HA3325: History Language Culture Terms 51-100

Summary of Benefits and Coverage (SBC)

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You willget the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

Navigator

An individual or organization that istrained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.

Advanced Practice Nurse (APN)

An umbrella term that describes a registered nurse (RN) who has met advancededucational and clinical practice requirements beyond the two to four years of basic nursing education required of allRNs.

Prior Authorization

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Bells and whistles

In the hearing health care domain,bells and whistlesrefers to add-on features to hearing aids that may be unnecessary or unwarranted butare offered to make a product more appealing to the consumer. Because consumers can spend considerable time and money to improve their hearing, hearing health professionals, including audiologists, should consider whether specific added features are truly beneficial for individual consumers.

Nurse Practitioners (NP)

Nurse practitionersorNPsareadvanced practice registered nurses(APRNs) whohave completed graduate-level education (earned a Master of Nursing or Doctor of NursingPractice degree). NPs can diagnose diseases and provide appropriate treatment including prescribing medications. They can serve as primary care providers (PCPs) or work within a medical practice. NPs have a holistic view and philosophy of individualized care and focus on medical conditions and wellness, prevention, and quality of life. NPs hold licensure and national board certification. NPs work in a variety of settings (within the Veterans Administration system, hospitals, private and community clinics, schools, nursing homes, and private medical practices).

Quality Ratings (or "star" rating)

Ratings of health plan quality used in the Health Insurance Marketplace, shown as 1 to 5 stars on plan information pages.Each health plan has an "Overall" quality rating, which is based on scores for 3 elements: member experience, medical care, and plan administration.The plans provided information to the Marketplace lastyear. The Marketplace confirmed the data and assigned this year's ratings.In some cases —like when plans are new or have low enrollment —ratings are notavailable.

Patient Centered Outcomes Research

Research that compares different medical treatments and interventions to provide evidence on which strategies are most effective in different populations and situations. The goal is to empower you and your doctor with additional information to make sound health care decisions.

Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Market Place

Shorthand for the "Health Insurance Marketplace," a shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010.In most states, the federal government runs the Marketplace (sometimes known as the "exchange") for individuals and families. On the web, it isfound at HealthCare.gov. Some states run their own Marketplaces at different websites

Bar coding

Similar to the process used in grocery stores and other non-medical environments, bar coding involves the use of a scanner to capture and read information. While it is most commonly used for medication, bar coding has been expanded to other areas of health care, including the tracking and identification of lab devices.

Skilled Nursing Facility Care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Rescission

The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.

Patient-centered medical home

ThePatient-Centered Medical Home (PCMH)model of care offers personalized care through coordination by a primary care provider (PCP). The PCP is responsible for being the lead to the interdisciplinary team, encouraging cooperation and collaboration between the providers and the patient. The primary distinguishing characteristic of the PCMH is the focus on a single practice with multiple physicians, while its counterpart, the accountable care organization (ACO), houses many practiceswithin one organizing entity.

US Food and Drug Administration (FDA)

TheU.S. Food and Drug Administration (FDA)is the federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of drugs, biological products, medical devices, the nation's food supply, and other areas. It hasresponsibility for regulating the manufacturing, marketing, and distribution of medical devices (including audiologic equipment and hearing aids).

Health information technology

This is the general term used to refer to all digital or computerized processes used in the field of health care. This can range from the automation of certain administrative tasks to the use of EMRs and linking clinical information to billing system.

Natural Language Processing

This technology offers voice transcription, reducing some of the inefficiencies of collecting patient data. It is being implemented in some EHRs. The hope is that natural language processing with save the health care industry both time and money.

Clinical decision support system

DSS technologies are capable of providingphysicians, nurses,and other health care professionals with diagnostic and treatment recommendations in real-time. CDSS may be incorporated into electronic health records.

Family Practitioners

Family practitioners are medical doctors who have completed a family practice residency and are board certified or eligible. The scope of practice includes children and adults of all ages.

Payment Bundling

A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than beingpaid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments.

Actuary

A person in the insurance field who decides insurance policy rates and reserves dividends as well asconducts various other statistical studies.

Specialist

A physician specialist 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.

Public Health

A field that seeks to improve lives and the health of communities through the prevention and treatment of disease and the promotion of healthy behaviors such as healthy eating and exercise.

Service Area

A geographic area where a health insurance plan accepts members ifit limits membershipbased on where people live. For plans that limit which doctors and hospitals you may use, it isalso generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan's service area.

Pre-existing Condition

A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies cannotrefuse to cover treatment for your pre-existing condition or charge you more.

Acute Care

A pattern of health care in which a patient is treated for an acute (immediate and severe) episode ofillness; for the subsequent treatment of injuries related to an accident or other trauma; or during recovery fromsurgery. Acute care is usually delivered in a hospital setting by specialized personnel using complex andsophisticated technical equipment and materials. Unlike chronic care, acute care is usually only delivered over ashort time span of 30 days or less.

Zero Cost Sharing Plan

A plan available to members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders whose income is between 100% and 300% of the federal poverty level and qualify for premium tax credits. People enrolled in this type of plan:•Do notpay co-payments, deductibles, or coinsurance when getting care from an Indian health care provider or when getting essential health benefits through a Marketplace plan•Do notneed a referral from an Indian health care provider when getting essential health benefits through a Marketplace plan•Can get zero costs sharing with a plan at any metal level on the Marketplace•Must agree to have their income verified in order toenroll

Medicare Part D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

Non- Preferred provider

A provider who does nothave a contract with your health insurer or plan to provide services to you. You willpay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.

State Health Insurance Assistance Program (SHIP)

A state program that gets funding from the federal government to provide free localhealth coverage counseling to people with Medicare.

Risk Adjustment

A statistical process that takes into account the underlying health status and spending of the enrollees in an insurance plan when looking at their health care outcomesor health care costs.

Social Security

A system that distributes financial benefits to retired or disabled people, their spouses, and their dependent children based on their reported earnings. While you work, you may pay taxes into the Social Security system. When you retire or become disabled, you, your spouse, and your dependent children may get monthly benefits that are based on your reported earnings. Your survivors may be able to collect Social Security benefits if you die.

Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less ifyou use providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you needto get a referral before you can get medical care from anyone except your primary care doctor. If you do notget a referral first, the plan maynot pay for the services.

Acute care services

Coordinated services related to the examination, diagnosis, care, treatment, and disposition of acute episodes of illnesses.

Chart conversion

Currently being undertaken by manyhealth care providers, chart conversion is the process by which data from patients' paper charts is inputted into an electronic medical record system.

Physician assistants (PAs)

Depending on state laws, physician assistants (PAs) generally have a formal relationship with a physician supervisor. The physician must be licensed within the state in which the PA is working butdoes not have to work at the same location. Supervision can be in person or via telecommunications or consultation. Many PAs practice alone in remote or underserved areas in satellite clinics. Physician assistants conduct physical exams, diagnose,and treat illnesses, order,and interpret tests, counsel on preventive health care, assist in surgery, give medical orders, and write prescriptions. PAs work in hospitals, clinics, and other types of health facilitiesand exercise autonomy in medical decision making as determined by the supervising physician.

Direct to consumer

Direct-to-consumerrefers to thepractice of promoting and/or selling a product or service directly to potential consumers via broadcast and print media such as television, radio, magazines, billboards, and the Internet.

electronic health records (EHRs)

EHRs are electronic histories of patients' individual health records. They include data from all sources of patient care and can beaccessed across networks, meaning both primary care physicians and specialists can instantly access a patient's medical history.

Electronic materials management (EMM)

EMMis used by health care organizations to manage and track inventory, such as pharmaceuticals and medical supplies.

electronic medical records (EMRs)

EMRs are a computerized history of a patient's individual health record withina single practice. They differ from EHRs in that they only contain information about care that was delivered in one particular delivery setting.

External forces

External forcescomprise pressuresfrom outside a business that can affect the business; such factors include the market prices for supplies and devices, the consumer demand for accessible and affordable care and products, and government regulations and competition.

Uncompensated Care

Health care or services provided by hospitals or health care providers that do notget reimbursed. Often uncompensated care arises when people do nothave insuranceand cannot afford topay the cost of care.

Primary Care

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

Value- Based Purchasing (VBP)

Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects,accidents, injuries,or medical conditions.

Health Insurance Portability and Accountability Act (HIPPA)

The Health Insurance Portability and Accountability Actis a law designed to improve the efficiency and effectiveness of the nation's health care system, and involves ensuring health insurance coverage, and the privacy and security of health information.

UCR (usual, customary, and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Network

The facilities, providers,and suppliers your health insurer or plan has contracted with to provide health care services.

Patient Protection and Affordable Care Act

The first part of the comprehensive health care reform law enacted on March 23, 2010.The law also expands the Medicaid program to cover more people with low incomes.