital care, prescriptions, mental health, dental, and vision. Unlike marketplace plans, MinnesotaCare enrollment is open year-round through MNsure or county offices. MinnesotaCare is an important option for Minnesotans affected by the 2026 subsidy cliff who find marketplace premiums unaffordable.

Minnesota Earned Sick and Safe Time (ESST) is a state law effective January 1, 2024, requiring all Minnesota employers to provide paid time off for illness, safety concerns, and certain emergencies. Employees earn 1 hour of sick and safe time for every 30 hours worked, up to 48 hours per year. Time can be used for the employee's own illness or medical appointments, caring for a sick family member, domestic abuse or stalking situations, and closures due to weather or public health emergencies. Employees can begin using accrued time after 90 days of employment. ESST is separate from Minnesota PFML—ESST covers short-term needs like doctor appointments or the flu, while PFML provides longer-term leave (up to 20 weeks) for serious health conditions. Employers must comply with both laws.

A survey-based estimate of the average price pharmacies pay for drugs, calculated monthly by CMS. Used by some state Medicaid programs and PBMs as a reimbursement benchmark instead of AWP.

Unique identifier for medications in US assigned by FDA. Three-segment number identifying manufacturer, product, package size. Used for pharmacy claims, drug utilization review, tracking medication. Essential for prescription drug billing and inventory management.

Unique 10-digit identification number for healthcare providers mandated by HIPAA. Does not change if provider changes locations, specialties, or states. Used on claims, prescriptions, coordination of care. Individual providers and organizations both have NPIs. Obtained from National Plan and Provider Enumeration System. Public information searchable in NPI registry.

Pediatrician specializing in care of newborns, especially premature or critically ill infants. Works in neonatal intensive care units (NICU). Manages respiratory distress, infections, congenital abnormalities, feeding problems. Requires pediatrics training plus neonatal-perinatal medicine fellowship. On-call for high-risk deliveries.

Physician specializing in kidney diseases and conditions. Treats chronic kidney disease, acute kidney injury, kidney stones, electrolyte disorders, hypertension. Manages dialysis and post-kidney transplant care. Coordinates with surgeons for transplants. Essential for advanced kidney disease management.

Physician specializing in nervous system disorders affecting brain, spinal cord, nerves. Treats stroke, epilepsy, multiple sclerosis, Parkinson's disease, Alzheimer's disease, migraines, neuropathy. Performs EMG, EEG, lumbar puncture. Does not perform surgery (that is neurosurgeon).

A family deductible structure where the full family deductible must be met before any family member receives cost-sharing benefits, regardless of individual expenses. Also called an aggregate deductible.

Advanced practice registered nurse with graduate degree able to provide primary and specialty care. Can diagnose conditions, order tests, prescribe medications, manage chronic diseases. May practice independently or with physician collaboration depending on state. Similar scope to physician assistants.

Facility providing 24-hour nursing care, personal care, meals, rehabilitation for people unable to live independently. Provides both short-term rehabilitation and long-term custodial care. Medicare covers short skilled care stays. Long-term care typically private pay or Medicaid after assets depleted. State-licensed and inspected.

Women's health specialists covering reproductive health, pregnancy, childbirth (obstetrics) and female reproductive system diseases/disorders (gynecology). Perform deliveries, C-sections, gynecologic surgeries, Pap smears. Residency in OB/GYN.

Characterized by unwanted, intrusive thoughts (obsessions) causing anxiety and repetitive behaviors or mental acts (compulsions) performed to reduce that anxiety. Obsessions might involve contamination fears, doubts, need for symmetry, or forbidden thoughts. Significantly time-consuming and distressing.

Healthcare professional helping patients develop, recover, or maintain daily living and work skills. Treats physical, sensory, cognitive conditions affecting ability to perform activities. Works with injuries, disabilities, aging adults, children. Requires master's degree. May require referral.

Physician specializing in cancer diagnosis and treatment. Medical oncologists use chemotherapy, immunotherapy, targeted therapy. Surgical oncologists perform cancer surgeries. Radiation oncologists deliver radiation therapy. Often work in multidisciplinary teams. May require referral, especially for specialized cancer centers.

The annual timeframe (typically November 1 through mid-December for marketplace plans) when anyone can enroll in health insurance, switch plans, or modify coverage. Missing open enrollment means waiting a full year for coverage unless you qualify for a special enrollment period.

Medical doctor specializing in eye and vision care. Diagnoses and treats eye diseases, performs eye surgery including cataract removal, LASIK, glaucoma surgery. Can prescribe medications and glasses. Differs from optometrist by medical degree and surgical training.

Technician specializing in fitting eyeglasses and contact lenses based on prescriptions from ophthalmologists or optometrists. Helps select frames, adjusts glasses for proper fit. Does not perform eye exams or diagnose/treat eye conditions.

Doctor of Optometry providing primary vision care. Performs comprehensive eye exams, prescribes eyeglasses and contact lenses, diagnoses and treats many eye diseases, prescribes medications in most states. Cannot perform surgery. Requires 4 years optometry school.

Specialist performing tooth extractions, wisdom teeth removal, jaw surgery, facial trauma repair, and dental implant placement. Hospital privileges for complex surgeries.

Medication developed to treat rare disease affecting fewer than 200,000 people in US. Financial incentives (tax credits, market exclusivity) encourage development despite small patient population. Often very expensive. FDA Orphan Drug Program grants special status. May have accelerated approval pathway.

Specialty focusing on correcting misaligned teeth and jaws. Improves bite, function, appearance, and long-term oral health. Includes braces and clear aligners.

Specialist in straightening teeth and correcting jaw alignment using braces, aligners, and other appliances. Requires 2-3 years additional training after dental school.

Surgeon specializing in musculoskeletal system including bones, joints, ligaments, tendons, muscles. Treats fractures, arthritis, sports injuries, spine problems, bone tumors. Performs joint replacements, spinal surgery, arthroscopy. Both operative and non-operative treatments.

Most common form of arthritis, occurring when cartilage cushioning bone ends wears down over time. Causes pain, stiffness, loss of flexibility, bone spurs. Most commonly affects hands, knees, hips, spine. Risk increases with age, obesity, injuries. Treated with exercise, weight loss, pain medications, injections, joint replacement.

Physician specializing in ear, nose, throat, head, and neck disorders. Treats sinus infections, hearing loss, tonsillitis, sleep apnea, thyroid disorders, head/neck cancers. Performs tonsillectomy, sinus surgery, thyroid surgery. Both medical and surgical specialist.

Healthcare providers without contracts with your insurance plan. Using out-of-network providers typically results in significantly higher costs, reduced coverage, or no coverage. Some plans (HMOs, EPOs) don't cover out-of-network care except in emergencies, and you may face balance billing.

The annual spending cap on your cost-sharing for covered services. Once you reach this limit (which includes deductibles, copays, and coinsurance), your insurance pays 100% of covered services for the remainder of the year. This critical protection prevents catastrophic medical expenses but doesn't include premiums or charges from out-of-network providers.

Medication available without prescription. Deemed safe and effective for self-treatment by FDA. Examples include pain relievers, cold medicine, antacids, allergy medicine. Still can have side effects and interactions. Some insurance plans cover certain OTC medications. Some former prescription drugs now available OTC.

Surgery implanting small device under skin near collarbone that sends electrical impulses to maintain adequate heart rate. Treats slow or irregular heart rhythms. Device has pulse generator and leads to heart. Outpatient or short stay procedure. Device replaced every 5-15 years as battery depletes.

Physician providing specialized care for people with serious illnesses focusing on relief from symptoms and stress. Improves quality of life for patient and family. Can be provided alongside curative treatment. Addresses pain, shortness of breath, nausea, anxiety, depression. Coordinates care team.

Cancer beginning in pancreas, often detected late due to lack of early symptoms and location deep in body. Difficult to treat and has poor prognosis. Symptoms include jaundice, abdominal pain, weight loss, appearing late in disease. Treatment may include surgery if caught early, chemotherapy, radiation.

Inflammation of pancreas occurring when digestive enzymes activate while still in pancreas, damaging tissue. Can be acute or chronic. Caused by gallstones, alcohol abuse, medications, infections. Symptoms include severe abdominal pain, nausea, fever. Acute pancreatitis requires hospitalization. Chronic can lead to permanent damage, diabetes.

A discrete episode of intense fear or discomfort reaching a peak within minutes, with physical symptoms like heart palpitations, sweating, trembling, chest pain, nausea, dizziness, chills, or numbness. Can occur with or without triggers.

Characterized by recurrent, unexpected panic attacks—sudden periods of intense fear with physical symptoms like racing heart, sweating, shaking, shortness of breath, and feeling of impending doom. Often leads to persistent worry about future attacks.

Image of entire mouth including all teeth, jaws, sinuses, and jaw joints. Shows impacted teeth, jaw problems, and tumors. Typically covered every 3-5 years.

Progressive nervous system disorder affecting movement. Symptoms start gradually: tremor (often in hands), stiffness, slow movement, balance problems, changes in speech/writing. Caused by loss of dopamine-producing brain cells. No cure; medications and surgery can help manage symptoms.

Progressive nervous system disorder affecting movement due to dopamine-producing brain cell death. Symptoms include tremor, slowness, stiffness, balance problems, often starting on one side. No cure but medications can significantly improve symptoms. Eventually may require deep brain stimulation. Progresses over years to decades.

Day treatment program providing 5-7 days per week of therapeutic programming (typically 6 hours per day) while patients return home evenings. More intensive than outpatient but allows sleeping at home. Bridge between inpatient and outpatient care.

Controversial settlements where brand-name drug manufacturers pay generic manufacturers to delay launching competing generic drugs. Also called reverse payment settlements. Subject to antitrust scrutiny as they can keep drug prices high.

Surgeon specializing in operations on infants, children, adolescents. Treats congenital abnormalities, childhood cancers, trauma, appendicitis, hernias. Requires general surgery training plus pediatric surgery fellowship. Works closely with pediatricians and neonatologists. Performs minimally invasive procedures when possible.

Doctors specializing in children's health from birth through adolescence (typically to age 18-21). Training includes child development, childhood diseases, immunizations. Subspecialties include neonatology, pediatric cardiology, pediatric oncology.

Minimally invasive procedure opening blocked coronary arteries using balloon-tipped catheter inserted through blood vessel in wrist or groin. Often includes stent placement to keep artery open. Done in catheterization lab. Faster recovery than bypass surgery. May need repeat procedures.

Specialist in preventing, diagnosing, and treating gum disease. Performs gum surgeries, bone grafts, and places dental implants.

Advanced gum disease causing gum recession, bone loss, and potentially tooth loss. Irreversible but manageable with treatment. Requires deep cleanings and ongoing maintenance.

Procedure opening blocked arteries in legs or arms using balloon catheter, often with stent. Treats peripheral artery disease causing leg pain when walking. Done through small puncture in groin or arm. Improves blood flow, reduces pain, helps wounds heal. May need repeat procedures.

Narrowing of peripheral arteries, usually in legs, reducing blood flow to limbs. Caused by atherosclerosis. Symptoms include leg pain when walking (claudication), numbness, cold legs. Increases risk of heart attack and stroke. Treated with lifestyle changes, medications, sometimes angioplasty or surgery.

Assistance with activities of daily living including bathing, dressing, grooming, eating, toileting, transferring. Custodial care, not medical. Provided by aides in home or facility. Primary component of long-term care. Not covered by Medicare. May be covered by Medicaid or long-term care insurance.

For Minnesota PFML purposes, includes spouse, domestic partner, child (biological, adopted, foster, step), parent, legal guardian, sibling, grandparent, grandchild, in-laws, or someone with a personal relationship creating an expectation of care.

A licensed professional authorized to certify serious health conditions for Minnesota PFML, including physicians, physician assistants, nurse practitioners, mental health professionals, alcohol and drug counselors, and other qualified practitioners.

Minnesota PFML guarantee that employees can return to the same position or equivalent role with equal pay, benefits, and status after taking leave. Begins 90 days after hire date. Applies to employers participating in the state plan.

Leave taken for an employee's own serious health condition under Minnesota PFML, including medical care related to pregnancy, childbirth, recovery, or any condition lasting more than seven days requiring treatment by a healthcare provider.

The payroll tax that funds Minnesota PFML, totaling 0.88% of covered wages. Employers must pay at least 50% (0.44%), and employees pay up to 0.44% through payroll deduction.

The preparation of customized medications for individual patients with specific needs that cannot be met by commercially available products. May involve altering dosage forms, strengths, flavors, or combining ingredients. Subject to FDA and state pharmacy board oversight.

Healthcare professional with doctoral degree (PharmD) expert in medications. Dispenses prescriptions, counsels on proper use, checks for interactions, administers vaccines, provides disease management services. Works in retail pharmacies, hospitals, clinics. Can prescribe in some states under collaborative agreements.

Authority in some states for pharmacists to prescribe certain medications without a doctor s prescription, such as contraceptives, tobacco cessation products, or medications under collaborative practice agreements. Scope varies by state law.

A company that manages prescription drug benefits on behalf of health insurers, self-insured employers, and government programs. PBMs negotiate drug prices with manufacturers, develop formularies, process claims, and manage pharmacy networks.

A program requiring certain patients, typically those identified as at-risk for medication misuse or overuse, to obtain prescriptions from a single pharmacy and sometimes a single prescriber. Used to prevent doctor shopping and pharmacy hopping.

Pharmacies contracted with a health plan or PBM to fill prescriptions for plan members at negotiated rates. Network tiers (preferred vs. standard) offer different cost-sharing. Mail-order and specialty pharmacies are often separate network channels.

Healthcare professional helping patients improve movement and manage pain through exercise, manual therapy, education. Treats injuries, post-surgery recovery, chronic conditions, developmental disabilities. Requires doctoral degree (DPT). Works in clinics, hospitals, homes. Often requires physician referral and prior authorization.

Healthcare professional licensed to practice medicine under physician supervision. Can diagnose conditions, develop treatment plans, prescribe medications in most states, perform procedures. Master's degree required. Works collaboratively with physicians, can provide similar care for many conditions.

Two-digit code indicating location where healthcare service was provided. Used on claims to determine appropriate payment rates. Examples include 11 (office), 21 (inpatient hospital), 22 (outpatient hospital), 23 (emergency room), 31 (skilled nursing facility). Different places have different reimbursement rates. Required field on CMS-1500 form.

The 12-month period during which a health insurance plan provides coverage. For individual plans, it typically starts on January 1. For employer plans, it may start on any date the employer chooses. Benefits and deductibles reset at the start of each plan year.

Infection inflaming air sacs in one or both lungs, which may fill with fluid or pus. Caused by bacteria, viruses, or fungi. Symptoms include cough with phlegm, fever, chills, difficulty breathing, chest pain. Can be mild or life-threatening, especially for infants, elderly, immunocompromised. Treated with antibiotics if bacterial.

Healthcare provider specializing in foot, ankle, and lower leg problems. Treats bunions, heel pain, ingrown toenails, diabetic foot problems, sports injuries, arthritis. Can prescribe medications, order imaging, perform surgery. Degree is DPM (Doctor of Podiatric Medicine), not MD/DO.

Hybrid plans combining HMO and PPO features. You choose a primary care physician and need referrals for specialists (like HMOs), but can access out-of-network providers at higher costs (like PPOs). POS plans offer middle-ground pricing and flexibility.

Hormonal disorder affecting women of reproductive age causing irregular periods, excess androgen, polycystic ovaries. Symptoms include irregular periods, excess hair growth, acne, male-pattern baldness, weight gain, infertility. Increases risk of diabetes and heart disease. Treated with birth control, diabetes medications, lifestyle changes.

Mental health condition triggered by experiencing or witnessing terrifying event. Symptoms include flashbacks, nightmares, severe anxiety, uncontrollable thoughts about event. May also cause emotional numbness, avoidance, hypervigilance. Treated with trauma-focused psychotherapy and medications.

Flexible plans allowing you to see any provider without referrals, though in-network care costs significantly less than out-of-network services. PPOs offer maximum provider choice and don't require primary care physician coordination, but charge higher premiums for this flexibility.

The monthly payment required to maintain health insurance coverage, regardless of whether you use medical services. This is your baseline cost for having insurance, similar to a membership fee. Premiums don't count toward your deductible or out-of-pocket maximum.

When one family member reaches the individual deductible, their medical expenses count toward satisfying both the individual and family deductible. This allows the family deductible to be met faster when one member has high expenses.

Money returned to policyholders when an insurer fails to meet the medical loss ratio requirement. The rebate represents premiums collected but not spent on medical care as required by law.

A tax credit reducing monthly insurance premiums for marketplace coverage when household income falls within qualifying ranges. You can apply the credit directly to lower monthly bills or claim it when filing taxes.

Age-related loss of focusing ability for near vision, typically starting in mid-40s. Natural part of aging as lens becomes less flexible. Requires reading glasses, bifocals, or progressive lenses. Eventually affects everyone.

A state-run electronic database tracking prescriptions for controlled substances and sometimes other monitored drugs. Prescribers and pharmacists can check patient prescription history to identify potential misuse, doctor shopping, or dangerous combinations.

Routine healthcare services designed to prevent illness, including screenings, checkups, immunizations, and counseling. Under the Affordable Care Act, most preventive services must be covered at 100% without deductibles, copays, or coinsurance when using in-network providers.

A rebate paid by drug manufacturers when drug price increases exceed an agreed-upon rate, typically inflation. Designed to protect payers from excessive price increases. Common in government programs like Medicaid and increasingly in commercial contracts.

Doctor serving as first point of contact and ongoing care coordinator. Provides preventive care, treats common illnesses, manages chronic conditions, refers to specialists. May be family medicine doctor, internal medicine doctor, or pediatrician. HMO plans require selecting PCP.

Insurance approval required before receiving certain services, procedures, or medications for coverage. Your provider requests authorization by demonstrating medical necessity. Without prior authorization, insurers may deny coverage, leaving you responsible for full costs.

A process where a provider can request expedited approval for a medication when prior authorization is denied or delayed and the patient has an urgent medical need. May involve peer-to-peer review between prescriber and plan medical director.

Community-based program providing comprehensive medical and social services to frail older adults living at home. Covers all Medicare and Medicaid benefits plus additional services. Interdisciplinary team approach. Day center based. Goal is preventing nursing home placement. Available only in areas with PACE programs.

Professional teeth cleaning removing plaque and tartar buildup. Typically covered 100% twice yearly. Types include regular cleaning (healthy gums) and deep cleaning (diseased gums).

Cancer of prostate gland in men, often slow-growing. Most common cancer in men. Detected through PSA blood test and digital rectal exam. Treatment options include active surveillance, surgery, radiation, hormone therapy depending on stage and aggressiveness. Many men die with prostate cancer rather than from it.

Healthcare providers contracted with your insurance plan to provide services at pre-negotiated rates. Using in-network providers maximizes benefits, minimizes costs, and protects you from surprise bills. Always verify network status before receiving non-emergency care.

Chronic autoimmune condition causing rapid skin cell buildup resulting in thick, scaly, itchy, painful patches. Most common form is plaque psoriasis. Can also affect nails and joints (psoriatic arthritis). Triggered by stress, infections, medications. Requires ongoing treatment with topicals, phototherapy, or systemic medications including biologics.

Inflammatory arthritis affecting some people with psoriasis, causing joint pain, stiffness, swelling. Can affect any joint and cause permanent joint damage if untreated. May occur before, with, or after skin symptoms. Requires disease-modifying drugs, often biologics, to prevent joint damage.

Medical doctor specializing in mental health disorders. Can diagnose mental illness, prescribe medications, provide psychotherapy. Treats depression, anxiety, bipolar disorder, schizophrenia, ADHD, substance abuse. Differs from psychologist by medical training and ability to prescribe.

Mental health professional with doctoral degree (PhD or PsyD) providing therapy, psychological testing, and assessment. Cannot prescribe medication in most states. Specialize in various therapeutic approaches and populations.

Treatment involving discussion with a trained mental health professional to explore thoughts, feelings, and behaviors. Helps treat emotional difficulties, mental health conditions, and life challenges through various structured approaches.

Blockage in pulmonary artery in lungs, usually by blood clot traveling from legs (deep vein thrombosis). Life-threatening. Symptoms include shortness of breath, chest pain, rapid heart rate, coughing blood. Requires immediate treatment with blood thinners or clot-dissolving medications. Can be fatal if untreated.

Lung disease causing lung scarring (fibrosis), making lungs stiff and reducing oxygen transfer. Causes include environmental exposures, medications, autoimmune diseases, or unknown (idiopathic). Progressive condition causing increasing shortness of breath, dry cough, fatigue. No cure but treatments can slow progression. May require oxygen therapy or transplant.

Group of tests measuring lung function including how much air lungs hold and how well air moves in and out. Diagnoses asthma, COPD, pulmonary fibrosis, other lung diseases. Monitors disease progression and treatment response. Patient breathes into machine (spirometer). Includes spirometry, lung volume measurement, diffusion capacity. Non-invasive.

Physician specializing in respiratory system and lung diseases. Treats asthma, COPD, pneumonia, lung cancer, sleep disorders, pulmonary fibrosis, pulmonary embolism. Performs bronchoscopy, manages ventilators, sleep studies. Important for complex lung conditions and critical care.

Minnesota's Premium Security Plan is the official name for the state's reinsurance program established in 2017. It uses federal pass-through funding and state appropriations to stabilize the individual health insurance market by covering a portion of high-cost claims. For 2026, the program received $335.6 million and helps reduce premiums by 20-25% compared to what they would be without the program.

A need arising from a military member's active duty service or notice of impending deployment under Minnesota PFML. This includes arranging childcare, making financial or legal arrangements, attending military events, spending time during rest leave, or making arrangements following a military member's death.

Life changes that trigger special enrollment eligibility, including marriage, childbirth, adoption, divorce, losing other coverage, moving to a new area, gaining citizenship, or income changes affecting subsidy eligibility.

Maximum amount of medication insurance covers per prescription or timeframe. Based on FDA-approved dosing and safety. Prevents stockpiling, misuse, and waste. Can request override if medically necessary higher dosage prescribed.

Cancer treatment using high-energy radiation to kill cancer cells. External beam targets tumor from outside body. Brachytherapy places radioactive material inside body near cancer. Given over several weeks in small daily doses. Causes fatigue and localized skin changes. Can be curative or palliative.

A geographic region used by insurers to set premium rates. States define rating areas, which may be counties, groups of counties, or three-digit zip code areas. Premiums vary by rating area based on local healthcare costs and competition.

Health plan payment method setting maximum amount plan will pay for specific service based on reference price (often Medicare rate plus percentage). If provider charges more, patient may pay difference. Encourages price shopping. Can result in balance billing. More common in self-funded employer plans seeking cost control.

A pharmacy edit preventing prescription refills before a specified percentage of the previous fill should be used (typically 75-80%). Prevents early refills that waste medication, indicate misuse, or gaming of deductibles and out-of-pocket maximums.

Healthcare professional with nursing degree licensed to provide patient care, administer medications, monitor conditions, educate patients. Can be associate or bachelor degree. Works in hospitals, clinics, home health, schools, many settings. Coordinates care, implements treatment plans. Cannot prescribe medications independently.

A mechanism where the federal government or states reimburse insurers for high-cost enrollees, reducing premiums for all consumers. The ACA included temporary reinsurance for 2014-2016. Some states have established their own reinsurance programs to stabilize markets.

Numeric value Medicare assigns to medical services representing resources required. Three components: physician work, practice expense, malpractice insurance. Total RVUs multiplied by conversion factor and geographic adjustment equals Medicare payment. Used by many insurers. Updated annually.

Document explaining payment, denial, or adjustment details from insurance company. Electronic version is 835 transaction. Shows what was billed, allowed amount, what insurance paid, patient responsibility. Reconciles claim with payment. Essential for billing and accounts receivable management.

Risk Evaluation and Mitigation Strategies required by FDA for certain drugs with serious safety concerns. May include medication guides, communication plans, Elements to Assure Safe Use (restricted distribution, provider certification, patient monitoring), and implementation systems.

Temporary care allowing family caregivers to take break from caregiving responsibilities. Can be in-home, at facility, or at adult day center. Prevents caregiver burnout. May be few hours to several weeks. Private pay, sometimes Medicaid waiver, Veterans benefits, or long-term care insurance. Not Medicare-covered service.

Health insurance provided by former employer to retirees before Medicare eligibility or as supplement to Medicare. Becoming less common due to cost. May require minimum years of service. Premium costs often shared with retiree. COBRA is not retiree coverage - it is temporary continuation of active employee coverage.

Insurance review of medical services after they've been provided to determine if they were medically necessary and appropriately billed. Can result in claim denials if services are deemed unnecessary after the fact.

Three or four-digit code identifying hospital departments or types of service on facility claims. Describes accommodation, ancillary services, supplies. Used on UB-04 claim forms. Examples: 450 (emergency room), 636 (drugs requiring detailed coding), 360 (operating room).

Autoimmune disease causing chronic inflammation of joints and potentially other organs. Immune system attacks joint linings causing pain, swelling, stiffness, eventual joint damage. Typically affects hands, wrists, knees symmetrically. Requires disease-modifying medications, often biologics. Lifelong condition with flares and remissions.

Physician specializing in arthritis and autoimmune diseases affecting joints, muscles, bones. Treats rheumatoid arthritis, lupus, osteoarthritis, gout, psoriatic arthritis, vasculitis. Uses complex medication regimens including biologics. Important for chronic inflammatory conditions requiring specialized management.

A program that transfers funds from insurers with healthier enrollees to those with sicker enrollees to reduce the incentive to avoid covering high-cost individuals. Calculated using demographic and diagnosis data to measure the relative risk of each insurer s population.

A temporary ACA program (2014-2016) designed to limit insurer losses and gains. Insurers with unexpectedly high costs received payments, while those with unexpectedly low costs paid in. Aimed to encourage participation and stabilize premiums during market transition.

Procedure removing infected or damaged pulp from inside tooth, cleaning and sealing root canals. Needed when decay reaches nerve or tooth severely damaged. Saves tooth from extraction. Typically 50-80% covered. Usually requires crown afterward.

Surgery repairing torn tendons in shoulder, usually arthroscopically. Treats torn rotator cuff causing pain and weakness. Tendons reattached to bone using sutures and anchors. May be open surgery if tear is large. Requires shoulder immobilization followed by physical therapy. Recovery takes months.

Leave taken under Minnesota PFML due to domestic abuse, sexual assault, or stalking affecting the employee or their family member. Can be used to seek medical attention, obtain victim services, seek counseling, relocate, or take legal action.

Deep cleaning below gumline removing plaque and tartar from tooth roots. Smooths root surfaces so gums can reattach. Treatment for gum disease. Typically done in quadrants under local anesthesia. Typically 50-80% covered.

Serious mental disorder affecting how person thinks, feels, behaves. Symptoms include delusions, hallucinations, disorganized thinking and speech, impaired functioning. Typically emerges late teens to early 30s. Lifelong condition requiring ongoing treatment. Antipsychotic medications and psychosocial therapy can manage symptoms.

Protective plastic coating applied to chewing surfaces of back teeth preventing decay. Typically covered for children under 14-18. Applied to permanent molars soon after eruption.

A worker in hospitality employed for no more than 150 days during any 52-week period by an employer whose receipts vary significantly by season. May be exempt from Minnesota PFML coverage if designated by employer.

Optional Minnesota PFML coverage for self-employed individuals who earn at least 5.3% of the state's average annual wage in net self-employment income. Must apply and maintain coverage for at least 104 consecutive weeks. Pay premiums based on self-employment income.

Life-threatening condition arising when body s response to infection damages its own tissues and organs. Can lead to septic shock, multiple organ failure, death. Symptoms include fever, increased heart rate, rapid breathing, confusion. Requires immediate medical attention and treatment with antibiotics and IV fluids. Medical emergency.

A physical or mental illness, injury, impairment, or substance use disorder that involves inpatient care or continuing treatment by a healthcare provider, lasting more than seven days. Includes conditions requiring periodic visits, chronic conditions, pregnancy-related care, and recovery from treatments under Minnesota PFML.

Health insurance that provides temporary coverage for gaps in coverage, typically up to 364 days. These plans are not required to cover essential health benefits, can deny coverage based on pre-existing conditions, and may have coverage gaps. Not available in all states.

Inherited blood disorder where red blood cells become sickle-shaped, causing pain crises, anemia, organ damage, infections. Requires lifelong management. Complications include stroke, acute chest syndrome, kidney disease. Treatments include pain management, blood transfusions, hydroxyurea, bone marrow transplant. Primarily affects people of African descent.

A marketplace pricing strategy where insurers increase Silver plan premiums more than other metal tiers to account for cost-sharing reduction subsidies. This makes Bronze plans more affordable and increases premium tax credits for all metal tiers, benefiting subsidized consumers.

Medically necessary services requiring licensed healthcare professionals (nurses, therapists). Examples include wound care, IV therapy, injections, physical therapy, feeding tubes. Medicare covers when medically necessary. More intensive than custodial care.

Facility providing skilled nursing care and rehabilitation services for people recovering from surgery, illness, or injury. Medicare covers short-term stays (typically up to 100 days) if medically necessary after 3-day hospital stay. Most long-term care is custodial, not covered by Medicare. Also called nursing home.

Serious sleep disorder where breathing repeatedly stops and starts during sleep. Most common is obstructive sleep apnea where throat muscles relax. Causes loud snoring, gasping for air, morning headaches, daytime fatigue. Increases risk of high blood pressure, heart problems, diabetes. Treated with CPAP machine or oral appliances.

Overnight test monitoring breathing, oxygen levels, heart rate, brain waves, body movements during sleep. Diagnoses sleep apnea, insomnia, narcolepsy, restless leg syndrome, other sleep disorders. Done in sleep lab (polysomnography) or at home (home sleep apnea test). Patient sleeps while connected to monitoring equipment. Results guide treatment decisions.

The health insurance market for businesses with typically 1-50 employees. These businesses have access to special insurance plans and rates. Some states define small group differently, and the ACA expanded the definition to include businesses with up to 100 employees.

Antidepressants that increase both serotonin and norepinephrine levels. Used for depression, anxiety, and chronic pain conditions. Examples include venlafaxine (Effexor), duloxetine (Cymbalta). May be more effective than SSRIs for some people.

Intense fear of social situations where one might be scrutinized, judged, or embarrassed. Goes beyond normal shyness, causing significant avoidance of social interactions, performances, or eating in front of others. Can severely impact work, school, and relationships.

A window outside open enrollment when you can enroll or change plans due to qualifying life events. You typically have 60 days before or after the event to enroll, ensuring life changes don't leave you without coverage.

High-cost medications (typically >$600-1,000 monthly) requiring special handling, administration, or monitoring. Used for complex, chronic conditions like cancer, rheumatoid arthritis, multiple sclerosis, HIV. Often require injection or infusion. Must be filled through specialty pharmacies.

Pharmacy specifically equipped to handle specialty medications requiring special storage, handling, or administration. Provides patient education, side effect monitoring, financial assistance coordination, and adherence support. Required for most specialty tier medications.

Pharmacies specifically contracted to dispense specialty medications - high-cost drugs for complex conditions. These pharmacies provide additional services like patient education, adherence support, side effect management, and coordination with providers.

Process of depleting assets to qualify for Medicaid long-term care coverage. Medicaid has strict asset and income limits. People with resources above limits must spend down by paying for care until eligible. Exempt assets include primary home (with limits), vehicle, personal items. Five-year look-back for asset transfers.

Surgery implanting device that sends electrical signals to spinal cord to mask pain signals. Treats chronic back, leg, arm pain unresponsive to other treatments. Leads placed near spinal cord, generator implanted under skin. Trial period before permanent implant. Programmable. Can significantly reduce pain.

Surgery permanently connecting two or more vertebrae to eliminate painful motion between them. Bone graft or bone substitute placed between vertebrae, may use rods or screws for stability. Treats degenerative disc disease, spinal stenosis, scoliosis, fractures. Takes months to fully heal. May limit flexibility.

A practice where PBMs charge health plans more for drugs than they reimburse pharmacies, keeping the difference as profit. Has been controversial and some states have banned or limited spread pricing in Medicaid managed care.

Most commonly prescribed class of antidepressants that increase serotonin levels in the brain by blocking its reabsorption. First-line treatment for depression and many anxiety disorders. Examples include fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro). Generally well-tolerated.

Similar to COBRA but applies to employers with fewer than 20 employees in states that mandate such coverage. Rules vary by state but generally allow former employees to continue coverage for a limited time by paying the full premium.

A requirement to try less expensive, proven-effective medications before insurance covers pricier drugs for your condition. Sometimes called "fail first," step therapy requires demonstrating that lower-cost alternatives didn't work before "stepping up" to more expensive medications.

Preparation of medications in a sterile environment to prevent microbial contamination. Includes IV medications, injections, and eye drops. Requires specialized facilities, training, and quality procedures due to high risk of infection if contaminated. Regulated by USP 797 standards.

Medications increasing dopamine and norepinephrine levels, primarily for ADHD. Two main types: methylphenidate-based (Ritalin, Concerta) and amphetamine-based (Adderall, Vyvanse). Available in short-acting and long-acting formulations. Controlled substances with abuse potential.

Insurance that employers with self-funded health plans purchase to limit their financial risk. It reimburses the employer for claims exceeding a specified dollar amount, either per individual (specific stop-loss) or for the entire group (aggregate stop-loss).

Medical emergency when blood supply to brain interrupted. Ischemic stroke (85% of cases) caused by blood clot blocking brain artery. Hemorrhagic stroke caused by bleeding in brain. Symptoms include sudden numbness/weakness (especially one side), confusion, trouble speaking/seeing, severe headache.

Health coverage designed for college and university students. May be offered through school or purchased individually. Often required for international students. Covers on-campus health services plus off-campus care. Usually active during academic year. May have limited network. Can be waived if student has other coverage.

The sharp cut-off of premium tax credits at 400% of the federal poverty level under original ACA rules. The American Rescue Plan Act eliminated this cliff through 2025, extending subsidies to people above 400% FPL and limiting premiums to 8.5% of household income.

Pattern of substance use causing significant impairment or distress. Ranges from mild to severe based on number of criteria met. Includes cravings, inability to control use, continued use despite problems, tolerance, and withdrawal. Requires specialized addiction treatment.

Additional payments from an employer to supplement Minnesota PFML benefits, such as using accrued vacation or sick time. Employers may allow but are not required to permit supplemental payments. Combined benefits cannot exceed regular wages.

Unexpected balance bills from out-of-network providers in situations patient couldn't control—emergency care, out-of-network provider at in-network facility. No Surprises Act (effective January 2022) protects against most surprise bills.

The subsidy cliff refers to the sudden and complete loss of premium tax credit eligibility when household income exceeds 400% of the Federal Poverty Level (FPL). Under original ACA rules (restored in 2026), earning even $1 above 400% FPL means receiving zero subsidies, regardless of how expensive premiums are. For 2026, the cliff is $62,600 for an individual and $128,600 for a family of four.

Insurance practice of covering alternative medication in same therapeutic class instead of prescribed drug. Based on clinical equivalence. Requires prescriber or patient approval. Cost-saving measure that may require medication switch.

Lowest-cost tier containing preferred generic medications and some low-cost brands. Typically $0-25 copay. Most cost-effective option with widest availability. Plans encourage use of Tier 1 medications.

Higher-cost generic medications or preferred brands without generic equivalents. Moderate copay, typically $25-50. Still more affordable than higher tiers.

Brand-name medications without lower-cost generic alternatives or preferred brands. Higher copay, typically $50-100. Insurance has negotiated favorable pricing with manufacturers.

Non-preferred brand and higher-cost generic medications when therapeutic alternatives available in lower tiers. High copay or coinsurance (30-50% of cost). Plans discourage use through high cost-sharing.

Highest tier for specialty medications - high-cost drugs for complex conditions. Typically highest cost-sharing, often 25-33% coinsurance with caps ($100-500/month). Limited to 30-day supplies. Must use specialty pharmacy.

The deadline by which a provider must submit a claim to an insurance company. This varies by insurer but is typically 90-180 days from the date of service. Claims submitted after the timely filing limit may be denied.

The practice of charging higher premiums to tobacco users. Under the ACA, insurers can charge tobacco users up to 50% more than non-tobacco users. Some states prohibit or limit tobacco rating.

Removal of visible tooth that can be extracted without surgical intervention. Done under local anesthesia. Typically 50-80% covered.

Surgery replacing damaged hip joint with artificial joint (prosthesis). Treats severe arthritis or hip fracture. Removes damaged bone and cartilage, implants metal, plastic, or ceramic components. Major surgery requiring hospital stay and rehabilitation. Relieves pain, improves mobility. May last 15-20 years.

Surgery replacing weight-bearing surfaces of knee joint with artificial components. Treats severe arthritis causing pain and disability. Damaged cartilage and bone removed and replaced with metal and plastic parts. Requires hospital stay and physical therapy. Relieves pain, improves function. May last 15-20 years.

Minimally invasive procedure replacing diseased aortic valve without open-heart surgery. New valve threaded through catheter from leg artery or small chest incision. For patients too high-risk for traditional surgery. Shorter recovery than open surgery. Growing use in lower-risk patients.

Surgery removing prostate tissue obstructing urine flow. Treats benign prostatic hyperplasia (enlarged prostate). Instrument inserted through urethra, tissue cut away with wire loop. No external incisions. Hospital stay 1-2 days. Improves urination. May affect sexual function.

Short-term health insurance for trips, covering medical emergencies, evacuation, and sometimes trip interruption while traveling. Designed for tourists, business travelers, and others on temporary trips. Duration typically ranges from days to several months.

Department of Defense healthcare program for active duty service members, military retirees, and their families. Offers several plan options including TRICARE Prime (HMO-like), TRICARE Select (PPO-like), and TRICARE For Life (for Medicare-eligible beneficiaries).

Bacterial infection primarily affecting lungs but can spread to other organs. Spread through airborne particles when infected person coughs or sneezes. Can be latent (inactive) or active. Active TB causes cough, fever, night sweats, weight loss. Requires 6-9 months of multiple antibiotics. Drug-resistant forms increasingly problematic.

Surgery removing cancerous or non-cancerous tumor. Extent depends on tumor size, location, type. May remove surrounding tissue to ensure complete removal. Can be curative if cancer has not spread. May be followed by chemotherapy or radiation. Can be major surgery depending on location.

Autoimmune disease destroying insulin-producing beta cells in pancreas. Body cannot produce insulin, hormone regulating blood sugar. Usually diagnosed in children/young adults. Requires lifelong insulin therapy via injections or pump. Complications include heart disease, nerve damage, kidney damage, eye damage.

Most common form of diabetes where body becomes resistant to insulin or doesn't produce enough. High blood sugar damages blood vessels, nerves, organs. Risk factors include obesity, inactivity, genetics, age. Managed with lifestyle changes, oral medications, sometimes insulin.

The average number of hours an employee worked per week during the last two quarters before applying for Minnesota PFML benefits. Used to calculate benefit amounts for part-time workers.

Standard paper claim form for billing institutional services from hospitals, skilled nursing facilities, home health agencies. Also called CMS-1450. Contains patient information, revenue codes, diagnosis codes, procedure codes, charges. Electronic equivalent is 837I transaction.

Chronic inflammatory bowel disease causing inflammation and ulcers in colon and rectum lining. Symptoms include bloody diarrhea, abdominal cramping, urgency, fatigue. Flares alternate with remission periods. Treatment includes anti-inflammatory drugs, immunosuppressants, biologics. Severe cases may require colon removal surgery.

Imaging technique using high-frequency sound waves to create images of structures inside body. Safe, painless, no radiation. Commonly used in pregnancy to monitor baby. Also used to examine organs like heart, kidneys, liver, blood vessels.

Improper billing practice of separately billing components of service that should be billed together under comprehensive code. Increases reimbursement illegally. Example: billing multiple parts of surgical procedure separately when one code covers all. Subject to audits and penalties.

Illegal practice of billing higher-level service code than actually provided to receive higher reimbursement. Example: billing complex office visit when only simple visit occurred. Subject to audits and penalties. Fraud and abuse violation. Can result in fines, exclusion from programs, criminal charges.

Physician specializing in urinary tract and male reproductive system. Treats kidney stones, prostate problems, bladder conditions, urinary incontinence, male infertility, erectile dysfunction. Performs cystoscopy, vasectomy, prostate surgery. Both medical and surgical specialist.

Method determining allowed amount for service. Usual fee is what provider typically charges. Customary fee is what most providers in area charge. Reasonable fee is generally accepted fee for service. Insurers use UCR to set maximum payment amounts.

Healthcare program operated by the Department of Veterans Affairs for eligible veterans who served and weren't dishonorably discharged. Includes medical, dental, mental health, and pharmacy services at VA facilities.

Open-heart surgery replacing diseased heart valve with mechanical or biological valve. Treats severe valve stenosis or regurgitation. Requires heart-lung bypass machine. Mechanical valves require lifelong blood thinners. Biological valves may need replacement after 10-20 years. Major surgery.

Surgeon specializing in diseases of blood vessels (arteries and veins) excluding heart and brain. Treats aneurysms, carotid artery disease, peripheral artery disease, varicose veins, dialysis access. Performs open surgery and minimally invasive procedures. Requires general surgery or vascular surgery training.

Long-term care services available to eligible veterans through VA. Includes nursing homes, assisted living, home-based primary care, adult day care, respite care. Eligibility based on service-connected disability rating, income. May require copayments. Some services limited or have waiting lists. State Veterans Homes also provide care.

Coverage for routine eye exams, eyeglasses, and contact lenses, typically separate from medical insurance. Usually structured with annual benefits (one exam per year, eyewear every 1-2 years) and copays for services. Medical eye conditions covered under regular health insurance.

Measures sharpness of vision using eye chart (typically Snellen chart with letters). Results expressed as fraction (20/20, 20/40, etc.). 20/20 means normal vision—can see at 20 feet what person with normal vision sees at 20 feet.

The amount of wages earned during the base period in covered employment, used to determine eligibility for Minnesota PFML benefits. Must equal at least 5.3% of the state's average annual wage (approximately $3,900 in 2026).

Time after enrolling before certain services covered. Preventive care usually immediate. Basic services may require 3-6 months. Major services often require 6-12 months. Prevents people from enrolling only when needing expensive work.

The amount of Minnesota PFML benefits an eligible employee receives each week. Calculated as 90% of wages up to 50% of the state's average weekly wage, then 66% for wages between 50-100% of average, with a maximum benefit of $1,423 in 2026.

The manufacturer s list price for a drug to wholesalers or direct purchasers, excluding rebates or discounts. Used as a more transparent pricing benchmark than AWP for pharmacy reimbursement and cost-sharing calculations.

Last teeth to develop, usually emerging late teens/early twenties. Often impacted (stuck beneath gum) or misaligned, requiring extraction. All four commonly removed preventively.

Imaging test using small amount of radiation to produce pictures of structures inside body, especially bones. Quick, painless, commonly used. Detects fractures, infections, arthritis, dental problems, lung conditions.