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Definitions of commonly used terms in healthcare

Beneficiary- A person who is eligible for or receiving benefits under an insurance policy or plan.

10 Common Health Care Terms: Do You Know Them?

Benefits- The services that members are entitled to receive based on their health plan. Blue Cross and Blue Shield are separate organizations that have different benefits, premiums and policies. Individuals who have met all requirements, but have not completed the exam are referred to as "board eligible. Back To Top C Cafeteria plan-This benefit plan gives employees a set amount of funds that they can choose to spend on a different benefit options, such as health insurance or retirement savings Capitation- A fixed prepayment, per patient covered, to a healthcare provider to deliver medical services to a particular group of patients.

The payment is the same no matter how many services or what type of services each patient actually gets. Under capitation, the provider is financially responsible.

  • A team-based healthcare delivery model led by a physician that provides comprehensive and continuous medical care to patients;
  • Quality Assurance and Quality Improvement- A systematic process to improve quality of healthcare by monitoring quality, finding out what is not working, and fixing the problems of healthcare delivery;
  • Protein, Fat, Carbohydrates, and Sugars.

Care Guidelines- A set of medical treatments for a particular condition or group of patients that has been reviewed and endorsed by a national organization, such as the Agency for Healthcare Policy Research.

Carrier- A private organization, usually an insurance company, that finances healthcare. Carve-out- Medical services that are separated out and contracted for independently from any other benefits.

Chronic Care- Treatment given to people whose health problems are long-term and continuing. Nu nursing homes, mental hospitals and rehabilitation facilities are chronic care facilities.

  • Health Insurance Portability and Accountability Act HIPAA - Also known as Kennedy-Kassebaum law, this guarantees that people who lose their group health insurance will have access to individual insurance, regardless of pre-existing medical problems;
  • A process if an individual has two group health plans, the amount payable is divided between the plans so that the combined coverage amounts to, but does not exceed, 100 percent of the charges.

Chronic Disease- A medical problem that will not improve, that lasts a lifetime, or recurs. Claims- Bills for services. Doctors, hospitals, labs and other providers send billed claims to health insurance plans, and what the plans pay are called paid claims. COBRA- Consolidated Omnibus Budget Reconciliation Act of 1985 Designed to provide definitions of commonly used terms in healthcare coverage to workers between jobs, this legal act lets workers who leave a company buy health insurance from that company at the employer's group rate rather than an individual rate.

Co-insurance-A cost-sharing requirement under some health insurance policies in which the insured person pays some of the costs of covered services.

Cost Containment- The method of preventing healthcare costs from increasing beyond a set level by controlling or reducing inefficiency and waste in the healthcare system. Cost Sharing- An insurance policy requires the insured person to pay a portion of the costs of covered services. Deductibles, co-insurance and co-payments are cost sharing. Cost Shifting- When one group of patients does not pay for services, such as uninsured or Medicare patients, healthcare providers pass on the costs for these health services to other groups of patients.

Coverage- A person's healthcare costs are paid by their insurance or by the government. Covered services- Treatments or other services for which a health plan pays at least part of the charge. Back To Top D Deductible- The amount of money, or value of certain services such as one physician visita patient or family must pay before costs or percentages of costs are covered by the health plan or insurance company, usually per year. Diagnostic related groups DRGs - A system for classifying hospital stays according to the diagnosis of the medical problem being treated, for the purposes of payment.

Direct access- The ability to see a doctor or receive a medical service without a referral from your primary care physician. Disease management- Programs for people who have chronic illnesses, such as asthma or diabetes, that try to encourage them to have a healthy lifestyle, to take medications as prescribed, and that coordinate care.

Disposable Personal Income- The amount of a person's income that is left over after money has been spent on basic necessities such as rent, food, and clothing.

Back To Top E Early and Periodic Screening, Diagnosis, and Treatment Program EPSDT - As part of the Medicaid program, the law requires that all states have a program for eligible children under age 21 to receive a medical assessment, medical treatments and other measures to correct any problems and treat chronic conditions.

Elective- A healthcare procedure that is not an emergency and that the patient and doctor plan in advance. Emergency- A medical condition that starts suddenly and requires immediate care. Companies that have self-funded health benefit plans operating under ERISA are not subject to state insurance regulations and healthcare legislation. Employer Contribution- The contribution is the money a company pays for its employees' healthcare. Exclusions- Health conditions that are explicitly not covered in an insurance package and that your insurance will not pay for.

Federal employees may choose to participate in one of two or more plans.

  1. Claims- Bills for services.
  2. Disposable Personal Income- The amount of a person's income that is left over after money has been spent on basic necessities such as rent, food, and clothing.
  3. A system in which a payer negotiates lower prices with certain doctors and hospitals.

Fee-for-Service- Physicians or other providers bill separately for each patient encounter or service they provide. This method of billing means the insurance company pays all or some set percentage of the fees that hospitals and doctors set and charge. Expenditures increase if the increaseThis is still the main system of paying for healthcare services in the United States. First Dollar Coverage- A system in which the insurer pays for all employee out-of-pocket healthcare costs.

Under first dollar coverage, the beneficiary has no deductible and no co-payments. Flex plan- An account that lets workers set aside pretax dollars to pay for medical benefits, childcare, and other services. Formulary- A list of medications that a managed care company encourages or requires physicians to prescribe as necessary in order to reduce costs. Back To Top G Gag clause- A contractual agreement between a managed care organization and a provider that restricts what the provider can say about the managed care company Gatekeeper- The person in a managed care organization, often a primary care provider, who controls a patient's access to healthcare services and whose approval is required for referrals to other services or other specialists.

  1. Ambulance services for an emergency medical condition.
  2. Primary Care- Basic or general routine office medical care, usually from an internist, obstetrician-gynecologist, family practitioner, or pediatrician.
  3. Mental health can be treated and be attentive to teens' behavior. Patients who go to a preferred or in-network provider get a higher benefit-for example, 90 percent or 100 percent coverage of their costs-than patients who go outside the network.
  4. Inactivity can also contribute to health issues and also a lack of sleep, excessive alcohol consumption, and neglect of oral hygiene Moffett2013.

General Practice- Physicians without specialty training who provide a wide range of primary healthcare services to patients. Global Budgeting- A way of containing hospital costs in which participating hospitals share a budget, agreeing together to set the maximum amount of money that will be paid for healthcare. Group Insurance- Health insurance offered through business, union trusts or other groups and associations. The most common system of health insurance in the United States, in which the cost of insurance is based on the age, sex, health status and occupation of the people in the group.

Group model HMO- An HMO that contracts with an independent group practice to provide medical services Guaranteed Issue- The requirement that an insurance plan accept everyone who applies for coverage and guarantee the renewal of that coverage as long as the covered person pays the policy premium.

H Healthcare Benefits- The specific services and procedures covered by a health plan or definitions of commonly used terms in healthcare. HCFA also does research to support these programs and oversees more than a quarter of all healthcare costs in the United States. Health Insurance- Financial protection against the healthcare costs caused by treating disease or accidental injury.

Health Insurance Portability and Accountability Act HIPAA - Also known as Kennedy-Kassebaum law, this guarantees that people who lose their group health insurance will have access to individual insurance, regardless of pre-existing medical problems. The law also allows employees to secure health insurance from their new employer when they switch jobs even if they have a pre-existing medical condition.

Health Insurance Purchasing Cooperatives HIPCs - Public or private organizations that get health insurance coverage for certain populations of people, combining everyone in a specific geographic region and basing insurance rates on the people in that area. Health Maintenance Organization HMO - A health plan provides comprehensive medical services to its members for a fixed, prepaid premium.

Members must use participating providers and are enrolled for a fixed period of time. HMOs can do business either on a for-profit or not-for-profit basis. Health Plan Employer Data and Information Set HEDIS - Performance measures designed by the National Committee for Quality Assurance to give participating managed health plans and employers to information about the value of their healthcare and trends in their health plan performance compared with other health plans.

Home healthcare- Skilled nurses and trained aides who provide nursing services and related care to someone at home. Hospice Care- Care given to terminally ill patients. Hospital Alliances- Groups of hospitals that join together to cut their costs by purchasing services and equipment in volume. Back To Top I Indemnity Insurance- A system of health insurance in which the insurer pays for the costs of covered services after care has been given, and which usually defines the maximum amounts which will be paid for covered services.

This is the most common type of insurance in the United States. Independent Practice Association IPA - A group of private physicians who join together in an association to contract with a managed care organization.

Indigent Care- Care provided, at no cost, to people who do not have health insurance or are not covered by Medicare, Medicaid, or other public programs. In-patient- A person who has been admitted to a hospital or other health facility, for a period of at least 24 hours. Integrated Provider IP - A group of providers that offer comprehensive and coordinated care, and usually provides a range of medical care facilities and service plans including hospitals, group practices, a health plan and other related healthcare services.

It may be the maximum cost or number of days that a service or treatment is covered. Limited Service Hospital- A hospital, often located in a rural area, that provides a limited set of medical and surgical services. Long-term Care- Healthcare, personal care and social services provided to people who have a chronic illness or disability and do not have full functional capacity. This care can take place in an institution or at home, on a long-term basis. Mandate- Law requiring that a health plan or insurance carrier must offer a particular procedure or type of coverage.

Means Test- An assessment of a person's or family's income or assets so that it can be determined if they are eligible to receive public support, such as Medicaid.

Medicaid- An insurance program for people with low incomes who are unable to afford healthcare. Although funded by the federal government, Medicaid is administered by each state.

Following very broad federal guidelines, states determine definitions of commonly used terms in healthcare benefits and amounts of payment for providers. Medical IRAs- Personal accounts which, like individual retirement plans, allow a person to accumulate funds for future use.

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The money in these accounts must be used to pay for medical services. The employee decides how much money he or she will spend on healthcare. Medically Indigent- A person who does not have insurance and is not covered by Medicaid, Medicare or other public programs.

Medicare- A federal program of medical care benefits created in 1965 designed for those over age 65 or permanently disabled.

Health Care Glossary

Medicare consists of two separate programs: Medicare Part A, which is automatic at age 65, covers hospital costs and is financed largely by employer payroll taxes. Medicare Part B covers outpatient care and is financed through taxes and individual payments toward a premium. Medicare Supplements or Medigap- A privately-purchased health insurance policy available to Medicare beneficiaries to cover costs of care that Medicare does not pay. Some policies cover additional costs, such as preventive care, prescription drugs, or at-home care.

Member- The person enrolled in a health plan. Non-contributory Plan- A group insurance plan that requires no payment from employees for their healthcare coverage. Non-participating Provider- A healthcare provider who is not part of a health plan. Usually patients must pay their own healthcare costs to see a non-participating provider. In some states nurse practitioners do not have to be supervised by a doctor.

O Open Enrollment Period- A specified period of time during which people are allowed to change health plans. Open Panel- A right included in an HMO, which allows the covered person to get non-emergency covered services from a specialist without getting a referral from the primary care physician or gatekeeper.

Out of Pocket costs or expenditures- The amount of money that a person must pay for his or her healthcare, including: Outcomes- Measures of the effectiveness of particular kinds of medical treatment.

  • It analyzes the health status and history, claims experience cost , age and general health risks of the individual or group who is applying for insurance coverage;
  • Having a mental illness can seriously impair, temporarily or permanently, the mental functioning of a person;
  • The law also allows employees to secure health insurance from their new employer when they switch jobs even if they have a pre-existing medical condition;
  • A set dollar amount that a person must pay before insurance coverage for medical expenses can begin;
  • Non-participating Provider- A healthcare provider who is not part of a health plan;
  • Usually patients must pay their own healthcare costs to see a non-participating provider.

This refers to what is quantified to determine if a specific treatment or type of service works. Out of Pocket Maximum- The maximum amount that a person must pay under a plan or insurance contract. Outpatient Care- Healthcare services that do not require a patient to receive overnight care in a hospital.

Back To Top P Participating Physician or Provider- Healthcare providers who have contracted with a managed care plan to provide eligible healthcare services to members of that plan.