Sunday, April 18, 2021


A Glossary of Common Healthcare Terms…

August 27, 2009 by  
Filed under Health, News, Weekly Columns

(Akiit.com) Remember when you were a child and the “grown-ups” were having a conversation, and you knew they were talking about something that would affect you, but you didn’t understand enough to know exactly what they were talking about? Well, for many of us, that’s what the debate over Healthcare reform is like.

In the continuing spirit of empowering folks with information to make good decisions about their health, here is a glossary of some of the more common terms you are hearing being thrown around:

Co-ops – Private, nonprofit health organizations set up by some states to compete with private health insurers.

COBRA – Temporary continuation of health coverage at group rates available to certain former employees, retirees, spouses, and dependent children when coverage is lost due to a qualifying event, such as loss of employment. Generally, COBRA participants pay the entire premium themselves.

Coordination of benefits (COB) – A person can have more than one kind of insurance coverage, say one plan from their employer and one from their spouse’s employer. In that case, the two health plans work together to coordinate which one pays first, and how much. This process is called coordination of benefits.

Deductible – A fixed, annual dollar amount that a member pays for medical services before the insurance company begins paying for covered medical services.

Diagnostic Tests – Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include but are not limited to radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Emergency Care – Those health care services that are provided in an emergency facility or setting after the onset of an illness or medical condition that manifests itself by symptoms of sufficient severity that without immediate medical attention could be reasonably expected by the prudent lay person, who possesses an average knowledge of health and medicine, to result in: a) placing the Member’s physical and or mental health in serious jeopardy; b) serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Employer-based health care – Refers to health plans that are offered at the workplace for employees.

Experimental treatment – A type of treatment that is still under medical study. Many health-care plans will not pay the costs of experimental treatments.

Formulary – List of prescription medications covered by a health plan.

Generic Drug – A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength, dosage form, and effectiveness as the brand drug.

Government-run plan – A government-run health plan, also known as a public or single-payer plan, is modeled after Medicare, which provides individuals health care through the federal government, rather than from a private insurance company

Health maintenance organization (HMO) – A type of health plan that requires subscribers to receive all medical care from network providers, usually under the direction of a primary care physician (PCP)

Home Health Care – Health services other than Custodial Care, rendered by a home health agency to an individual in his or her residence. Such services are provided to disabled, sick or convalescent individuals who do not need inpatient care, but who do need nursing services or therapy, medical supplies and special outpatient services. It is important to read your Contract to determine which services are Covered Services.

Hospice – A facility or service that provides care for the terminally ill patient and which provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

Individual mandate – In the context of health care reform, a much-discussed idea is an individual mandate, which would require all Americans to have health insurance coverage. In turn, everyone would be guaranteed coverage, regardless of age or preexisting conditions.

Inpatient – An individual who is receiving care for 24 hours or more as a registered bed patient in a Hospital or other facility, where a room and board charge is made.

Long-Term Care – Services that include those needed by people to live independently in the community, such as home health and personal care, as well as services provided in institutional settings such as nursing homes. Medicaid is the primary payer for long-term care.

Medicaid – A government program that pays the cost of medical care for low-income people with few assets. The income level is set by the state you live in. Not all doctors and hospitals accept Medicaid patients.

Medically Necessary – Procedures, treatment, supplies, equipment or services determined to be: appropriate for the symptoms, diagnosis or treatment of a medical condition, and provided for the diagnosis or direct care and treatment of the medical condition; and within generally accepted standards of good medical practice; and not primarily for the convenience of the Member or the Member’s Provider; and the most appropriate procedure, treatment, supply, equipment or level of service which can be safely provided.

Medicare – A two-part federal program that helps with medical costs for those over 65 or permanently disabled. Medicare Part A covers some inpatient hospital expenses for everyone enrolled at no cost. Part B is optional, and covers physicians’ services, outpatient care and more for a small cost to enrollees.

Outpatient Surgery – Surgical procedures performed that do not require an Inpatient admission. Such surgery can be performed in a Hospital, an Ambulatory Surgery center, or a physician office.

Participating Provider – A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a Health Benefit Plan to provide services or supplies to a Member enrolled in a Health Benefit Plan.

Participating provider network – Providers (such as hospitals and physicians) who have agreed to provide services to patients at rates pre-negotiated by the patient’s health plan.

Pre-Authorization – A procedure governed by the Contract used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-Emergency Care before the services are provided. Also called Pre-Certification and Prior Authorization.

Preventive Care – Care rendered by a physician to promote health and prevent future health problems for a Member who does not exhibit any symptoms (for example routine physical examination, immunizations).

Pre-existing condition – If someone has shown symptoms of a health condition, or been treated for one, before their coverage begins, it is called a pre-existing condition. Usually, there is a limit to how far back a health plan can check for such conditions.

Premium -The amount an individual pays for coverage.

Primary care provider (PCP) – Your regular doctor or health professional that provides basic care and coordinates other care through referrals to specialists as needed.

Provider network – A group of providers (such as hospitals and physicians) who agree to a pre-negotiated price for services they provide. To get that price, a patient must be covered by a particular health plan that uses that network.

Socialized medicine – European-style health system where the government employs health care providers and owns and operates health care facilities.

Single-payer health care – In a single-payer health care system, the government collects money, primarily through tax revenue, and pays all the health care bills for its citizens.

Skilled nursing facility (SNF) – A facility licensed to provide inpatient care, including round-the-clock nursing.

Standard of care – An accepted mode of treatment for a given disease or condition.

Uninsurable – In health insurance, individuals who are “uninsurable” can’t get coverage (or can get it only at higher rates) because of their medical history. It often refers to people who are already seriously ill when they apply for coverage.

Utilization Management -The process used to determine the Medical Necessity, appropriateness, efficacy or efficiency of health care services. Techniques include inpatient admission review, continued inpatient stay review, discharge planning, post-care review and case management.

Urgent Care – Services received for an unexpected episode of illness or injury requiring treatment which cannot be postponed, but is not Emergency Care. Urgent Care conditions include, but are not limited to earache, sore throat, fever not higher than 104º. Treatment of an Urgent Care condition does not require use of an emergency room at a Hospital.

Wellness Program – A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability which respond positively to lifestyle related interventions.

Remember, I’m not a doctor, I just sound like one.

Take good care of yourself, and live the best life possible!

Written By Glenn Ellis


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