| Term | Definition |
| Affordability Offices | State-established offices, agencies, commissions, or other entities dedicated to improving health care affordability. |
| AHEAD Model | The Achieving Healthcare Efficiency through Accountable Design (AHEAD) model is a voluntary, state-level total cost of care (TCOC) demonstration supported by the Center for Medicare & Medicaid Services. Participating states will assume responsibility for managing health care quality and costs across all payers, including Medicare, Medicaid, and private coverage. See here for more information. |
| All-or-Nothing | A provision in a payer/provider contract which requires that all of a health system’s providers and facilities be included in an insurer’s network. |
| Anti-Competitive Contracting Restrictions | Some states prohibit provisions that restrict or limit price competition in payer/provider contracts, including, but not limited to, all-or-nothing, anti- steering, anti-tiering, and most-favored nations clauses. |
| Anti-Steering | A provision in a payer/provider contract which prevents the insurer from using financial incentives to encourage patients to choose lower-cost or higher-quality healthcare providers. |
| Anti-Tiering | A provision in a payer/provider contract which prevents the insurer from assigning the provider to a non- preferred provider network tier, thereby limiting the insurer’s ability to direct consumers toward high-quality or low-cost providers. |
| Audited Financial Statement | Financial reports that have been examined and verified by an independent, certified public accountant (CPA) using professional auditing standards. AFSs include the entity’s balance sheet, cash flow statement, income statement, and changes in net assets. |
| Billing Complaints | In some states, consumers may submit complaints about billing practices, such as balance billing, billing errors, and billing clarity, to state agencies with investigative authority. |
| Billing Integrity | Requirements to ensure accurate and standardized billing practices. |
| Certificate of Public Advantage (COPA) | Some states use Certificate of Public Advantage (COPA) authority to provide hospital transactions, such as mergers and acquisitions, with antitrust immunity, often in exchange for state regulatory oversight. |
| Certificate of Need (CON) | Some states use Certificate of Need (CON) authority to control the number of health care resources in the state. Under these laws, providers must obtain state approval to expand existing services or build new capacity. State CON laws can encompass a wide range of resources, including different types of hospitals, nursing facilities, assisted living facilities, hospices, and home health agencies, among others. |
| Contract Review | Some state Departments of Insurance review and approve contracts between payers and providers. |
| Cost-Growth Benchmarks | Some states use cost-growth benchmarks, or growth targets, to track health care spending with the goal of containing total health care spending growth. |
| Enhanced Rate Review | Authority that enables state insurance regulators to focus on underlying factors driving premium rate increases, such as contracted provider rates and pharmaceutical prices. |
| Facility Fee | Charges that institutional health care providers, such as hospital outpatient departments, bill to cover operational and overhead expenses. This charge is separate from and in addition to professional fees for health care services. |
| Financial Assistance | Hospitals may offer, or be required to offer, low-income or uninsured patients financial assistance, such as free care, discounted services, and low-interest payment plans. |
| Financial Reporting | Some states require hospitals to submit Medicare Cost Reports, Form 990s, Audited Financial Statements, and other sources of hospital financial data to state regulators. |
| Form 990 | An informational tax return that most tax-exempt organizations file with the Internal Revenue Service on an annual basis. Hospitals and health systems use Schedule H of Form 990 to provide information on their hospital and non-hospital facilities’ activities and policies and the community benefits they provide. |
| Global Budget | A pre-determined, prospective, fixed budget payment to hospitals for all inpatient and outpatient services, for a defined patient population, in a given year. Global budgets incentivize hospitals to manage volume and cost within a budget constraint. |
| Medical Debt | Debt that arises from unpaid bills for health care services, such as a provider visit or hospital stay. Patients without health insurance, with inadequate health insurance, or with significant cost-sharing responsibilities are more likely to incur medical debt. |
| Medicare Cost Reports | Annual reporting forms all hospitals must submit to the Centers for Medicare & Medicaid services containing hospital-reported financial information, such as facility characteristics, utilization data, cost and charges by cost center (in total and for Medicare), and Medicare settlement data. These reports are unaudited and submitted by individual hospitals, not hospital systems. |
| Most-Favored-Nation | A provision in a payer/provider contract that guarantees that the insurer will receive the lowest reimbursement rate that the healthcare provider offers to any other insurer. |
| Ownership Transparency | Ownership information on hospitals and health systems that states collect as part of licensure processes or other state requirements. States may use this information to monitor and understand their changing healthcare markets. |
| Price Regulation | Government-administered pricing systems that determine how much public and/or private payers will pay for health care services. Elements may include defined prices for specific services, limits on how quickly prices may grow, limits or caps on how much payers can pay for specific services, and/or global budgets. |
| Reference Pricing | A pricing system that establishes payment rates or payment limits that are equal to or a percentage of a reference rate, such as the price Medicare pays for the same service. |
| Transaction Oversight | States may oversee or regulate health industry transactions, such as mergers between two or more hospitals or hospitals’ acquisition of other providers, such as physician practices. This authority ranges from notification requirements, to transaction review and approval authority, to post-transaction oversight, and may apply to certain types of hospitals or transactions above a certain dollar value. |
