A.
ACA (Affordable Care Act)
Federal law establishing minimum coverage standards for employer-sponsored health plans.
Administrative Services Only (ASO)
A model where an employer self-funds medical claims and contracts with a TPA for administration.
Aggregate Stop Loss (Agg)
Protection for employers when total plan claims exceed an annual threshold.
Allowed Amount
The maximum amount a plan will consider for payment of a covered service. In RBP plans, this is typically based on objective benchmarks like Medicare rates or cost-plus pricing.
Appeals & Grievances
Formal processes for reviewing claim decisions or member concerns.
Attachment Point
The dollar level at which stop loss insurance begins reimbursing the employer.
B.
Balance Billing
A bill a provider may send if they charge more than the plan’s allowed amount. Under Homestead’s Balance Bill Protection, Homestead works directly with providers so members are not responsible for excess charges.
Benchmark Pricing
The method used to calculate allowed amounts in RBP plans, often a percentage of Medicare or a cost-based model.
Benefit Accumulators / Benefit Balances
Totals showing how much a member has paid toward deductibles, out-of-pocket maximums, and other cost-sharing limits.
C.
Cedar Gate Analytics
Homestead’s analytics platform provides employers and brokers with insight into claim trends, savings, utilization, population risk, and plan performance.
Claim
A request from a provider to be paid by a health plan for services received by a member. For example, a doctor submits a claim after an office visit.
Clear the Path™
Homestead’s proactive provider outreach program designed to prepare providers for RBP, address questions, and support seamless care access for members.
Coinsurance
The percentage of costs a member pays after meeting the deductible. For example, if a service costs $1,000 and coinsurance is 20%, the member pays $200, and the plan pays $800 until the out-of-pocket maximum is met.
Concierge Member Services
Homestead’s on-shore, specialized support team that assists members with benefit questions, provider navigation, billing issues, and claims concerns.
Copay
A fixed dollar amount a member pays at the time of service. For example, a $25 copay for a primary care visit.
Coordination of Benefits (COB)
Rules determining how payment responsibilities are divided when a member has multiple health plans.
Cost Containment
Strategies and programs designed to reduce healthcare spending while maintaining or improving member outcomes.
Covered Services
Medical services included in a member’s plan benefits. Some services may be covered before the deductible is met, while others are covered only after.
CPT / HCPCS Codes
Standardized codes used by providers to bill for medical procedures and services.
D.
Deductible
The amount a member must pay out of pocket for certain medical services before the health plan begins sharing costs. Lower deductibles mean the plan begins paying sooner.
Direct Primary Care (DPC)
A care model offering members unlimited primary care services for a monthly fee. Often paired with RBP plans to improve access and reduce overall costs.
Digital ID Card
A digital version of a member’s ID card accessible through the member portal.
E.
Eligibility File
A list of enrolled members and dependents provided by employers to the TPA for accurate claims processing.
EOB (Explanation of Benefits)
A statement sent by the health plan summarizing what was billed, what the plan paid, and what amount—if any—the member may owe. It is not a bill.
ERISA
The federal law governing employee benefit plans outlining fiduciary responsibilities, required disclosures, and compliance rules for employer-sponsored plans.
Experience Reporting
Financial and utilization reports provided to employers and brokers showing plan performance, cost drivers, and savings opportunities.
F.
Facility Provider
Institutions such as hospitals, surgical centers, and imaging facilities that deliver medical services.
Fee Schedule
A structured list of payment amounts used to adjudicate claims.
H.
High-Cost Claimant
A member whose annual claims exceed a defined threshold, often representing a significant portion of total plan costs.
HIPAA
Federal rules protecting the privacy and security of health information.
I.
IBNR (Incurred But Not Reported)
Claims that have occurred but have not yet been submitted. Important for financial projections and stop loss underwriting.
Incurred Date
The date on which a medical service was provided.
Incurred & Paid (I&P)
A stop loss contract type requiring claims to be both incurred and paid within the contract year to be eligible for reimbursement.
L.
Lasering
A stop loss underwriting practice where a higher deductible is assigned to a specific member expected to have high claims.
Level-Funded Plan
A type of self-funded plan where employers pay a fixed monthly amount covering claims, stop loss premiums, and admin fees, often with the potential for refunds if claims run low.
M.
Minimum Essential Coverage (MEC)
A type of health plan that meets federal requirements for basic coverage and includes preventive services. MEC plans are not major medical plans and generally do not cover services like emergency room visits or hospital stays.
Medical Management
Programs ensuring members receive safe, appropriate, and cost-effective medical care, including case management and utilization review.
Member Advocacy / Patient Advocacy
Support resources that guide members through provider navigation, billing concerns, benefits questions, and balance bill resolution—especially relevant in RBP plans.
Member Portal
An online resource where members access benefits information, digital ID cards, claims, balances, and educational tools.
N.
NPI (National Provider Identifier)
A unique identification number assigned to each provider and facility.
O.
Open Enrollment
The annual period when members can enroll in a health plan or make changes to their coverage.
Out-of-Pocket Maximum (OOPM)
The most a member will pay in a plan year for covered medical services. After this amount is reached, the plan pays 100% of covered expenses.
P.
Paid Claims Basis
A stop loss contract type that reimburses based on claims paid during the contract year, regardless of the date the services were incurred.
Plan Document (PD)
The governing document that outlines all covered services, exclusions, rights, and responsibilities for the health plan.
Plan Sponsor
The employer or organization that funds and manages the health plan.
Premium
The amount paid each month in exchange for health benefits coverage.
Preventive Care
Routine health services—such as annual exams, screenings, and immunizations—often covered at no cost to the member.
Prior Authorization
Approval required from the plan before a service is provided to ensure medical necessity and appropriate use.
Professional Provider
Individual licensed clinicians such as physicians, therapists, and nurse practitioners.
Provider
A broad term encompassing all clinicians, provider groups, hospitals, labs, and facilities that deliver medical services and submit claims.
Provider Appeal
A request from a provider asking the plan to reconsider a payment amount.
Provider Search
A resource used by members to locate providers familiar with—or supportive of—RBP arrangements.
R.
Reasonable & Customary (R&C)
A traditional pricing method based on historical provider charges. Often compared with RBP methodologies, which use standardized benchmarks.
Reference-Based Pricing (RBP)
A pricing model that uses transparent, objective benchmarks (such as Medicare rates or cost-plus formulas) instead of negotiated network contracts.
Revenue Code
Billing codes used by facilities to categorize charges for hospital or outpatient services.
Runout / Claims Runout Period
The period after a plan year ends when claims from the prior year can still be submitted, processed, and paid.
S.
Self-Funded Health Plan
A plan where the employer—not an insurance carrier—pays for members’ medical claims directly. The employer partners with a TPA, stop loss carrier, and often an RBP partner.
Single Case Agreement (SCA)
A negotiated contract with a specific provider for one member or episode of care.
Specific Stop Loss (Spec)
Protection for employers against large individual claims that exceed a set dollar threshold.
SPD (Summary Plan Description)
A plain-language summary of the health plan’s rules, coverage, exclusions, and member rights, required under ERISA.
Stop Loss Insurance / Reinsurance
Insurance purchased by employers to protect against unexpectedly high claims.
Superbill
An itemized document listing medical services provided, used to support billing claims.
T.
Telehealth / Virtual Care
Remote medical consultations provided via phone or video platforms.
Third-Party Administrator (TPA)
An organization responsible for administering the health plan, including claims processing, customer service, reporting, and compliance support.
Trend
The projected annual increase in healthcare costs used for underwriting, budgeting, and renewal calculations.
Utilization Management (UM)
Programs such as prior authorization and case review designed to ensure services are clinically appropriate and cost-effective.
U.
UCR (Usual, Customary & Reasonable)
A historical pricing approach based on average provider charges. RBP replaces UCR with transparent benchmarks tied to cost or Medicare data.
