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The ability of individuals to obtain health services when needed.</p> <p><strong><span style="color: #d91769;">Accumulator Program</span> </strong>— A tactic by insurance companies that prevents any of the amounts that the patient has paid using manufacturer assistance from counting toward the patient’s out-of-pocket costs.</p> <p><span style="color: #d91769;"><strong>Affordable Care Act (ACA)</strong></span> — U.S. healthcare reform law that expanded access to health insurance, increased consumer protections, and emphasized prevention and wellness.</p> <p><span style="color: #d91769;"><strong>Alternative Funding Programs (AFPs)</strong> </span>— Third parties that shift or deflect coverage for specialty drugs and treatments on behalf of a health plan sponsor, like an employer.</p> <p><span style="color: #d91769;"><strong>Benefits </strong></span>— The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.</p> <p><strong><span style="color: #d91769;">Biologics</span> </strong>— A class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell.</p> <p><span style="color: #d91769;"><strong>Biomarkers </strong></span>— Biological molecules that indicate a process or condition in the body, often used for diagnosis.</p> <p><span style="color: #d91769;"><strong>Biosimilar </strong></span>— A biological medicinal product that is nearly identical to the original product, but created by a separate manufacturer.</p> <p><span style="color: #d91769;"><strong>Brown Bagging </strong></span>— A practice where patients pick up their medications from a pharmacy and then bring them to their healthcare provider for administration.</p> <p><strong><span style="color: #d91769;">Centers for Disease Control and Prevention (CDC)</span> </strong>— The national public health institute in the United States that conducts and supports health promotion, prevention, and preparedness activities.</p> <p><span style="color: #d91769;"><strong>Centers for Medicare & Medicaid Services (CMS)</strong></span> — A federal agency that administers the nation’s major healthcare programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).</p> <p><strong><span style="color: #d91769;">Chronic Disease Management</span> </strong>— An approach to healthcare that involves ongoing care and support to individuals with chronic health conditions, including autoimmune diseases.</p> <p><span style="color: #d91769;"><strong>Claim</strong></span> — A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.</p> <p><strong><span style="color: #d91769;">Clinical Guidelines</span> </strong>— Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.</p> <p><span style="color: #d91769;"><strong>Clinical Trial</strong> </span>— Research studies performed in people that are aimed at evaluating a medical, surgical, or behavioral intervention.</p> <p><strong><span style="color: #d91769;">Copayment</span> </strong>— A fixed amount you pay for a covered health care service after you’ve paid your deductible.</p> <p><strong><span style="color: #d91769;">Deductible</span> </strong>— The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.</p> <p><span style="color: #d91769;"><strong>Department of Health and Human Services (HHS) </strong></span>— A Cabinet-level department of the federal government that aims to protect the health of all Americans and provides essential human services. HHS works to advance the sciences that support medicine, public health, and social services. HHS includes many sub-agencies, such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration(FDA), and the National Institutes of Health (NIH).</p> <p><span style="color: #d91769;"><strong>Disease Burden </strong></span>— The impact of a health problem on an individual or population, measured by financial cost, mortality, morbidity, or other indicators.</p> <p><span style="color: #d91769;"><strong>Drug Formulary</strong> </span>— A list of prescription medications covered by a prescription drug plan or another insurance plan offering prescription drug benefits.</p> <p><span style="color: #d91769;"><strong>Essential Health Benefits </strong></span>— A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services. Plans must offer dental coverage for children. Dental benefits for adults are optional.</p> <p><span style="color: #d91769;"><strong>Flexible Spending Account (FSA) </strong></span>— An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices.</p> <p><span style="color: #d91769;"><strong>Food and Drug Administration (FDA)</strong></span> — The FDA is a part of the Department of Health and Human Services. The FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation.</p> <p><span style="color: #d91769;"><strong>Formulary Tiering </strong></span>— Used by Pharmacy Benefit Managers (PBMs)/health insurance plans to categorize prescription medications into different tiers generally based on their cost and clinical effectiveness. Typically, medications in lower tiers have lower copayments or coinsurance for patients, while those in higher tiers require higher out-of-pocket costs. Tiering may also be based on factors some with perverse incentives.</p> <p><span style="color: #d91769;"><strong>Health Disparities </strong></span>— Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.</p> <p><span style="color: #d91769;"><strong>Health Equity </strong></span>— The state in which everyone has a fair and just opportunity to attain their highest level of health.</p> <p><span style="color: #d91769;"><strong>Health Insurance Marketplace</strong>®</span> — A service that helps people shop for and enroll in health insurance. The federal government operates the Health Insurance Marketplace®, available at HealthCare.gov, for most states. Some states run their own Marketplaces.</p> <p><span style="color: #d91769;"><strong>Health Policy</strong> </span>— Decisions, plans, and actions undertaken to achieve specific health care goals within a society.</p> <p><span style="color: #d91769;"><strong>Health Savings Account (HSA)</strong> </span>— A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in an HSA to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your out-of-pocket health care costs.</p> <p><strong><span style="color: #d91769;">Health Insurance Portability and Accountability Act (HIPAA)</span> </strong>— U.S. legislation that provides data privacy and security provisions for safeguarding medical information.</p> <p><strong><span style="color: #d91769;">Informed Consent</span> </strong>— The process by which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, including clinical trials, and then agrees to receive the treatment or participate in the trial.</p> <p><strong><span style="color: #d91769;">Maximizer Program</span> </strong>— A tactic by insurance companies that exhausts the maximum available patient assistance that a drug manufacturer offers to patients for prescription medicines, and does so in a manner that does not count that assistance toward patients’ annual cost-sharing limits.</p> <p><strong><span style="color: #d91769;">Medicaid</span> </strong>— A state-run, partially federally funded program that helps with medical costs for some people with limited income and resources.</p> <p><strong><span style="color: #d91769;">Medicare</span> </strong>— A federal health insurance program for people who are 65 or older and certain younger people with disabilities.</p> <p><strong><span style="color: #d91769;">Medicare Part D</span> </strong>— A federal government program that help seniors and people with long-term disabilities who are Medicare beneficiaries pay for self-administered prescription drugs.</p> <p><span style="color: #d91769;"><strong>National Institutes of Health (NIH) </strong></span>—The NIH is the primary Federal agency for conducting and supporting medical research.</p> <p><strong><span style="color: #d91769;">Non-Medical Switching</span> </strong>— When an insurance company changes its terms or coverage of a medication for reasons that are not clinically based or medically recommended. This requires the patient to stop taking a medicine and switch to a different treatment that has not been recommended by a medical doctor or other qualified provider, but is preferred by the insurance company for financial reasons.</p> <p><strong><span style="color: #d91769;">Office of Autoimmune Disease Research (OADR)</span> </strong>— A governmental or organizational entity dedicated to researching autoimmune diseases. Its primary focus is on understanding the causes, mechanisms, treatments, and potential cures for autoimmune conditions.</p> <p><span style="color: #d91769;"><strong>Open Enrollment Period</strong> </span>— The yearly period (November 1 – January 15) when people can enroll in a Marketplace health insurance plan.</p> <p><strong><span style="color: #d91769;">Orphan Drug</span> </strong>— A pharmaceutical agent developed to treat medical conditions which, because they are so rare, would not be profitable to produce without government assistance.</p> <p><strong><span style="color: #d91769;">Out-of-Pocket Maximum/Limit</span> </strong>— The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.</p> <p><strong><span style="color: #d91769;">Patient Advocacy</span> </strong>— Activities aimed at representing the interests and rights of patients within the health care system.</p> <p><strong><span style="color: #d91769;">Patient-Centered Care</span> </strong>— Providing care that is respectful of, and responsive to, individual patient preferences, needs, and values.</p> <p><strong><span style="color: #d91769;">Pharmacy Benefit Managers</span> </strong>— Corporations that administer drug prescription plans for insurance companies; they manage high-cost specialty medication. They help to control what medications are available, which can potentially restrict access for patients.</p> <p><span style="color: #d91769;"><strong>Premiums</strong></span> — The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit.</p> <p><strong><span style="color: #d91769;">Prior Authorization</span> —</strong> A process used by healthcare insurers or managed care organizations to determine if they will cover the cost of a prescribed medication or medical service. Healthcare providers must obtain approval from the insurer before the medication or service can be provided. This process typically involves submitting documentation to demonstrate the medical necessity of the treatment.</p> <p><strong><span style="color: #d91769;">Public Health</span> </strong>— The science and art of preventing disease, prolonging life, and promoting health through organized community efforts.</p> <p><span style="color: #d91769;"><strong>Quality of Care</strong></span> — The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.</p> <p><strong><span style="color: #d91769;">Reimbursement</span> </strong>— Compensation or repayment for healthcare services, often by insurance providers.</p> <p><strong><span style="color: #d91769;">Research and Development (R&D)</span> </strong>— Activities undertaken by companies and organizations to innovate and introduce new products and services, including medical research.</p> <p><strong><span style="color: #d91769;">Specialty Pharmacy</span> </strong>— Pharmacies that focus on high-cost, high-complexity, and/or high-touch medication therapy for patients with complex diseases.</p> <p><span style="color: #d91769;"><strong>Stakeholders</strong> </span>— Individuals or groups with an interest in healthcare policy, including patients, providers, payers, and policymakers.</p> <p><span style="color: #d91769;"><strong>State Insurance Department </strong></span>— A state agency that regulates insurance and can provide information about health coverage in its state.</p> <p><span style="color: #d91769;"><strong>Step Therapy</strong></span> — Insurance company tactic that often requires patients to “fail first” on one or more drugs before getting the medicine that doctors originally prescribed.</p> <p><span style="color: #d91769;"><strong>Utilization Management Protocols</strong> </span>— The use of managed care techniques such as prior authorization and step therapy that allow insurance companies to manage the cost of healthcare by assessing whether patients can receive necessary medication that their physicians have prescribed.</p> <p><strong><span style="color: #d91769;">Value-Based Care</span> </strong>— A healthcare delivery model in which providers are paid based on patient health outcomes.</p> <p><strong><span style="color: #d91769;">White Bagging</span> </strong>— The practice in healthcare where a patient’s medication is dispensed by a specialty pharmacy and then shipped directly to the healthcare provider (e.g., a clinic, hospital) for administration.</p> <p><strong><span style="color: #d91769;">340B Program</span> </strong>— A federal initiative in the United States that allows certain eligible healthcare organizations, known as covered entities, to purchase outpatient prescription drugs at discounted prices.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> </div> </div> </div> </div> </section> </div> </div> </div> </div> </div> <div class="full-width"> <section class="section section-cta callout"> <div class="container"> <div class="callout__inner"> <h2 class="callout__title">Take action for autoimmune disease </h2> <div class="callout__body"><p><span style="font-weight: 400">Immediate action is often needed when Congress or your state legislature is voting on important legislation. Contact your legislators on critical issues and make your voice heard! This one step can truly make a significant impact.</span></p> </div> <div class="callout__button"> <a class="btn btn-pink btn-pink--long" aria-label="Link" href="/get-involved/help-change-policy" target="_blank"> Help Change Policy </a> </div> </div> </div> </section> </div> </div> <footer class="footer"> <div class="footer__inner"> <div class="container"> <div class="row"> <div class="col-lg-3"> <a href="https://autoimmune.org/" class="footer__logo" aria-label="Link"> <img data-src="https://autoimmune.org/wp-content/uploads/2021/08/logo-horizontal.svg" alt="Logo Horizontal" width="236" height="66" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload" style="--smush-placeholder-width: 236px; --smush-placeholder-aspect-ratio: 236/66;"> </a> <div class="socials footer-socials"> <ul> <li> <a href="https://www.facebook.com/Autoimmunity" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/1.svg" alt="" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://www.instagram.com/autoimmune_diseases/" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/insta.svg" alt="insta" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://twitter.com/AutoimmuneAssoc" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/x.svg" alt="x" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://www.linkedin.com/company/american-autoimmune-related-diseases-association-aarda-" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/linkedin.svg" alt="linkedin" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://www.youtube.com/aardatube" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/youtube.svg" alt="youtube" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://www.tiktok.com/@autoimmuneassociation" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/08/tiktok.svg" alt="tiktok" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload"> </a> </li> <li> <a href="https://www.inspire.com/groups/autoimmune-disease/" aria-label="Link" target="_blank" rel="noopener"> <img data-src="https://autoimmune.org/wp-content/uploads/2023/11/Inspire-icon.png" alt="Inspire icon" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" class="lazyload" style="--smush-placeholder-width: 100px; 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