Plain Language Glossary of Health Care Enrollment Terms

ACE TA Center

Quick reference glossary with plain language explanations of health care enrollment terms and phrases for HIV providers.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z


Adjusted Gross Income: The amount you earn or receive before taxes are taken out, minus certain allowed tax deductions, such as some business and medical costs.

Affordable Care Act (ACA): The health care reform law passed in 2010 that makes health insurance available and more affordable to many people who did not have health insurance before. The Affordable Care Act is also known as ‘Obamacare.’

AIDS Drug Assistance Program (ADAP): The government program that is administered at the state level and provides free HIV medications to people with low incomes. In many states, the program also helps pay for insurance for people with HIV. ADAP is authorized by the Ryan White HIV/AIDS Program (RWHAP), but neither ADAP nor RWHAP are health insurance. (See People with HIV, Ryan White HIV/AIDS Program)

Advance Premium Tax Credit (APTC): The premium tax credit helps lower the cost of health insurance premiums for people with low-income. Advance payments of the tax credit are applied to premium payments right away to help lower the cost of premiums paid for health care coverage purchased through the Health Insurance Marketplace for a person or family. (See Premium, Premium Tax Credit)

Affordable: Low cost

Agent/Broker: A person who can help you apply for and enroll in a Qualified Health Plan (QHP) through the Marketplace. An agent/broker can make a recommendation about which plan you should enroll in. Agent/brokers are licensed and regulated by the state and are typically paid by a health insurance company for enrolling you in the company’s plans. Some agents/brokers may only be able to sell plans from specific companies. (See Qualified Health Plan)

Appeal: A request for the health insurance company or the Marketplace to review a decision that denies a benefit or payment.

Assistance: Help


Benefits: The health care services or items covered under a health insurance plan. Covered benefits and excluded services are listed in the health insurance plan’s coverage documents.

In Medicaid and the Children’s Health Insurance Program (CHIP), covered benefits and excluded services are defined by state program rules. (See Medicaid, Children’s Health Insurance Program)


Call Center: A phone number to call for help applying for, enrolling in, and using health coverage. Help is often available in multiple languages.

Certified Application Counselor (CAC): A type of enrollment assister trained to help you:

  • Look for health insurance options
  • Compare health insurance options
  • Complete application forms

CACs can provide information about various health plans but cannot tell you which health plan to choose. Their services are free. (See Enrollment Assister, Marketplace)

COBRA (Consolidated Omnibus Budget Reconciliation Act): The Consolidated Omnibus Budget Reconciliation Act allows people who lose their jobs to continue their employer-sponsored insurance coverage for up to 18 months.

Consumer Assistance Program (CAP): The programs in some states that help with problems or questions about health insurance. They can help you learn about your rights and file a complaint or appeal with your health plan. (See Appeal)

Children’s Health Insurance Program (CHIP): The government program that provides free or low-cost health coverage for children up to age 19 in families whose income is too high to qualify for Medicaid but too low to afford private insurance. CHIP covers U.S. citizens and eligible immigrants. In some states, CHIP covers pregnant people. CHIP goes by different names in some states. (See Medicaid)

Claim: A request for payment that you or your health care provider submits to your health insurer to be paid or reimbursed for items or services you have received. Most often, you will not be  responsible for making claim requests. Usually, billing and claims specialists employed by the health care provider (e.g. primary care office, hospital) will make the claim on your behalf.

Coinsurance: People with health insurance may have to pay for part of their health care services. Coinsurance is a fixed percentage of a health care service that you are responsible for paying for after you’ve reached your insurance deductible. (See Deductible). 

For example, if your plan has a coinsurance requirement of 20% and a health service costs $100, your health insurance would pay $80 and you would pay the remaining $20 if you had reached your deductible.

Coinsurance is different from co-payment. Co-payments are usually a flat fee paid at the time of service, and coinsurance is paid after the insurance company pays their percentage of the cost. (See Co-payment)

Co-payment/Co-pay: A fixed amount you pay for some health care services. You usually pay a co-pay when you get the service. The amount may change for different types of care. For example, your co-pay might be $15 when you go in for a doctor’s visit and $30 when you go to the emergency room.

Co-payment is different from coinsurance. Coinsurance is paid after the insurance company pays its percentage of the cost. Co-payments are usually a flat fee paid at the time of service. (See Coinsurance)

Comprehensive Coverage: A health insurance plan that covers the full range of care that you may need. This may include preventive services (like flu shots), physical exams, prescription drugs, and doctor or hospital care. 

Cost sharing: The amount of out-of-pocket costs that you must pay for services covered by health insurance. Some examples include co-payments, deductibles, and coinsurance. (See Coinsurance, Co-payments, Deductible, Out-of-Pocket Costs).

Cost-sharing reduction (CSR): A reduction in the amount of out-of-pocket costs (such as coinsurance, co-payments, and deductibles) that you have to pay. Cost-sharing reductions are available for certain plan types offered by the Marketplace and are sometimes referred to as “extra savings”.  (See Coinsurance, Co-payments, Deductible).


Deductible: The deductible is the annual amount that you may have to pay for eligible health care services before your health insurance plan begins to pay.

For example, if your deductible is $500, your plan won’t pay anything until you’ve paid $500 for health care services covered by your health plan. After that, your health insurance plan will pay for services.

Some plans have lower deductibles and other costs that you must pay. (See Out-of-Pocket Costs, Coinsurance, Co-payments).

Deductions: Certain expenses that you are allowed to subtract from your income to reduce your taxes.

Demographics: Information about certain characteristics of a group of people, such as sexual orientation, gender identity, race, ethnicity, age, income level, and education. (See Sexual Orientation, Gender Identity, Income)

Dependent: A person who relies on someone else (usually a family member) for financial support. A dependent is someone you include on your tax form, even if that person doesn’t live with you.

Under the Affordable Care Act, you may be able to get a premium tax credit to help cover the cost of insurance for yourself and the dependents who you list on your tax form. (See Affordable Care Act, Premium Tax Credit).

Determination: A decision made by your insurance provider about your health insurance coverage. For example, your health insurance provider may decide not to pay for a service you received.

Disability: A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions). 

There are many types of disabilities, such as those that affect a person’s: vision, movement, thinking, remembering, learning, communicating, hearing, mental health, or social relationships. Some disabilities may be hidden or not easy to see.

Discrimination: Treating a person or group of people unfairly or differently from other people or groups of people (for example, discrimination based on their race, sex, or gender identity).

Dual Eligibility: When you meet the requirements for two forms of health coverage at the same time. Commonly used to refer to simultaneous eligibility for Medicare and Medicaid.


Eligibility: Whether you meet the requirements to get a certain kind of health coverage.

Eligibility Renewal: Re-application for health coverage.

Eligible Immigration Status: Some immigrants are eligible for (allowed to get) Medicaid or buy health insurance through the Marketplace. The rules for who is eligible are different for Medicaid and the Marketplace. A family may have some members who are eligible and others who are not because of their immigration status. (See Eligibility, Medicaid, Marketplace)

Emergency Department/Emergency Room: A place to go for care when you are very sick, seriously injured, in a life-threatening situation, or are experiencing any other medical emergency.

Employed: Someone who has a paid job.

Employee: Someone who works for another person or organization and is paid for their work. The benefits available to employees may vary based on the size of the employer. Some workers may instead be categorized as independent contractors. (See Independent Contractor

Employer: The person or organization that someone works for. Someone who works for a business that they own is self-employed. (See Self-Employed)

Employer-Sponsored Health Insurance (Job-Based Health Coverage): Health insurance that is offered to employees and their dependents (and in most cases, spouses) as a benefit of employment. (See Employee)

Enrollment Assister: A person who is trained to help you look for health insurance options through the Marketplace. An enrollment assister can help you understand what you are eligible for, compare health plans, and complete application forms. Enrollment assisters can provide information but cannot tell you which health plan to choose. Their help is free. Enrollment assisters include Certified Application Counselors, in-person assisters, and navigators.

Enrollment/Enroll: To join or sign up for a health plan.

Essential Health Benefits (EHB): The 10 types of health services that must be covered by health insurance plans, including:

  1. Ambulatory patient services (care you get without be admitted into a hospital)
  2. Emergency services (evaluation of an emergency medical condition and treatment to keep the condition from getting worse)
  3. Hospitalization (care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care)
  4. Pregnancy, maternity, and newborn care (both before and after birth)
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs (medication that, by law, require a prescription)
  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  8. Laboratory services (tests done for your injury or illness)
  9. Preventive and wellness services and chronic disease management (physicals, immunizations, screenings)
  10. Pediatric services (children’s health services), including oral (mouth) and vision (eye) care. (See Preventive Services)

Exchange: See Marketplace

Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency). (See In-Network)

Expenses: Costs

Extra Savings: See Cost-sharing Reductions


Financial Assistance/Financial Help: Help paying for insurance costs. You may be able to get help paying for premiums or out-of-pocket costs. (See Premium, Premium Tax Credit, Out-of-Pocket Costs).

Formulary: A list of prescription drugs covered by a health plan. This includes both generic and specialty medications. A formulary may include how much you pay for each drug.


Gender Identity: Your inner sense of being a girl/woman/female, a boy/man/male, something else, or having no gender.

Grievance: A complaint made to your health insurer or health plan. For example, you may want to file a complaint if:

  • Your health plan is denying payment for a treatment you feel should be covered (See Appeal)
  • If doctors, nurses, clinic staff, or someone else is rude or disrespectful to you
  • Any other problem you have with your health care

Gross Income: The total income, including cash, that you earn during a time period (usually a year) before taxes are taken out.

H See Marketplace

Health Disparities: Health disparities are preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by some racial, ethnic, and other population groups, and communities.

Health Equity: The absence of disparities or avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.

Health Insurance Coverage: An agreement you make with a payor to help pay for medical care, such as doctors’ visits and medication. The insurer pays part of your health care costs because you have been making regular payments (premiums) to the insurance company. Someone else, like ADAP, may make these payments for the person. (See Premium, Public Coverage, Private Health Insurance)

Note that the Ryan White HIV/AIDS Program (RWHAP) is not health insurance. (See Ryan White HIV/AIDS Program)

Health Insurance Literacy: The degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family's) financial and health circumstances, and use the plan once enrolled.

Health Insurance Marketplace: A service that helps you shop for and enroll in health insurance. The federal government operates the Health Insurance Marketplace, available at, for most states. Some states run their own Marketplaces. (See Marketplace)

Health Maintenance Organization (HMO): A health plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. HMO plans often require you to get a referral from their primary care doctor in order to see a specialist. (See Primary Care Provider, Specialist)

Household: You, your spouse if you’re married, and your tax dependents. (See Dependent)


Income: How much money you make or receive in a year.

Independent Contractor: People who are in an independent trade, business, or profession in which they offer their services to the general public. Generally, a person is an independent contractor if the person paying them has the right to control or direct only the result of the work and not what will be done and how it will be done. You are not an independent contractor if you perform services that can be controlled by an employer (what will be done and how it will be done). If you are an independent contractor, you are self-employed and your earnings are subject to Self-Employment Tax. (See Employee)

Individual Mandate: A legal requirement to have health insurance that meets the standards of minimum essential coverage. Some states have an individual mandate for health insurance and residents of those states may have to pay a fee if they do not obtain health insurance. (The fee is sometimes called a penalty, fine, or individual responsibility payment.) You may be exempt from the individual mandate if:

  • No affordable coverage is available to you
  • You have a short gap in coverage during the year for less than three consecutive months
  • You qualify for a minimum essential coverage exemption.

(See Minimum Essential Coverage)

In-Network: The doctors, clinics, health centers, and hospitals whose services are covered by a health insurance plan, sometimes referred to as preferred providers. It is important to get health services from doctors, clinics, health centers and hospitals that are in your health plan’s network, when possible, to keep your costs down. (See Out-of-Network)

Integrated Care: A health care model that involves a high degree of collaboration and communication among health professionals about their patients to develop a comprehensive care plan that addresses multiple health care areas, such as primary care, behavioral health, and social services. Integrated care may also refer to the coordination of health care financing, benefits, care delivery, and/or administrative requirements between insurers for people with more than one form of health coverage. (See Dual Eligibility)

Interest Income: Money earned from investments, such as money saved in a bank account or stocks. You should include interest as part of your income if you are applying for help paying for health insurance.


Lesbian, Gay, Bisexual, and Transgender (LBGT): An acronym that stands for lesbian, gay, bisexual, transgender, and queer or questioning (in regards to a person’s sexual orientation or gender identity). (See Transgender)

Life Changing Event: Changes in the number of people in your household or income that may affect your health insurance eligibility. Life changes can include: income, where you live, disability status, marriage, divorce, pregnancy, birth or adoption of a child, or putting a child up for adoption, gaining or losing a dependent, or any other events that change your income or the number of people in your household. (See Household, Income, Qualifying Life Event)


Managed Care Organization (MCO): Groups of doctors, clinics, hospitals, pharmacies, and other medical providers that work together to take care of patients’ health care needs. Sometimes a managed care organization is called a ‘network’ or ‘health plan.’

Marketplace: The Marketplace is where individuals, families, and small businesses can:

  • Learn about health insurance options
  • Compare health insurance plans
  • Choose a plan
  • Enroll in insurance

You can access the Marketplace through websites, call centers, and in-person assistance. The Marketplace has information on how people with low- to moderate-income can save money on health insurance. The Marketplace provides information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP).

The Marketplace is sometimes referred to as the Exchange. is the website for the national Marketplace. Your state may have its own Marketplace website with a different name.

Medicaid: The state-run government program that provides health coverage for:

  • Families and children with low incomes 
  • Pregnant people
  • Senior citizens
  • People with disabilities
  • In some states, other adults with low incomes

The federal government provides a portion of the funding for Medicaid and sets rules for the program. States can choose how they design their Medicaid program, so Medicaid varies by state. States may have their own name for this program.

Medically Necessary: Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medicare: The federal health coverage program for people who are 65 or older and certain people under 65 who have a qualifying disability. HIV status alone does not usually qualify someone for Medicare. Medicare is broken up into different Parts, and each Part covers a different aspect of a person’s care (hospital, medical, and prescription drug). When a person enrolls in Medicare, they will choose whether they want to enroll in:

  • Original Medicare: Includes Part A (hospital) and Part B (medical) coverage. Medicare Part D (prescription drug coverage) is optional and is purchased separately.
  • Medicare Advantage: Medicare Advantage plans, also called Medicare Part C, are bundled plans that include Part A (hospital) and Part B (medical) coverage. It usually also includes Part D (prescription drug coverage).

Minimum Essential Coverage: Health coverage that is affordable and provides a minimum set of services. Generally includes health insurance plans available through the Health Insurance Marketplace, Medicare, Medicaid, CHIP, and certain other coverage. (See Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program)

Minimum Essential Coverage Exemption: A status that allows you to not have to make a payment for not having minimum essential coverage. You may be eligible for an exemption if you:

  • Lacked access to affordable coverage
  • Had a short coverage gap
  • Experienced certain hardships
  • Had income below your filing threshold
  • Were not lawfully present in the United States

Modified Adjusted Gross Income (MAGI): The total amount of money you make or receive in a year. This number is used to decide if you are eligible for a lower-cost health plan. Generally, MAGI is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. (See Gross Income)


Navigator: A person or organization that is trained and able to help people, small businesses, and their employees look for health coverage options through the Marketplace. Navigators can help complete eligibility and enrollment forms. They are required to treat everyone equally, and their help is free. (See Enrollment Assister)

Net Income: The amount of money you make or receive in a year, minus what you paid in taxes.

Network: See In-Network, Out-of-Network

Non-Preferred Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll generally pay more to see a non-preferred (or Out-of-Network) provider than to see a preferred (or In-Network) provider. (See In-Network, Out-of-Network)


Off-Marketplace Plans: Health plans sold by private insurance companies. These plans may or may not meet minimum essential coverage requirements, and are not eligible for premium tax credits or other savings based on your income. (See Minimum Essential Coverage, Premium Tax Credits)

Open Enrollment Period: Open Enrollment is a period of time each year when you can enroll in a health insurance plan. Many types of plans, including Marketplace, employer-sponsored insurance, and Medicare, have open enrollment periods.

Opt-In: To choose to take part in something. For example, a person may choose to take part in (opt-in) his or her company’s health insurance plan.

Organizational Health Literacy: The degree to which organizations equitably help people to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Out-of-Pocket Costs (OOP): Health care costs that aren’t paid by the insurance plan, but are instead paid with your own money. Out-of-pocket costs include:

  • Deductibles
  • Coinsurance
  • Co-payments for covered services
  • All other costs for any services your insurance plan doesn’t cover

(See Cost sharing, Deductible, Coinsurance, Co-payment)

Out-of-Network: The doctors, clinics, health centers, and hospitals whose services may cost more or not be covered at all by your health plan. (See In-Network)

Out-of-Pocket Limit/Out-of-Pocket Maximum: The most you will pay with your own money for covered services during a health insurance policy period (usually a year). After you reach this limit, your health insurance plan will pay 100% of the allowed costs for services covered by your health plan.

For example, if your plan’s out-of-pocket limit is $3,000, once you have paid $3,000 of your own money in deductibles, co-pays, and coinsurance (all added together), you won’t have to pay any more health insurance costs during the plan year.

However, your premium, costs for health services that your plan doesn’t cover, and certain other costs don’t count toward the out-of-pocket limit. Different health insurance plans count different things toward the out-of-pocket limit, so be sure you understand your plan’s rules. (See Premium, Deductible, Coinsurance, Out-of-Network)

Outreach: Finding ways to give information and bring people into services.


Passive Enrollment: A process through which individuals are automatically enrolled into a health plan. In many but not all cases, individuals have the option to opt out of coverage after they have been enrolled.

Pending: Waiting for something (often a decision or approval).

People with HIV (PWH): People who have HIV (human immunodeficiency virus).

Personal Health Literacy: The degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Plan: See Qualified Health Plan

Point of Service (POS): A health plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist. (See Primary Care Doctor, Specialist)

Preferred Provider Organization (PPO): A health plan where you pay less if you use providers that belong to the plan’s network. PPO plans allow you to see doctors, hospitals, and other health care providers outside of the network without a referral for an additional cost. 

Premium: The amount you pay for a health insurance plan. A premium may be paid every month, every three months, or every year. Part or all of your premium may be paid by your employer, ADAP, or someone else.

Premium Tax Credit (PTC): A tax credit that helps to lower the cost of premiums for health care coverage purchased through the Health Insurance Marketplace. (See Advance Premium Tax Credit, Premium)

Presumptive Eligibility: Short-term health coverage that begins right away so that you can get medical care while your insurance application is being processed.

Preventive Services: Routine health care that includes annual physicals, tests, and counseling to prevent illnesses, disease, and other health problems.

Primary Care Doctor: Your main health care provider who you go to for treatment of common illnesses and routine care like check-ups and shots. Your primary care provider also helps you decide if you need to go to the hospital or seek specialized treatment.

Primary care providers include:

  • Family medicine (a doctor who treats people of all ages)
  • Pediatricians (a doctor who treats children)
  • Internist (a doctor who treats adults)
  • In some states, nurse practitioners and physician assistants are also considered primary 

Prior Authorization: A process used by your health plan to determine whether it will cover a prescribed procedure, service, medication, or medical equipment. Prior authorization is also referred to as precertification, preauthorization, or prior approval.

Private Health Insurance: Health coverage provided through a job, purchased through a state or federal Marketplace, or purchased directly from a private health insurance company. (See Employer-Sponsored Health Insurance, Off-Marketplace Plan, Qualified Health Plan)

Public Coverage: Health coverage programs that are funded and administered by the state and/or federal government. Public coverage includes programs such as Medicaid, Medicare, TRICARE, and the Children’s Health Insurance Program (CHIP). (See Medicaid, Medicare, Children’s Health Insurance Program, TRICARE)


Qualified Health Plan (QHP): A health insurance plan that is approved by the Marketplace. QHPs:

  • Provide essential health benefits
  • Follow limits on how much of their own money people pay for services covered by the health plan, such as limits on deductibles, co-payments, and out-of-pocket maximum amounts
  • Meet other requirements, such as being a licensed insurer

A qualified health plan must be approved by each Marketplace in which it is sold. (See Essential Health Benefits, Deductibles, Co-payments, Out-of-Pocket Limits, Marketplace)

Qualify: To meet the requirements to get insurance.

Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events include moving to a new state, certain changes in your income, and changes in your family size. (See Special Enrollment Period)

Quantity Limits: A limit on the quantity of a prescription drug that can be dispensed at one time. For example, your health plan may limit you to a 30-day supply of a particular medication per month.


Renewal: Signing up to continue with your health plan each year.

Ryan White HIV/AIDS Program (RWHAP): The government program that helps people with HIV and low incomes to get HIV-related health care. The program fills gaps in HIV care not covered by other options. The RWHAP is not health insurance.


Self-Employed: A person who works for them self and does not have a boss. For example, you are self-employed if you own your own business or work as a freelancer. (See Independent Contractor)

Sex Assigned at Birth: The label assigned to an infant, typically male or female, based on medical factors such as their hormones, chromosomes, and genitalia.

Sexual Orientation: How people characterize their emotional and physical attraction to others.

Special Enrollment Period (SEP): A period of time outside of the Open Enrollment Period when you become eligible to sign up for, or change job-based health coverage (health insurance paid in part or fully by the employer, also called employer-sponsored health insurance) or Marketplace health coverage. There are also Special Enrollment Periods and Open Enrollment Periods for Medicare. Eligible individuals are allowed to enroll in Medicaid and CHIP at any time. (See Open Enrollment, Employer-Sponsored Health Insurance, Medicare, Medicaid, Children’s Health Insurance Program, Marketplace)

Specialist: A doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. There are many kinds of specialists, and HIV providers may be considered specialists.

State-Based Exchange/State-Based Marketplace: State-run exchanges/marketplaces responsible for performing all marketplace functions to support individuals enrolling in health coverage. 

Step Therapy: A health plan requirement for you to try a lower-cost medication for a period of time before being allowed to switch to a higher-cost medication.

Substance Use Disorder (SUD): A complex condition in which there is uncontrolled use of a substance (e.g. alcohol, tobacco, or illicit drugs) despite harmful consequences. 

Summary of Benefits and Coverage: A document that uses clear, plain language to summarize key features of the plan, such as covered benefits, cost-sharing provisions, and coverage limitations. 


Tax Credit: See Premium Tax Credit

Teachback: A technique that helps providers and staff understand whether they explained the information well enough to their client.

TRICARE: The health care program for uniformed service members, retirees, and their families.


Urgent Care Clinic: Where to go for care when you have an illness or injury that is not life-threatening and when your regular doctor isn’t available. (See Emergency Department)

Unemployed: Someone who does not have a paid job.

Utilization Management: A policy used by insurance companies to evaluate the medical necessity, appropriateness, and clinical effectiveness of a health care service, medication, or procedure to manage the cost of a covered health care benefit. Common utilization management methods include prior authorization and step therapy. (See Medically Necessary, Prior Authorization, and Step Therapy)

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