End-Stage Renal Disease

Kidney failure that requires dialysis treatments or a kidney transplant; patients with ESRD qualify for Medicare regardless of age.

Entitlement Program

Programs for people who have a federal right to benefits if eligibility criteria is met. Changes to the eligibility for these programs must be done through legislation and enrollment cannot be capped. Unlike discretionary funds, the federal government is required to spend the necessary funds for these programs

Episode of Care

Refers to a period of illness, a hospital stay, or the duration of treatment for one condition.

Episode Payment

Refers to a single price for all of the services needed by a patient for an entire episode of care.

Essential Health Benefits (EHB)

The Affordable Care Act requires that health plans on the individual and small group market, including all plans sold on the exchanges, contain a package of items and services. Required care services include: emergency services, ambulatory patient services, maternity care, pediatric care, mental health care, laboratory services, prescription drugs, and others.

Evidence of Insurability

Forms required by many insurance providers that proves an applicant meets requirements for insurance.

Excepted Benefits

Benefits not offered by a specific health plan.

Excessive Waiting Period

The Affordable Care Act prohibits excessive waiting periods for employer-sponsored insurance coverage, defined as waiting periods over 90 days. In other words, an employer cannot make an employee wait more than 90 days for their insurance coverage to begin.

Exchange-eligible Employer

Employers allowed to purchase employee coverage through state health care exchanges.

Exchange-eligible Individual

Individuals allowed to purchase coverage through state health care exchanges.

Self-Insured Firm

A company that pays medical claims for their employees rather than holding insurance, usually hiring an insurance company to administer the benefits. Common among large…