Healthcare Key Terms

socialized medicine

A health care delivery system in which the provision of services is controlled by the government

dependent

Someone or something needing or relying on someone else or something else

electronic medical record

A computerized database that typically includes demographics, past medical and surgical, preventive, laboratory and radiographic, and drug information about a patient. It is the repository for active notations about a patient's health. Most EMRs also contains billing and insurance information and other accounting tools

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A group of federal laws that establish rights, protections, and other standards of care for working people with pre-existing medical conditions. These laws affect obstetrical and neonatal care, the health care of women in general, the treatment of people with psychiatric illnesses, the confidentiality of medical records, and other aspects of health care.

health maintenance organization (HMO)

A prepaid health care program of group practice that provides comprehensive medical care, esp. preventive care, while also striving to control health care expenditures

health savings account (HSA)

A savings account in which deposits may accumulate tax-free and be used as self-financed health insurance to pay present or future medical expenses

deductible

An expense borne by an insured party before any obligated payments are made by the insurer

participating provider organization (PPO)

An incorporated group of physicians, hospital(s), nurses, and other health care workers, who jointly assume the clinical and financial responsibilities for delivering health care to enrolled groups of insured patients. The providers are semi-independent agents who agree to provide care at reduced rates

grandfathering

As provisions of the ACA go into effect, grandfathering provides for a smoother transition by allowing health plans to remain as is and not be required to implement certain aspects of the law's new rules and protections. How plans maintain this status: a plan had to be in existence as of March 23, 2010 (when the health reform law passed) and not make any major changes in coverage since then. Some examples of changes in coverage that would cause a plan to lose grandfathering include: Eliminating benefits to diagnose or treat a condition. Increasing the up-front deductible patients must pay before coverage kicks in by more than the cumulative growth in medical inflation since March 23, 2010, plus 15 percentage points. Reducing the share of the premium the employer pays by more than five percentage points since March 23, 2010. For employer-sponsored insurance, any change in grandfathered status is up to the employer, who can choose whether to make changes to the plan

COBRA

Consolidated Omnibus Reconciliation Act - Federal legislation that requires employers with 20 or more employees to offer health insurance coverage to their employees for as long as 18 months after employment ends

short term health insurance

Designed for healthy individuals and families, short-term policies provide an affordable safety net while switching from one life event to another without a health plan. Lose your job, recent college graduate, divorced, or retired and not quite eligible for Medicare? Then consider short-term insurance (but remember that most of those scenarios are qualifying events, which means you'd be eligible to purchase an ACA-compliant plan instead - so check those options too.) Short-term plans are not regulated by the Affordable Care Act (Obamacare), so they are still available year-round. For people who missed open enrollment and do not have a qualifying event that allows them to purchase an ACA-compliant plan, a short-term policy can be a good solution to bridge a short gap until general open enrollment begins again, or until an expected qualifying event. Three-month limit on short-term plans: Repealed as of October 2018. Short-term plans are available in nearly every state, with regulations that vary by state. The Obama Administration enacted regulations (which were enforced as of April 2017) that limited short-term plans to no more than three months (90 days), in an effort to ensure that people wouldn't use short-term health insurance as a relatively long-term substitute for ACA-compliant coverage. Prior to the Obama Administration rule, the federal definition of "short-term" was a plan that lasted no more than 364 days, although some states capped them at six months, some didn't allow them at all, and insurers often only offered six-month terms for short-term coverage, even in states that used the 364-day federal limit. Under the Trump Administration, HHS has finalized a rule change that will revert to the pre-2017 definition of "short-term." The new rules will take effect in October 2018 (60 days after being published in the Federal Register) and will allow insurers to once again offer short-term plans with initial terms of up to 364 days. The federal regulations will also allow those plans to be renewed, as long as a single policy isn't in effect for more than 36 months. The availability of these longer-term plans will still be limited by state regulations and insurers' willingness to offer them

medical necessity

For services to be considered as this, they must be reasonable and necessary for the treatment of illness, injury, disease, disability, or developmental condition. Medical necessity is a critical factor for determining eligibility for Medicaid-reimbursable therapy and treatment services. Each state determines its own medical necessity criteria for Medicaid reimbursement. According to ASHA's Speech-Language Pathology Medical Review Guidelines [PDF], Medicaid claims may be supported when providers document the following basic elements: Reasonable: Appropriate amount, frequency, and duration of treatment in accordance with standards of practice. Necessary: Appropriate treatment for the patient's diagnosis and condition Specific: Treatment targeted to particular goals. Effective: Treatment expected to yield improvement within a reasonable amount of time. Skilled: Treatment requiring the knowledge, skills, and judgment of a speech-language pathologist (SLP) or audiologist

exclusion

In medical insurance programs, a list of specific hazards, perils, or conditions for which the policy will not provide benefits or coverage payments. Common exclusions include preexisting conditions such as cancer, heart disease, diabetes, hypertension, a pregnancy that began before the effective date of the policy, self-inflicted injuries, combat injuries, plastic surgery for cosmetic reasons, and on-the-job injuries covered by workers' compensation (Davis, 2019). https://www.tabers.com/tabersonline

group insurance (policy)

In medical insurance, a policy that covers all the employees of an organization. Employee dependents are also typically indemnified. The employer may pay a percentage of the premium as a benefit to the employee.

generic drug

In pharmaceuticals, for example, it applies to a drug that does not have a brand name and is not sold under one but is identified and sold only by its chemical name

government-sponsored health insurance

In the U.S., a federally sponsored health insurance program for people over age 65 who have worked at least 10 years and are U.S. citizens or permanent residents, for some younger disabled people, and for those with end-stage renal disease. Approval for Medicare is managed by the Social Security Administration. The government pays directly for the health care services that a client receives. A client can see any physician who takes Medicare (and most do) anywhere in the country without prior permission and pays coinsurance for each service received (fee-for-service). There are limits on how much physicians and hospitals are allowed to charge a client. A client can also choose to receive Medicare benefits from a Medicare private health plan, which must offer at least the same benefits as Original Medicare but can also have different rules, costs, and restrictions. A client may be automatically enrolled in a Medicare private health plan if his or her employer sponsors one when the client becomes eligible for Medicare

capitation

In the health care industry, a regular form of payment for services in which the insurer pays a provider or group of providers a fixed amount for each enrolled patient assigned to the care of the subcontracting provider regardless of whether the patient seeks care. This arrangement provides incentives to the provider to limit health care costs because it places the provider at financial risk if the cost of care provided exceeds the payment received

health insurance

Insurance protection to cover some or all of the costs of treating an injury or a disease. In the U.S., about 70% of all health care costs are covered by private insurance, Medicare, or Medicaid (Davis, 2019). https://www.tabers.com/tabersonline

third party administrator (TPA)

It is for employee health benefits. It is a person or organization that performs administrative services, such as claims processing, adjudication or record-keeping, typically on behalf of an employer that self-insured health benefits. They've become prominent players in the managed care industry of health insurance and are contacted by the self-insuring company Usually, these operate as an independent entity relative to health insurance carriers and the insured employer. Today, more than 40 states have a this type of licensing requirement, while several more have other minimum requirements

student health insurance

Many colleges require their students to carry health insurance coverage, and the ACA also requires nearly all Americans to maintain health insurance coverage or face a tax penalty. Most four-year colleges offer health plans for their students, but traditionally, those plans included low lifetime and annual benefit maximums, and benefits that weren't particularly comprehensive. That changed with the ACA, however. The ACA prohibited lifetime maximums on essential benefits in student plans as of July 2012, and prohibited annual maximums on essential health benefits as of 2014. These requirements make student health plans more of a true safety net than they were in the past. Student health insurance marketed by the university is not the only option, though. Students may opt instead to remain on their parents' plan through age 26, or seek coverage through an employer's plan if they're employed full time. If they're in a state that has expanded Medicaid and have an income below 138 percent of the poverty level (that's about $16,394 in 2016), they can enroll in Medicaid. They can also purchase their own individual health insurance plan through the exchange or off-exchange, with subsidies in the exchange based on income (note that if the student is a tax dependent on someone else's return, the income of the entire tax household is taken into consideration, relative to the total number of people in the household) (HealthInsurance.org, 2019). https://www.healthinsurance.org/glossary/student-health-insurance/

gatekeeper

One who decides whether further medical assistance or care should be sought or allowed

fee for service

Payment for specific health care services provided to a patient (as opposed to payments received for the number of patients seen, the number of hours worked, or the number of patients enrolled in a health care panel). The individual or an insurance carrier may make the payment.

out of network

Pertaining to a health care provider or service that is not a part of an individual's health insurance plan. Health insurers may or may not pay for services provided out of network. The recipient must pay out of his or her own funds for those out-of-network services not covered by the insurance plan

essential health benefits

The Affordable Care Act requires non-grand-fathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care

health information technology/ABBR: HIT

The application of information technology to the collection, storage, processing, retrieval, and communication of information relevant to patient care within a health care system

co-payment

The fee insured persons must pay, in addition to their health insurance premiums and deductibles, for specific medical services such as emergency department visits, appointments with primary care providers, laboratory studies, prescriptions, or x-ray examinations

coinsurance

The percentage of the price of an office visit, procedure, laboratory study, pharmaceutical prescription, or hospitalization that a patient is obligated to pay under his or her health insurance plan. It differs from co-payment in that it is not a fixed cost but one that varies with the cost of the service provided

health reimbursement account (HRA)

These are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. They are sometimes called Health Reimbursement Arrangements

waiting period

These were among the fears vocalized by opponents of single-payer health care systems. Critics of single-payer systems in countries such as Canada cite lengthy waits for some elective surgeries. Proponents of single-payer systems note that a high percentage of Americans already are being unable to obtain medical care - including medication, testing, and treatment - because of costs, while a much smaller percentage of residents in single-payer systems report that costs had limited their access to care

birthday rule

This is a method used to determine when a plan is primary or secondary for a dependent child when covered by both parents' benefit plan. The parent whose birthday (month and day) falls first in a calendar year is the parent with the primary coverage for the dependent. If both parents have the same birthday, then the plan that has been in effect the longest pays as primary.

allowed charge

This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. This charge is typically a discounted rate rather than the actual charge.

Beneficiary

This person is the one enrolled in a health insurance plan and receives benefits through the policy in the form of paid claims and/or network-negotiated rates for the portion of the claim that the beneficiary has to pay. The term is also used in the context of life insurance and refers to the person (or people) who receives payment under the plan in the event that the insured person passes away.

effective date

Under HIPAA, this is the date that a final rule is effective, which is usually 60 days after it is published in the Federal Register

electronic health record

a digital version of a patient's paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider's office and can be inclusive of a broader view of a patient's care

Advance Directive

is a document in which a person indicates what actions should be taken on his or her behalf in the event that he or she is physically or mentally unable to make medical decisions. It can include specific treatments that you do or do not want, and it can also designate a person to make decisions on your behalf if you become unable to make your own medical decisions.

Affordable care act (ACA); Obamacare; Patient Protection & Affordable Care Act (PPACA)

is a federal statute signed into law on March 23, 2010 by President Barack Obama. The law was created to improve access to affordable, quality health insurance for all Americans. It dramatically changed the U.S. individual health insurance market by implementing provisions designed to make individual plans more affordable and while improving quality of coverage. The ACA's major provisions began taking effect in 2014, although some had taken effect as early as 2010. By 2016, the Act had lowered the percentage of uninsured Americans from 16% to 8.9%. The health reform battle that delivered Obamacare was driven by a dysfunctional U.S. healthcare system. Eighty-two percent of Americans said the system needed an overhaul. Under the ACA, Americans are required to have ACA-compliant health coverage or pay the individual mandate penalty. The term Obamacare was originally coined by Republicans who opposed the legislation, but President Obama had embraced it by 2011, and the term is now used by both supporters and opponents of the law. There continues to be some confusion, however (as recently as 2017), among people who aren't aware that Obamacare and the ACA are the same thing.

pre-existing condition/pre-existing health condition

is a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company. In the individual market, starting in 2014, pre-existing conditions could no longer be excluded, factored into premium calculations, or cause an application to be declined

out-of-pocket maximum

is a predetermined, limited amount of money that an individual must pay before an insurance company or (self-insured employer) will pay 100 percent of an individual's health care expenses for the remainder of the year. Health plans can set their own out-of-pocket maximums, but they're constrained by federal regulations that impose an upper limit on how high out-of-pocket costs can be. In 2019, the upper limit is $7,900 for an individual and $15,800 for a family. In 2020, it will be $8,150 for an individual and $16,300 for family coverage (these caps apply to in-network care that's considered an essential health benefit, and only to plans that are not grandfathered or grandmothered, as those plans do not have restrictions on their out-of-pocket exposure.)

flexible spending account (FSA); medical spending account

is a tax-advantaged account maintained by employers where employees can set aside a portion of each paycheck to pay for out-of-pocket medical expenses. No payroll taxes are due on funds allocated to an FSA, and the employee can use the money to pay for qualified medical expenses throughout the year. Starting in 2013, the Affordable Care Act capped the amount that workers could set aside in their FSAs. In 2017, the cap is $2,600. For 2018, it's $2,650. There is a "use-it-or-lose-it" requirement with FSAs: Any money left in the account at the end of the plan year (or by March 15th of the following year if the employer offers a grace period) is lost to the employee, so it's important to only allocate for expenses that you know you'll incur. FSAs can be used in conjunction with high deductible or more traditional health plans (HealthInsurance.org, 2019). https://www.healthinsurance.org/glossary/medical-flexible-spending-account/

individual health insurance (policy)

is coverage that you purchase on your own, on an individual or family basis, as opposed to obtaining through an employer in-network -Of a provider of covered health services, under contract with a health insurance plan

minimum essential coverage

is health insurance coverage that satisfies the Affordable Care Act's shared responsibility provision (individual mandate) — in other words, people with minimum essential coverage are considered insured and thus do not have to pay a penalty for being uninsured. Under the ACA, anyone who does not maintain health insurance that is deemed minimum essential coverage must pay a penalty, unless they qualify for an exemption

preventative care

is the care you receive to prevent illnesses or diseases. It also includes counseling to prevent health problems. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy. Preventive care may also help reduce your health care costs down the road if you catch a problem early, or if an immunization keeps you from getting a serious illness

explanation of benefits

is the insurance company's written explanation regarding a claim, showing what they paid and what the patient must pay. The document is sometimes accompanied by a benefits check, but it's more typical for the insurer to send payment directly to the medical provider. The EOB is not a bill, although it will explain any charges that the patient still owes or may have already paid (in the form of a copay at the time the medical care was received, for example). If the patient owes additional money after the insurance company has paid its portion, the medical provider will send a separate bill, which should match the patient's portion listed on the EOB

lifetime maximum benefit

is the maximum dollar amount a health plan will pay in benefits to an insured individual during that individual's lifetime. The ACA did away with lifetime benefit maximums for essential health benefits. Policies issued on or renewing after September 23, 2010 are required to have no lifetime benefit maximums on any essential health benefits covered by the plan. Grandmothered and grandfathered plans do not have to cover all of the ACA's essential health benefits, and neither do large group plans (in most states, "large group" means employers with 51 or more employees, but in Colorado, California, Maryland, New York, and Vermont, it only includes employers with 101 or more employees). But for essential health benefits that are covered by these plans, there cannot be any dollar limits applied to the total lifetime benefits (HealthInsurance.org, 2019). https://www.healthinsurance.org/glossary/lifetime-maximum-benefit-or-maximum-lifetime-benefit/

usual, reasonable and customary (fees)

refer to the amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment

precertification

refers to approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary)

privately sponsored health insurance; private health insurance

refers to health insurance plans marketed by the private health insurance industry, as opposed to government-run insurance programs. This kind of health insurance currently dominates the U.S. health care landscape, covering more than half of the US population. Coverage includes policies obtained through employer-sponsored insurance, with approximately 49 percent of Americans receiving insurance provided as a benefit of employment in 2016. Another 7 percent of Americans bought coverage outside of the workplace on the individual health insurance market, both on and off-exchange