ability to obtain healthcare services.
Acute Care- Medical
treatment rendered to people whose illnesses or medical problems
are short-term or don't require long-term continuing care. Acute
care facilities are hospitals that mainly treat people with short-term
Aggregate Indemnity- The maximum amount
of payment provided by an insurer for each covered service for a
group of insured people.
Aid to Families with Dependent Children (AFDC)- A
state-based federal assistance program that provided cash payments
to needy children (and their caretakers), who met certain income
requirements. AFDC has now been replaced by a new block grant program,
but the requirements, or criteria, can still be used for determining
eligibility for Medicaid.
Alliance- Large businesses, small businesses,
and individuals who form a group for insurance coverage.
All-payer System- A
proposed healthcare system in which, no matter who is paying, prices
for health services and payment methods are the same. Federal or
state government, a private insurance company, a self-insured employer
plan, an individual, or any other payer would pay the same rates.
Also called Multiple Payer system.
Ambulatory Care- All health services that
are provided on an out-patient basis, that don't require overnight
care. Also called out-patient care.
Ancillary Services- Supplemental services,
including laboratory, radiology and physical therapy, that are provided
along with medical or hospital care.
A person who is eligible for or receiving
benefits under an insurance policy or plan.
Benefits- The services that members are entitled to receive
based on their health plan.
Blue Cross/Blue Shield- Non-profit, tax-exempt insurance service
plans that cover hospital care, physician care and related services.
Blue Cross and Blue Shield are separate organizations that have
different benefits, premiums and policies. These organizations are
in all states, and The Blue Cross and Blue Shield Association of
America is their national organization.
Board Certified- Status granted to a medical specialist who
completes required training and passes and examination in his/her
specialized area. Individuals who have met all requirements, but
have not completed the exam are referred to as "board eligible."
Board Eligible- Reference to medical specialists who have completed
all required training but have not completed the exam in his/her
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.
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
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.
Case management- Intended to improve health outcomes or control
costs, services and education are tailored to a patient's needs,
which are designed to improve health outcomes and/or control costs
Catastrophic Health Insurance- Health insurance that provides
coverage for treating severe or lengthy illnesses or disability.
CHAMPUS- (Civilian Health and Medical Program of the Uniformed
Services) A health plan that serves the dependents of active duty
military personnel and retired military personnel and their dependents.
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.
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 health 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
Co-insurance-A cost-sharing requirement under some health insurance
policies in which the insured person pays some of the costs of covered
Cooperatives/Co-ops- HMOs that are managed by the members of
the health plan or insurance purchasing arrangements in which businesses
or other groups join together to gain the buying power of large
employers or groups.
Co-pay- Flat fees or payments (often $5-10) that a patient pays
for each doctor visit or prescription.
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.
The amount of money, or value of certain services (such as one physician
visit), a patient or family must pay before costs (or percentages
of costs) are covered by the health plan or insurance company, usually
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
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.
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
Employee Retirement Income Security Act (ERISA)- A Federal act,
passed in 1974, that established new standards for employer-funded
health benefit and pension programs. 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.
Exclusive Provider Organizations (EPO)/Exclusive Provider Arrangement
(EPA)- An indemnity or service plan that provides benefits only
if those hospitals or doctors with which it contracts provide the
medical services, with some exceptions for emergency and out-of-area
Employee Health Benefit Program (FEP)-
Health insurance program for Federal workers and their dependents,
established in 1959 under the Federal Employees Health Benefits
Act. Federal employees may choose to participate in one of two or
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.
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.
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.
Benefits- The specific services and procedures
covered by a health plan or insurer.
Healthcare Financing Administration (HCFA)- The federal government
agency within the Department of Health and Human Services that directs
the Medicare and Medicaid programs. 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
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
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.
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
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 Delivery System (IDS)- An organization that usually
includes a hospital, a large medical group, and an insurer such
as an HMO or PPO.
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.
Commission on the Accreditation of Healthcare Organizations (JCAHO)-
A national private, non-profit organization that accredits healthcare
organizations and agencies and sets guidelines for operation for
A "cap" or limit on the amount of services that may be provided.
It may be the maximum cost or number of days that a service or treatment
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.
Insurance- Coverage for medical professionals
which pays the costs of legal fees and/or any damages assessed by
the court in a lawsuit brought against a professional who has been
charged with negligence.
Managed care- This term describes many types of health insurance,
including HMOs and PPOs. They control the use of health services
by their members so that they can contain healthcare costs and/or
improve the quality of care.
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 specific
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. 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. Medicare consists of two separate programs:
A and B. 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.
Committee on Quality Assurance (NCQA)-
An independent national organization that reviews and accredits
managed care plans and measures the quality of care offered by managed
Network- A group of affiliated contracted healthcare providers
(physicians, hospitals, testing centers, rehabilitation centers
etc.), such as an HMO, PPO, or Point of Service 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.
Nurse practitioner- A nurse specialist who provides primary
and/or specialty care to patients. In some states nurse practitioners
do not have to be supervised by a doctor.
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: deductibles,
co-pays, payments for services that are not covered, and/or health
insurance premiums that are not paid by his or her employer.
Outcomes- Measures of the effectiveness of particular kinds
of medical treatment. 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.
Physician or Provider- Healthcare providers
who have contracted with a managed care plan to provide eligible
healthcare services to members of that plan.
Payer- The organization responsible for the costs of healthcare
services. A payer may be private insurance, the government, or an
employer's self-funded plan.
Peer Review Organization (PRO or PSRO)- An agency that monitors
the quality and appropriateness of medical care delivered to Medicare
and Medicaid patients. Healthcare professionals in these agencies
review other professionals with similar training and experience.
[See Quality Improvement Organizations]
Percent of Poverty- A term that describes the income level a
person or family must have to be eligible for Medicaid.
Physician Assistant- A health professional who provides primary
and/or specialty care to patients under the supervision of a physician.
Physician Hospital Organizations (PHOs)- An organization that
contracts with payers on behalf of one or more hospitals and affiliated
physicians. Physicians still own their practices.
Play or Pay- This system would provide coverage for all people
by requiring employers either to provide health insurance for their
employees and dependents (play) or pay a contribution to a publicly-provided
system that covers uninsured or unemployed people without private
Point of Service (POS)- A type of insurance where each time
healthcare services are needed, the patient can choose from different
types of provider systems (indemnity plan, PPO or HMO). Usually,
members are required to pay more to see PPO or non-participating
providers than to see HMO providers.
Portability- A person's ability to keep his or her health coverage
during times of change in health status or personal situation (such
as change in employment or unemployment, marriage or divorce) or
while moving between health plans.
Postnatal Care- Healthcare services received by a woman immediately
following the delivery of her child
Pre-authorization- The process where, before a patient can be
admitted to the hospital or receive other types of specialty services,
the managed care company must approve of the proposed service in
order to cover it.
Pre-existing Condition- A medical condition or diagnosis that
began before coverage began under a current plan or insurance contract.
The insurance company may provide coverage but will specifically
exclude treatment for such a condition from that person's coverage
for a certain period of time, often six months to a year.
Preferred Provider Organization (PPO)- A type of insurance in
which the managed care company pays a higher percentage of the costs
when a preferred (in-plan) provider is used. The participating providers
have agreed to provide their services at negotiated discount fees.
Premium- The amount paid periodically to buy health insurance
coverage. Employers and employees usually share the cost of premiums.
Premium Cap- The maximum amount of money an insurance company
can charge for coverage.
Premium Tax- A state tax on insurance premiums.
Prepaid Group Practice- A type of HMO where participating providers
receive a fixed payment in advance for providing particular healthcare
Preventive Care- Healthcare services that prevent disease or
its consequences. It includes primary prevention to keep people
from getting sick (such as immunizations), secondary prevention
to detect early disease (such as Pap smears) and tertiary prevention
to keep ill people or those at high risk of disease from getting
sicker (such as helping someone with lung disease to quit smoking).
Primary Care- Basic or general routine office medical care,
usually from an internist, obstetrician-gynecologist, family practitioner,
Primary care provider (PCP)- The health professional who provides
basic healthcare services. The PCP may control patients' access
to the rest of the healthcare system through referrals.
Private Insurance- Health insurance that is provided by insurance
companies such as commercial insurers and Blue Cross plans, self-funded
plans sponsored by employers, HMOs or other managed care arrangements.
Provider- An individual or institution who provides medical
care, including a physician, hospital, skilled nursing facility,
or intensive care facility.
Provider-Sponsored Organization (PSO)- Healthcare providers
(physicians and/or hospitals) who form an affiliation to act as
insurer for an enrolled population.
Assessment- Measurement of the quality
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.
Quality Improvement Organization (QIO)- An organization contracting
with HCFA to review the medical necessity and quality of care provided
to Medicare beneficiaries.
Quality of care- How well health services result in desired
Setting-These programs were developed
by several states in the 1970's to establish in advance the amount
that hospitals would be paid no matter how high or low their costs
actually were in any particular year. (Also known as hospital rate
setting or prospective reimbursement programs)
Referral system- The process through which a primary care provider
authorizes a patient to see a specialist to receive additional care.
Reimbursement- The amount paid to providers
for services they provide to patients.
Risk- The responsibility for profiting or losing money based
on the cost of healthcare services provided. Traditionally, health
insurance companies have carried the risk. Under capitation, healthcare
providers bear risk.
A type of insurance arrangement where employers, usually large employers,
pay for medical claims out of their own funds rather than contracting
with an insurance company for coverage. This puts the employer at
risk for its employees' medical expenses rather than an insurance
Single Payer System- A healthcare reform proposal in which healthcare
costs are paid by taxes rather than by the employer and employee.
All people would have coverage paid by the government.
Socialized Medicine- A healthcare system in which providers
are paid by the government, and healthcare facilities are run by
Staff Model HMO- A type of managed care where physicians are
employees of the health plan, usually in the health plan's own health
center or facility.
Standard Benefit Package- A defined set of benefits provided
to all people covered under a health plan.
Party Administrator (TPA)- An organization
that processes health plan claims but does not carry any insurance
Third Party Payer- An organization other than the patient or
healthcare provider involved in the financing of personal health
Care- Healthcare provided to people who
cannot pay for it and who are not covered by any insurance. This
includes both charity care which is not billed and the cost of services
that were billed but never paid.
Underinsured- People who have some type of health insurance
but not enough insurance to cover their the cost of necessary healthcare.
This includes people who have very high deductibles of $1000 to
$5000 per year, or insurance policies that have specific exclusions
for costly services.
Underwriting- This process is the basis of insurance. 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.
Uninsured- People who do not have health insurance of any type.
Over 80 percent of the uninsured are working adults and their family
Universal Coverage- This refers to the proposal that all people
could get health insurance, regardless of the way that the system
Utilization Review- A program designed to help reduce unnecessary
medical expenses by studying the appropriateness of when certain
services are used and by how many patients they are used.
Utilization- How many times people use particular healthcare
services during particular periods of time.
Integration- A healthcare system that
includes the entire range of healthcare services from out-patient
to hospital and long-term care.
Period- The amount of time a person must
wait from the date he or she is accepted into a health plan (or
from when he or she applies) until the insurance becomes effective
and he or she can receive benefits.
Withhold- A percentage of providers' fees that managed care
companies hold back from providers which is only given to them if
the amount of care they provide (or that the entire plan provides)
is under a budgeted amount for each quarter or the whole year.
Worker's Compensation Coverage- States require employers to
provide coverage to compensate employees for work-related injuries