Glossary

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Activate

To cause something to start.

Activated Fiduciary

Administrative Service Agreement

Attestation

The process by which a health plan fiduciary provides proof of their good faith compliance effort as it applies to the gag clause prohibition requirement under CAA.

Attestor

Someone who attests. As related to the CAA this would be the Plan Sponsor Fiduciary or a third party on behalf of the Plan Sponsor with regards to Gag Clause Prohibition.

BUCAH or BUCA

Bundled Self-Insured

CAA

Consolidated Appropriations Act of 2021 that amends ERISA, with the legislative intent of mandating transparency of provider costs to health plans and requiring plan sponsor/fiduciaries to establish a fiduciary process on behalf of plan participants.

Cash Pay / Self-Pay Rate

Chargemaster

CMS Reimbursement Rate

Conflict of Interest

(COI) is a situation in which a person or organization is involved in multiple interests, financial or otherwise, and serving one interest could involve working against another. Typically, this relates to situations in which the personal interest of an individual or organization might adversely affect a duty owed to make decisions for the benefit of a third party.

Direct Contracting

Direct Pharmacy Procurement

Discounted Fee for Service Network (PPO)

DOL

Department of Labor.

Duty of Loyalty

Educate

The act of teaching and learning to become smarter on a topic or topics.

Educated Fiduciary

Employee Benefit Advisor

Employee Benefit Broker

Employee Benefit Consultant

ERISA

Exclusive Benefit Rule

Fiduciary

A party who is directly or indirectly designated by the health plan to exercise discretion with respect to administration of the plan and management and disposition of plan assets, on behalf of plan participants. Plan fiduciaries include, for example, plan trustees, plan administrators, and members of a plan’s investment committee. Fiduciaries who do not follow these principles of conduct may be personally liable to restore any losses to the plan, or to restore any profits made through improper use of plan assets. Courts may take whatever action is appropriate against fiduciaries who breach their duties under ERISA including their removal.²

Fiduciary Duty

Fiduciary Liability

Fiduciary Process

Fiduciary Team

A group of individuals responsible for ensuring a plan is being managed according to ERISA law, and to the exclusive benefit of participants.

Fully Insured

Gag Clause

Gag Clause Prohibition Compliance Attestation (GCPCA)

The gag clause prohibition in the CAA prohibits health plans from entering into contracts that restrict access to specific data and information that a plan can make available to another party. The first attestation is due by December 31, 2023, and subsequent attestations will be due by December 31 of each year thereafter.

Good Faith Compliance Effort

The standard to which a health plan fiduciary is held to on behalf of plan participants. It requires behavior equal to or greater than that of a prudent person and a reasonable interpretation of the law.

Health Plan Data

MHPAEA

Health Plan Pricing Transparency

HHS

Health and Human Services.

High Performance Network

Hospital Pricing Transparency

IRS

Internal Revenue Service.

Level Funded

National Health Plan

A top five health plan that provides health care coverage, administration, stop loss, claim processing, etc. With its own PPO provider network across the country.

Pharmacy Benefit Manager (PBM)

Companies that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers.

Pharmacy Rebates

Plan Benchmarking

Plan Sponsor

The employer who creates the health plan on behalf of its employees. The plan sponsor is always a plan fiduciary.

PPO

A type of health insurance plan that allows members to see any doctor or specialist they choose without a referral.

PPO Discounts

Insurance company-negotiated discounted rates with a group of “preferred” medical providers. These are also known as network or in-network doctors and medical facilities. The discount is typically applied to the Chargemaster Rate for Hospitals or Billed rates for doctors and other non-hospital entities.

Prudent Man (Person) Rule

Qualified Payment Amount (QPA)

Self-Insured

A company provides all the funds to pay for expected claims.

Spread Pricing

Stop Loss Insurance

Third-Party Administrator

An organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. National Health plans or BUCAH’s perform the TPA function of processing claims. Independent TPA’s pay claims in unbundled self-insured arrangements.

Third-Party Health Solution Partner

Transparency

Designed to make health care price information more transparent for plan participants, specifically:

Making certain cost and claims data available through posted machine-readable files
Establishing an internet-based, self-service tool to allow members to get real-time, accurate estimates of cost-sharing liability for specific services, furnished by specific providers, at specific location.

Unbundled Self-Insured

Intercompany Eliminations

¹ https://www.dol.gov/general/topic/health-plans/erisa ² https://www.dol.gov/general/topic/health-plans/fiduciaryresp

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