Glossary: sixty terms in plain English

How to read this glossary

The terms appear in a suggested conversation order, not alphabetically. Each entry gives a plain-English line and a technical line. The plain-English line is a teaching translation, not a substitute for the legal definition. Entries with a source link point to the public authority for the technical line. Entries marked “project definition” describe how this project uses a term where no single public definition controls.

Coverage and plans

1. Medicaid. Plain: shared federal-state health coverage. Technical: a state-administered program financed through federal participation in eligible expenditures within federal requirements. Source: CMS, Financial Management.
2. Oregon Health Plan, or OHP. Plain: Oregon's public coverage program. Technical: distinguish OHP Medicaid and CHIP from OHP Bridge, the Basic Health Program, rather than treating every OHP-labeled person as the same Medicaid financing category. Source: Oregon HealthCare, “Oregon Health Plan”.
3. Medicare. Plain: federal health coverage mainly for older people and some younger people with disabilities or specified conditions. Technical: Original Medicare and private Medicare Advantage arrangements are different payment contexts. Source: Oregon HealthCare, “Medicare” and “Medicare coverage options”.
4. Coordinated care organization, or CCO. Plain: a local OHP health plan. Technical: an organization coordinating covered physical, behavioral and dental care, whose plan payment must not be confused with its hospital payment. Source: OHA, “What are CCO plans?”.
5. Capitation. Plain: a periodic payment for each enrolled person. Technical: the state pays a contractor using an actuarially sound rate for covered services whether or not that person uses services during the period. Source: 42 CFR 438.2, “Capitation payment”.
6. Fee-for-service, or FFS. Plain: paying for covered services rather than enrolling someone in a capitated payment arrangement. Technical: a Medicaid payment route distinct from managed care and subject to its applicable state-plan and federal payment rules. Source: CMS, Financial Management.

How hospitals are paid

1. Diagnosis-related group, or DRG. Plain: a category used to price an inpatient stay. Technical: Medicare groups discharges by diagnosis, procedures and other characteristics and assigns relative resource weights. Source: CMS, IPPS, “Medicare Severity Diagnosis Related Groups”.
2. Inpatient prospective payment system, or IPPS. Plain: Medicare's advance-set case-payment system. Technical: payment for an acute inpatient discharge uses predetermined rates and adjustments rather than the individual patient's actual cost. Source: CMS, IPPS.
3. Base payment. Plain: the starting payment before separately identified additions. Technical: identify the governing formula and the components already included before adding supplements. (Project definition.)
4. Supplemental payment. Plain: an additional payment under a specified program. Technical: the definition is rule-specific, and 42 CFR 438.6(a) distinguishes supplemental payments from DSH and graduate medical education payments. Source: 42 CFR 438.6(a).
5. State-directed payment, or SDP. Plain: a state instruction governing how a Medicaid managed-care plan pays providers. Technical: an arrangement under 42 CFR 438.6(c), with requirements depending on its design, not automatically unrestricted new money. Source: 42 CFR 438.6(c)(1)–(2).
6. OPH2. Plain: the project's short name for Oregon's general DRG hospital quality-and-access directed payment. Technical: identify the specific approved year, provider class, payment form and financing separately rather than assuming last year's approval continues. (Project definition.)

Financing

1. Nonfederal share. Plain: the eligible funding that is not the federal matching portion. Technical: qualifying public funds must satisfy appropriation, transfer or certification rules, and federal funds ordinarily cannot match federal funds without statutory authorization. Source: 42 CFR 433.51(a)–(c).
2. Federal medical assistance percentage, or FMAP. Plain: the applicable federal share of eligible Medicaid spending. Technical: it is a financing percentage, not a hospital payment rate or margin. Source: CMS, Financial Management.
3. Intergovernmental transfer, or IGT. Plain: an eligible transfer of public money toward the state share. Technical: another public agency's funds must be transferred to the Medicaid agency and placed under its administrative control, subject to the other financing rules. Source: 42 CFR 433.51(b)–(c).
4. Certified public expenditure, or CPE. Plain: qualifying public spending documented for federal participation. Technical: the contributing public agency certifies eligible expenditures, which is not the same transaction as transferring cash. Source: 42 CFR 433.51(b). Federal matching funds are paid to the state. Any remittance to the certifying provider follows the applicable approved method; its certified expenditure is not a pool for other hospitals.
5. Hospital assessment. Plain: Oregon's hospital tax used in health-program financing. Technical: the assessment's taxable base, period, rate, reporting duties and fund uses are defined by statute and implementing rules, not by a guaranteed return to each taxpayer. Source: ORS 414.855–414.867.
6. Provider-related donation. Plain: a contribution linked to a provider that needs a special financing review. Technical: a bona fide donation cannot have a prohibited direct or indirect relationship to Medicaid payments to the donor, related entities or same-class providers. Source: 42 CFR 433.54(a)–(c).
7. Hold harmless. Plain: a prohibited protection that returns or offsets a provider's contribution or tax under the applicable tests. Technical: examine the actual direct or indirect guarantee and the governing donation or tax rule rather than relying on a transaction's label. Sources: 42 CFR 433.54(c); 42 CFR 433.68(f).

Money terms that are easy to confuse

1. Cost. Plain: resources used to deliver care. Technical: allowable cost depends on the payer, services, period, allocation and reporting method, so “cost” is not one universal number. (Project definition.)
2. Charges. Plain: the hospital's stated prices. Technical: they are not the same as net patient revenue after contractual allowances, charity care and bad debt. Source: OHA Databank Glossary, pages 1–2 and 4.
3. Allowed amount. Plain: the amount recognized under the applicable payer terms. Technical: separate it from billed charges, paid amounts, patient responsibility and deposited cash. (Project definition.)
4. Net patient revenue. Plain: patient-care revenue after specified reductions from charges. Technical: OHA's reporting definition deducts contractual allowances, charity care and bad debt. Source: OHA Databank Glossary, page 2.
5. Operating income or loss. Plain: the result from operating the hospital before nonoperating activity. Technical: operating revenue minus operating expense, called dollar operating margin in OHA's Databank glossary. Source: OHA Databank Glossary, page 3.
6. Operating margin percentage. Plain: the operating result for each dollar of operating revenue. Technical: divide operating revenue minus operating expense by operating revenue, retaining the period and reporting entity. Source: OHA Databank Glossary, page 3.
7. Cash. Plain: money actually available in the relevant account. Technical: distinguish a bank receipt from an accrued receivable and separately test restrictions on spending it. (Project definition.)
8. Claim and encounter. Plain: records describing care and the request or report associated with payment. Technical: a claim line, encounter and inpatient discharge are not interchangeable units, and the payment rule determines the unit to count. (Project definition.)
9. Remittance. Plain: the payer's explanation of what it paid or adjusted. Technical: adjudication and remittance records must be reconciled to cash and recoveries rather than treated as deposits by themselves. (Project definition.)
10. Reconciliation. Plain: checking that the records and calculations agree. Technical: match services, populations, periods, paid components, adjustments and governing limits, with a reproducible workpaper. (Project definition.)

Benchmarks and limits

1. Medicare benchmark. Plain: a specified Medicare-method comparison. Technical: define the service, rate year and required adjustments, since a DRG base rate alone omits wage-index and other applicable components. Source: CMS, IPPS.
2. Minimum fee schedule. Plain: a required minimum provider payment under specified terms. Technical: 42 CFR 438.6(c)(1)(iii) authorizes specified minimum schedules, and an exception from prior approval does not erase other applicable requirements. Source: 42 CFR 438.6(c)(1)(iii) and (c)(2).
3. Total payment rate. Plain: the counted combined rate, not just the proposed addition. Technical: the regulatory definition includes specified base, directed-payment and allowable pass-through components, with later statutory restrictions read alongside the regulation. Source: 42 CFR 438.6(a), “Total payment rate”.
4. Upper payment limit, or UPL. Plain: a ceiling for a defined fee-for-service payment group. Technical: inpatient UPL rules generally compare aggregate payments within ownership categories with a reasonable estimate of Medicare-principle payments, rather than promising each hospital the difference. Source: 42 CFR 447.272(a)–(c).
5. Headroom. Plain: calculated room under a particular limit. Technical: the relevant ceiling minus counted payments for the same scope is neither a cost shortfall, committed financing nor a collectible receivable. (Project definition.)
6. Grandfathering. Plain: limited transition treatment for a qualifying existing arrangement. Technical: identify the exact statutory eligibility, approval or submission evidence, payment scope and step-down rather than assuming a permanent exemption. (Project definition.)
7. Total computable payment. Plain: the eligible total containing both financing shares. Technical: federal and nonfederal shares finance one expenditure, so the state share must not be added again as an extra hospital benefit. Source: CMS, Financial Management.

Budget and federal approval

1. Appropriation. Plain: legal authority to spend public money for a purpose. Technical: spending authority, expenditure limitation, available cash and a policy request are separate questions under Oregon budgeting. (Project definition.)
2. General Fund. Plain: the state's general budget resources. Technical: a proposed General Fund contribution still requires lawful spending authority and a disclosed opportunity cost, not merely identification of the fund. (Project definition.)
3. State plan. Plain: the approved framework for a state's Medicaid program. Technical: provider-payment methods and changes must follow the applicable federal and state-plan requirements. Source: CMS, Financial Management.
4. State plan amendment, or SPA. Plain: a requested change to that approved framework. Technical: a change in state-plan provider-payment methodology is submitted to CMS for review and approval, rather than becoming effective merely because a bill names it. Source: CMS, Financial Management.
5. Section 1115 demonstration. Plain: a federally approved demonstration with specified permissions and conditions. Technical: its waiver and expenditure authorities, terms and dates do not amount to a general waiver of all Medicaid financing law. (Project definition.)
6. Cost-based reimbursement. Plain: payment calculated from defined covered-service costs. Technical: Oregon's qualifying rural-hospital fee-for-service rule uses audited Medicare cost-report information adjusted for Medicaid service mix, while managed-care treatment has separate conditions. Source: ORS 414.728 and 414.598(6).

Hospital categories

1. Type A hospital. Plain: a small, remote Oregon hospital category. Technical: 50 or fewer beds and more than 30 miles from another acute inpatient facility, within the definitions and exclusions of ORS 442.470. Source: ORS 442.470(6)(a)(A) and (6)(b).
2. Type B hospital. Plain: a small, rural Oregon hospital category. Technical: 50 or fewer beds and 30 miles or less from another acute inpatient facility, within the same statute's definitions and exclusions. Source: ORS 442.470(6)(a)(B) and (6)(b).
3. Critical access hospital, or CAH. Plain: a separate small-hospital Medicare provider category. Technical: among its conditions are no more than 25 inpatient or swing beds and an annual average acute inpatient stay of 96 hours or less, with separate distinct-part-unit rules. Source: CMS, Critical Access Hospitals.
4. Sole community hospital, or SCH. Plain: a Medicare classification recognizing specified access circumstances. Technical: it is not synonymous with critical access, rural referral center, public ownership or an Oregon payment entitlement. (Project definition.)
5. Rural referral center, or RRC. Plain: a distinct Medicare referral-hospital classification. Technical: current federal status and Oregon's pre-January 1, 1989 referral-hospital exclusion are separate questions requiring dated records. Statutory cross-check: ORS 442.470(6)(b).
6. Public hospital. Plain: a hospital with a specified government ownership or operating relationship. Technical: identify the rule's actual test, because a public building owner, a public operator and a public UPL class are not automatically the same. (Project definition.)
7. Nonprofit hospital. Plain: a hospital operated through a nonprofit structure. Technical: nonprofit status does not by itself establish government ownership, public-fund authority, local financing eligibility or unrestricted cash. (Project definition.)

Access and service

1. Network adequacy. Plain: whether the plan's network can provide required access. Technical: coverage, capacity, geography and contract standards must be tested separately from a hospital's entitlement to a particular rate. (Project definition.)
2. Service readiness. Plain: keeping a defined care capability available. Technical: specify staffing, capacity, hours, population, performance duties and existing paid obligations before pricing an additional readiness commitment. (Project definition.)
3. Payer mix. Plain: the distribution of hospital activity or revenue among payers. Technical: specify whether the denominator is patients, discharges, services or revenue, and do not substitute county insurance enrollment. (Project definition.)
4. Service area. Plain: the places and people a service actually reaches. Technical: define the method, services, origin data and period rather than assuming county borders equal patient catchment. (Project definition.)

Proposal and evaluation terms

1. Systemically Important Rural Hospital. Plain: the proposed designation for a hospital whose loss or contraction would disrupt the wider care network. Technical: it is the project's proposed term and would require an objective class and enacted operative provisions; it is not a current payment entitlement. (Project definition.)
2. Net retained benefit. Plain: what the hospital actually keeps because of the proposal. Technical: compare the same future period with and without the proposal, after assessments, displaced payments, restrictions, costs, recoveries and related-entity effects. (Project definition.)
3. Counterfactual. Plain: what would happen without the proposal. Technical: a supported same-period baseline, not automatically last year's receipts or a closure assumption. (Project definition.)
4. CCO ownership interest. Plain: a hospital or related entity's financial stake in a health-plan entity. Technical: distinguish direct and indirect ownership, control, risk contracts and distributions, with the entity and date attached. (Project definition.)
5. Award, obligation and disbursement. Plain: different stages between an announced grant and cash paid. Technical: record the recipient, approved purpose, executed obligation, payment conditions and actual receipt separately. (Project definition.)
6. Medicaid disproportionate share hospital payment, or DSH. Plain: support for qualifying hospitals serving Medicaid and uninsured people. Technical: statewide federal allotments, hospital-specific eligible uncompensated-cost limits and audit and reporting requirements apply, separately from Medicare DSH. Source: CMS, Medicaid DSH payments.
7. Audit trail. Plain: enough documentation for someone else to reproduce a claim. Technical: preserve source, version, period, unit, formula, exclusions and reviewer changes, without claiming that a workpaper is an independent audit or CMS approval. (Project definition.)

Evidence date and scope

Circulation draft. Resource evidence date: November 7, 2026. Public facts link to their original public sources; analysis, project positions and open questions are labeled. A reference to a hospital or other organization describes public information and does not mean that it has joined this project or endorsed its proposals.