Health care terminology doesn't have to be confusing. Here are simple definitions of the terms you're likely to find on this website and out in the health care world.
APPEAL - A special kind of complaint you make if you disagree with certain kinds of decisions made by your health plan.
BENEFICIARY - The name for a person who has health care insurance through the Medicaid program.
BENEFIT PERIOD - A "benefit period" begins the day you go to a hospital or skilled nursing facility (SNF). The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins.
CARRIER - A private company that has a contract with Medicaid to pay your physician and other bills.
CERTIFICATE OF CREDITABLE COVERAGE (COC) - A written certificate issued by a group health plan or health insurance company that states the period of time you were covered by your health plan.
CHILDREN'S HEALTH INSURANCE PROGRAM - Free or low-cost health insurance is available now in your state for uninsured children under age 19. Children's Health Insurance Programs (CHIP) help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage. Information on your state's program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669). You can also look at www.insurekidsnow.gov on the web for more information.
CMS HEARING OFFICER - An individual designated by the Centers for Medicare and Medicaid Services (CMS) to conduct the appeals process for a claim dispute.
COINSURANCE - The amount you may be required to pay for services after you pay any plan deductibles.
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) - A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician's services, physical therapy, social or psychological services, and outpatient rehabilitation.
COORDINATION OF BENEFITS - Process for determining the responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.
COPAYMENT - In some health and prescription drug plans, the amount you pay for each medical service, like a doctor's visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor's visit or prescription.
COST SHARING - The amount you pay for health care or prescriptions. This amount can include copayments, coinsurance and deductibles.
CREDIBLE COVERAGE - Health coverage you have had in the past, such as group health plan (including COBRA continuation coverage), an HMO, an individual health insurance policy, Medicare or Medicaid, and this prior coverage was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan.
CREDITABLE COVERAGE - Health coverage that you had in the past that gives you certain rights when you apply for new coverage.
CREDITABLE COVERAGE (MEDIGAP) - Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. (See pre-existing conditions.)
CREDITABLE PRESCRIPTION DRUG COVERAGE - Prescription drug coverage (like from an employer or union), that pays out, on average, as much as or more than Medicare's standard prescription drug coverage.
CRITICAL ACCESS HOSPITAL - A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
CUSTODIAL CARE - Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops.
DEDUCTIBLE - The amount you must pay for health care or prescriptions before your health plan, your prescription drug plan, or other insurance begins to pay.
DRUG LIST - A list of drugs covered by a plan. This list is also called a formulary.
DURABLE MEDICAL EQUIPMENT (DME) - any condition resulting in functional limitations that interfere with an individual's ability to perform his/her customary work and that results in substantial limitation of one or more major life activities.
DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC) - A private company that contracts with a health plan to pay bills for durable medical equipment.
END-STAGE RENAL DISEASE (ESRD) - Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
EXCESS CHARGES - The difference between a health care provider's actual charge and the amount allowed under the health care plan.
EXPEDITED ORGANIZATION DETERMINATION - A fast decision from the health plan about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
EXTRA HELP - A program to help people with limited income and resources pay prescription drug program costs, such as premiums, deductibles, and coinsurance.
FORMULARY - A list of drugs covered by a plan.
GRIEVANCE - A complaint about the way your health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).
GROUP HEALTH PLAN - A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.
HOME HEALTH CARE - Limited part-time or occasional skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies and other services.
HOSPICE CARE - A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient's family or caregiver as well.
INPATIENT CARE - Health care that you get when you are admitted to a hospital or skilled nursing facility.
INPATIENT REHABILITATION FACILITY - A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.
INSTITUTION - A facility that provides short term or long term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, such as an assisted living facility, or group home are not considered institutions for this purpose.
LONG-TERM CARE - A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn't pay for this type of care if this is the only kind of care you need.
LONG-TERM CARE HOSPITAL - Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
MEDICAID - A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
MEDICAL UNDERWRITING - The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.
MEDICALLY NECESSARY - Services or supplies that are needed for the diagnosis or treatment of your medical condition.
MEDICARE ADVANTAGE PLAN - A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.
MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PLAN - A Medicare Advantage plan that offers Medicare Prescription Drug coverage and Part A and Part B benefits in one plan.
MEDICARE MANAGED CARE PLAN - A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan's list. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extras, like prescription drugs. Your costs may be lower than in Original Medicare.
MEDICARE PLAN - Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans.
MEDIGAP POLICY - Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 plans labeled Plan A through Plan L. Medigap policies only work with Original Medicare.
NON-FORMULARY DRUGS - Drugs not on a plan-approved drug list.
ORIGINAL MEDICARE - A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
OUTPATIENT HOSPITAL CARE - Medical or surgical care at a hospital where you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be considered outpatient care, even if you stay under observation overnight.
PLAN ADMINISTRATOR - The person who is responsible for the management of the plan. The plan administrator is a person specifically designated by the terms of the plan.
PRE-EXISTING CONDITION - A health problem you had before the date that a new insurance policy starts.
PREMIUM - The periodic payment to an insurance company or a health care plan for health care or prescription drug coverage.
PREVENTIVE SERVICES - Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).
PRIMARY CARE DOCTOR - A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she may talk with other doctors and health care providers about your care and refer you to them. In many HMOs, you must see your primary care doctor before you can see any other health care provider.
PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) - PACE combines medical, social, and long-term care services for frail people to help people stay independent and living in their community as long as possible, while getting the high-quality care they need. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must:
- be 55 years old or older,
- live in the service area of the PACE program,
- be certified as eligible for nursing home care by the appropriate state agency, and
- be able to live safely in the community.
QUALITY - Quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person – and getting the best possible results.
REFERRAL - A written order from your primary care doctor for you to see a specialist or get certain services. In many health plans, you need to get a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for your care.
REHABILITATION - Services ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.
SECOND OPINION - This is when another doctor gives his or her view about what you have and how it should be treated.
SECONDARY PAYER - An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.
SERVICE AREA - The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
SIDE EFFECT - A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.
SIGNIFICANT BREAK IN COVERAGE - Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual's coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage.
SKILLED CARE - A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.
SKILLED NURSING FACILITY (SNF) - A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.
SKILLED NURSING FACILITY CARE - This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, can't be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility.
SPECIAL NEEDS PLAN - A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.
SPECIALIST - A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.
SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB) - A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
SPEECH-LANGUAGE THERAPY - Treatment to regain and strengthen speech skills.
STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP) - A State program that gets money from the federal government to give free local health insurance counseling to people with Medicare.
STATE INSURANCE DEPARTMENT - A state agency that regulates insurance and can provide information about Medigap policies and other private insurance.
STATE MEDICAL ASSISTANCE OFFICE - A state agency that is in charge of the state's Medicaid program and can give information about programs that help pay medical bills for people with low incomes.
STATE PHARMACY ASSISTANCE PROGRAM - A state program that provides people assistance in paying for drug coverage, based on financial need, age or medical condition and not based on current or former employment status. These programs are run and funded by the states.
STATE SURVEY AGENCY - Agency that inspects dialysis facilities and makes sure that Medicare standards are met.
SUBSIDIZED SENIOR HOUSING - A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.
SUBSIDY - A monetary grant paid by the government to a private person or company to assist an enterprise deemed advantageous to the public.
SUPPLIER - Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.
TIERS - To have lower costs, many plans place drugs into different "tiers," which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers.
- Tier 1 - Generic drugs. Tier 1 drugs will cost you the least amount.
- Tier 2 - Preferred brand-name drugs. Tier 2 drugs will cost you more than Tier 1 drugs.
- Tier 3 - Non-preferred brand-name drugs. Tier 3 drugs will cost you more than Tier 1 and Tier 2 drugs.
TREATMENT - Something done to help with a health problem. For example, medicine and surgery are treatments.
TREATMENT OPTIONS - The choices you have when there is more than one way to treat your health problem.
TRICARE - A health care program for active duty and retired uniformed services members and their families.
TRICARE FOR LIFE (TFL) - Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.
TTY - A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don't have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.
UNASSIGNED CLAIM - A claim submitted for a service or supply by a provider who does not accept assignment.
URGENT NEEDED CARE - Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than Original Medicare. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
VALIDATION - The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected.
WAITING PERIOD - The period that must pass before an employee or dependent is eligible to enroll (becomes covered) under the terms of the group health plan. If the employee or dependent enrolls as a late enrollee or on a special enrollment date, any period before the late or special enrollment is not a waiting period. If a plan has a waiting period and a pre-existing condition exclusion, the pre-existing condition exclusion period begins when the waiting period begins. Days in a waiting period are not counted toward creditable coverage unless there is other creditable coverage during that time. Days in a waiting period are not counted when determining a significant break in coverage.
WORKERS COMPENSATION - Insurance that employers are required to have to cover employees who get sick or injured on the job.