Adirondack Health Institute News

Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms (continued)

Plan – A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization – A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan my require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Preferred Provider – a provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium – The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug CoverageHealth insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs – Drugs and medications that by law require a prescription.

Primary Care Physician – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider – A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

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.

Rehabilitation Services – Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt of disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Skilled Nursing Care – Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialists – a physician specialist focuses on a specific area of medicine or a group or 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.

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 services. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Glossary of Health Care Terms (continued)

Excluded Services – Health care services that your health insurance or plan doesn’t pay for or cover.

Grievance – A complaint that you communicate to your health insurer or plan.

Habilitation Services – Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance – A contract that requires your health insurer to pay some or all of  your health care costs in exchange for a premium.

Home Health Care – Health care services a person receives at home.

Hospice Services - Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization – Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care – Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance – The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

In-network Co-payment – A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

Medically Necessary – Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

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

Non-Preferred Provider – A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay 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.

Out-of network Co-insurance – the percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Out-of-Network Co-payment – a fixed amount (for example $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.

Out-of-Pocket Limit – The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Physician Services – Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Glossary of Health Coverage and Medical Terms – Part 1

This glossary has many commonly used terms, but isn’t a full list.  These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan.  Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)

Allowed Amount – Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.”  If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Appeal – A request for your health insurer or planto review a decision or a grievance again.

Balance Billing - When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.  A preferred provider may not balance bill you for covered services.

Co-insurance - Your share of he costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy – Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency Cesarean section aren’t complications of pregnancy.

Co-payment – A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Deductible – The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.  For example if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Durable Medical Equipment (DME) – Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Emergency Medical Condition - An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation - Ambulance services for an emergency medical condition.

Emergency Room CareEmergency services you get in an emergency room.

Emergency Services - Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

more to follow….

Making Sense of Your Health Plan (continued)

A health plan may also be defined by the payment structure, such as the amount of the deductible.

High Deductible Health Plan – (HDHP) – a deductible is a fixed amount of money you must first pay before your health insurer will cover the costs of most of your health services. An HDHP is a type of plan that has a high deductible amount that you must pay before your health plan begins to pay. For example, if you have a HDHP with a deductible of $1,200 and a hospital bill totaling $1,500, you would be responsible for paying $1,200 of your medical expenses before the health plan would start paying. You will only have to pay co-pays for covered services after your meet the $1,200 deductible.

Employers and individuals may also open special accounts created to pay for Qualified Medical Expenses (QMEs). QMEs are defined in the tax code as any costs incurred in the process of receiving “medical care,” including expenses related to the diagnosis, treatment, or prevention of a medical problem that is or could lead to the proper functioning of the body.

Health Care Accounts for Qualified Medical Expenses

Health Reimbursement Arrangement (HRA) –  An HRA is used to reimburse employees for QMEs.  All employees are eligible.  Reimbursements are excluded from the employee’s gross income, giving the employee a tax advantage.  The employer is the sole contributor and unused funds may carry over, but may be capped.  An HRA is not portable.

Health Savings Accounts (HSA) –  An HSA is used with a HDHP to pay for QMEs of the account holder and dependents.  Anyone who is covered by an HDHP is eligible.  Contributors include the employee, employer or both.  The unused funds may carry over from year to year and is portable.  The account earns tax-free interest and employee contributions ae tax deductible.  Qualified withdrawals are untaxed.

Flexible Spending Accounts (FSA) – An FSA is created to reimburse QMEs or health insurance premiums for account holder and dependents.  All employees are eligible unless self-employed.  Contributors include employer, individuals, or both. This is a “use it or lose it” arrangement – it is not portable.  Employee contributions are made on a tax-fee basis.

Making Sense of Your Health Plan

Health insurance plans are often based on a network of doctors and other health care providers.  Different plan types offer different levels of access to providers outside of a plan’s network.  Below are some terms and their acronyms in an effort to help you understand them.

Health Maintenance Organization (HMO) – HMOs have networks of doctors, specialists, pharmacies, and labs.  You must stay within the network of your HMO to receive the care you need.  You must choose a Primary Care Physician (PCP), who is the person responsible for the coordination of your care. Your PCP must give you a referral to see an in-network specialist. You cannot go out-of-network to get care unless your plan approves it ahead of time, and approvals are often granted only if there is no in-network qualified provider in your area.

Preferred Provider Organization (PPO) – In a PPO, you have more provider choice since you may receive services in- or out-of-network. You also do not need a referral to see a specialist.  Most PPOs cover 70-80% of out of network costs, but the amount paid is based on how much the plan would pay a doctor in its own network. The unpaid amount is called co-insurance.  Doctors outside of the PPO’s network can charge whatever they like for your care, so this is important to discuss before receiving services.  Also, be sure to check your plan documents so that you are aware of your co-insurance and benefits if you choose to go out-of-network.

Point of Service (POS) – The POS plan is like a combination of the HMO and PPO plans.  You are required to designate an in-network physician to be your primary health care provider. You may go out-of-network if you choose but in doing so, you will have to pay most of the cost yourself.  The one exception to this rule occurs when your primary care physician refers you to a specific out-of-network doctor, in which case, the health plan will pay all or most of your bill.

Exclusive Provider Organizations (EPO) - EPO plans function similarly to HMOs, except that you cannot go out-of-network under any circumstances.  There are no out-of-network benefits. You must receive all of your care within the plan’s network. Unlike an HMO, you do not need to select a PCP, nor do you need to contact your PCP for referrals to specialists.  However, because you are responsible for choosing specialists and hospitals, it is especially important to check that your selected health care providers are in the network by calling the health plan or referring to its website.

In our next post, we will discuss payment structures for health care plans.