HCCI Research Glossary

Abridged Glossary

Allowed amounts:
See prices paid.

Allowed costs:
See prices paid.

Beneficiary:
See insured.

Brand prescription:
A drug or medical device that is prescribed by a health care provider and marketed under a trade name approved by the U.S. Food and Drug administration
(USFDA). See also generic prescription.

Charges:
The dollar amount a provider charged/asked for medical services rendered; such charges can differ from the prices paid to that provider for medical
services rendered. See also prices paid.

Coinsurance:
A portion of covered health care costs borne by an insured. After the insured meets a deductible requirement, insurers often apply coinsurance according to
a fixed percentage of the prices paid.

Copay:
A cost-sharing arrangement in which the insured pays a specified charge for a specified service. Typical co-payments are fixed flat amounts for physician
office visits, prescriptions, or hospital services.

Deductible:
The amount that the insured must pay out of pocket to providers before the health plan pays any reimbursement to the insured. For example, an insured with
a $1,000 deductible would pay the first $1,000 of service costs in the given year. After the deductible is satisfied, the beneficiary and the health plan
jointly pay further expenses according to the insurance contract.

Employer-sponsored insurance (ESI):
A health insurance policy provided by an employer to its employees and their families. The employer and employee usually jointly pay premiums. See also
fully-insured benefit program and self-funded benefit program.

Facility claim:
A request for payment from a facility that provided a medical service, limited to the cost of using a room and associated services within the facility; it
does not include any procedures performed by health professionals on the insured. Charges for physician services are rendered separately as “professional
procedure claims.”

Filled days:
The number of days’ supply for one filled drug or medical device prescription. See also prescription.

Filled script:
One prescription drug claim for a drug or medical device regardless of number of days filled; each refill equals one script. See also prescription.

Generic prescription:
A drug or medical device that is prescribed by a health care provider, is not marketed under a trade name, but is approved by the U.S. Food and Drug
administration (USFDA). Generics have the same quality and chemical composition as a brand prescription and enter the market once exclusions on the brand
prescription expire. See also brand prescription.

Inpatient admission:
An admission to a hospital that includes an overnight stay. See also length of stay.

Inpatient facility:
A medical setting, such as hospitals, hospices, and skilled nursing facilities, where patients are kept overnight for treatment.

Insured:
An individual covered by health insurance. See also beneficiary and member.

Insured months:
The number of months an insured has health insurance in a given year.

Intensity:
A measure of the complexity of a service, including the length of time, the severity of the illness addressed, and the amount of resources required for
treatment. It is a component of price per service.[1]

Intensity-adjusted price:
The amount paid by insurers and beneficiaries to a provider for a health care provision, modified for the resource mix (intensity) of the services
provided. It is a component of price per service.

Member:
An individual covered by a specific health insurance plan; could be the primary coverage holder or a dependent. See also beneficiary and insured.

Member months:
The number of months for which an individual is covered by a specific health insurance plan. An insured covered for 12 member months in a calendar year
would be covered for 1 year of insurance. See also insured months.

Out-of-pocket payments:
A portion of allowed costs for medical services and treatment paid by the patient, including copays, coinsurance, and deductibles. See also prices paid.

Outpatient facility:
A facility or unit in a facility that provides medical services not requiring an overnight stay or hospitalization.

Payer:
The party who is financially responsible for the amount of the claim covered by the contract.

Per capita expenditure:
The sum of prices paid divided by the insured population; also calculated by multiplying total utilization and price per service.

Prescription:
An order from a health care professional and given to a patient to obtain drugs or medical devices that cannot be purchased over the counter.

Price per service:
A combination of intensity-adjusted price and intensity; calculated by multiplying the components.

Prices paid:
The amount paid to a provider for a medical service or supply after provider discounts. It is also defined as negotiated rates paid by a health plan to a
provider for a medical service or supply that qualifies as a covered expense. This amount is the shared responsibility of the health plan and the insured
and excludes amounts for non-covered services. It includes the payment by the insurer and the out-of-pocket payments of the insured.

Professional procedure claim:
A claim filed by a health care professional for medical services rendered. It includes claims for professional procedures as opposed to facility claims,
including office visits, lab tests, and immunizations.

Unit price:
See intensity-adjusted price.

Utilization:
The amount of medical service consumed by patients within a given time period; used in aggregate in the report to be the average rate of use per insured
person or multiplied by 1,000 as the rate of use per 1,000 individuals.



[1]
For calculations of intensity, please see HCCI’s Analytic Methodology (http://www.healthcostinstitute.org/).