Citizens' Health Care Working Group

Access

A patient’s ability to obtain needed medical care. Access is more than having insurance coverage or the ability to pay for services. It is also determined by the availability of services, acceptability of services, cultural appropriateness, location, hours of operation, transportation needs, and cost.

acute care

Hospital care given to patients who generally require a stay of several days and that focuses on a physical or mental condition requiring immediate intervention and constant medical attention, equipment and personnel.

Adverse selection

Occurs when plan enrollees include a higher percentage of high-risk individuals than are in the average population, resulting in the potential for greater health care utilization and, therefore, increased costs.

Ancillary services

Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.

Appropriateness

The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient's needs. (See also, medically necessary)

Auto-enrollment

The automatic assignment of a person to a health insurance plan (typically done under Medicaid plans).

Behavioral healthcare

Continuum of services for individuals at risk of, or suffering from, mental, addictive, or other behavioral health disorders.

Benchmark

The industry measure of best performance for a particular indicator or performance goal. The benchmarking process identifies the best performance in the industry (health care or non-health care) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance.

Beneficiary

A person certified as eligible for health care services. A beneficiary may be a dependent or a subscriber.

Benefit Package

The list of covered services offered to a group or individual by an insurance company, health maintenance organization, preferred provider organization, or government agency.

Best practices

Actual practices, in use by qualified providers following the latest treatment modalities that produce the best measurable results on a given dimension.

Capitation

A method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.5

Caregiver

A healthcare professional, family member or friend who attends to the needs of a patient.

Carrier

An organization acting as an insurer for private plans or government programs.

Carve-in

A generic term that refers to any of a continuum of joint efforts between clinicians and service providers; also used specifically to refer to health care delivery and financing arrangements in which all covered benefits are administered and funded by an integrated system.

Carve-out

A health care delivery and financing arrangement in which certain specific health care services that are covered benefits (e.g., behavioral health care) are administered and funded separately from general health care services. The carve-out is typically done through separate contracting or sub-contracting for services to the special population.

Case Management

The process by which all health-related matters of a case are managed by a health care professional to ensure continuity of services and accessibility and to avoid misuse of facilities and resources.

Claim

A request by an individual (or his or her provider) to that individual's insurance company to pay for services obtained from a health care professional.

Coinsurance

Sharing the costs between insured and insurer according to a predetermined percentage.  In many traditional health insurance policies, the insured pays a 20-percent coinsurance and the insurer pays the remaining 80 percent, usually with a preset maximum for the insured’s out-of-pocket expenditure.

Closed access

A provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits.

Community rating

A rating method that sets premiums for financing medical care according to the health plan's expected costs of providing medical benefits to the community as a whole rather than to any sub-group within the community. Both low-risk and high-risk classes are factored into community rating, which spreads the expected medical care costs across the entire community.

Computer-based patient record

See Electronic medical record.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

An act that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment. COBRA imposes different restrictions on individuals who leave their jobs voluntarily versus involuntarily.

Consumer

Any individual who does or could receive health care or services. Includes other more specialized terms, such as beneficiary, client, customer, eligible member, recipient, or patient.

Consumer Price Index (CPI)

Widely used as an indicator of changes in the cost of living, as a measure of inflation, and as a means of studying price trends.  Measures the change in cost of a constant bundle of goods and services purchased by consumers.

Copayment

A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.

Cost-sharing

A health insurance policy provision that requires the insured party to pay a portion of the costs of covered services. Deductibles, coinsurance, and co-payment are types of cost sharing.

Coverage

Promise by an insurer or other agency to pay for all or part of expenses incurred for specified health care services. Refers to health insurance and the type of services that the insurer will pay.

Covered Service

Specific health care benefits, services and products a health plan or insurer will pay for.

Critical illness

A disease which may lead to death. Also see "terminal illness."

Deductible

The amount an individual must pay for health care expenses before insurance (or a self-insured company) begins to pay its contract share. Often insurance plans are based on yearly deductible amounts.

Diagnosis

The identification of a disease from its signs and symptoms. Also see "prognosis."

Drug Formulary

The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either "closed," including only certain drugs or "open," including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs.

Electronic medical record (EMR)

A computerized record of a patient's clinical, demographic, and administrative data.  Also known as a computer-based patient record.

End-of-life care

Care of critically ill and/or terminal patients.

Enrollee

A person eligible to receive benefits from a health maintenance organization or insurance policy.  Also called a “member,” the term includes both those who have enrolled or “subscribed” and their eligible dependents.

Enrollment

The total number of covered persons in a health plan. Also refers to the process by which a health plan enrolls groups and individuals for membership or the number of enrollees who sign up in any one group.

Fee for Service

A type of health care plan under which health care providers are paid for individual medical services rendered.

Fully funded plan

A health plan under which an insurer or MCO bears the financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs.

Gatekeeper

Primary care physician or local agency responsible for coordinating and managing the health care needs of members. Generally, in order for specialty services such as mental health and hospital care to be covered, the gatekeeper must first approve the referral.

Health care quality

According to the Institute of Medicine, "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Health information network (HIN)

A computer network that provides access to a database of medical information. Also known as a health data network.

Health Insurance Portability and Accountability Act (HIPAA)

This 1996 act provides protections for consumers in group health insurance plans. HIPAA prevents health plans from excluding health coverage of pre-existing conditions and discriminating on the basis of health status.

Health Maintenance Organization (HMO)

A type of managed care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Services are furnished through a network of providers.

Home health agency

An organization that provides medical, therapeutic or other health services in patients' homes.

Home Health Care

Service provided by health professionals in an individual’s place of residence to patients who require short- or long-term intervention by health professionals due to an injury, illness or disabling condition.

Hospice

Care for the terminally ill and their families, either in the patient’s home or in an inpatient facility, so that the patient can live as full a life as possible.

Indemnity plan

Indemnity insurance plans are an alternative to managed care plans. These plans charge consumers a set amount for coverage and reimburse (fully or partially) consumers for most medical services.

Individual Health Care Account

Similar to an Individual Retirement Account for retirement purposes; a method of financing health care by giving tax advantages to individuals who establish and maintain personal accounts for health care purposes.

Intensive care unit (ICU)

A specialized part of the hospital designed for care of the critically ill whose conditions necessitate constant monitoring.

Intermediate care facility

A facility providing a level of medical care that is less than the degree of care and treatment that a hospital or skilled nursing facility is designed to provide but greater than the level of room and board.

Length of Stay

The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility.

Long-Term Care (LTC)

Health, rehabilitative or personal services provided on a long-term basis for people who are chronically ill, aged, disabled or retarded.

Managed Care

An organized system for delivering comprehensive services that allows the managed care entity to determine what services will be provided to an individual in return for a prearranged financial payment. Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists, and the health plan operates under contract to a payer.

Managed care organization (MCO)   

Any entity that utilizes certain concepts or techniques to manage the accessibility, cost, and quality of health care. See also Health Maintenance Organization (HMO)

Medical group practice

A number of physicians working in a systematic association with the joint use of equipment and technical personnel and with centralized administration and financial organization.

Medically necessary

Health insurers often specify that, in order to be covered, a treatment or drug must be medically necessary for the consumer. Anything that falls outside of the realm of medical necessity is usually not covered. The plan will use prior authorization and utilization management procedures to determine whether or not the term "medically necessary" is applicable.

Medicaid

Health insurance assistance program funded by Federal, State, and local monies. It is run by State guidelines and assists low-income persons by paying for most medical expenses.

Medicare

Federal insurance program serving persons over the age of 65 and those eligible for Social Security disability payments. Most expenses are paid from trusts funded by deposits from payroll taxes, federal general revenues, and beneficiary premiums; deductibles and co-payments are required.

MediGap plans

Supplements to Medicare insurance; plans vary from state to state; standardized plans also may be known as Medicare Select plans.

Member

Used synonymously with the terms enrollee and insured. A member is any individual or dependent who is enrolled in and covered by a managed health care plan.

Network

The system of participating providers and institutions in a managed care plan.

Open access

A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider.

Out-of-area benefits

The coverage allowed to HMO members for emergency and other situations outside of the prescribed geographic area of the HMO.

Out-of-pocket maximums

Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.

Outcomes

The results of a specific health care service or benefit package.

Outcomes measure

A tool to assess the impact of health services in terms of improved quality and/or longevity of life and functioning.

Outcomes research

Studies that measure the effects of care or services.

Outpatient

A person who receives health care services without being admitted to a hospital.

Outpatient care

Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

Palliative care

Treatment focused on improving quality of life through pain management and relief from psychological, emotional and spiritual stress. May be used in tandem with a curative course of treatment.

Payer

The public or private organization that is responsible for payment for health care expenses.

Peer review

A system in which the appropriateness of healthcare services delivered by a provider to health plan members is evaluated by a panel of medical professionals.

Performance measure

A measure that describes the health care being provided. Current performance measures indicate whether a health plan or provider has appropriately provided certain services expected to lead to desirable outcomes.

Personal care physician

See primary care provider.

Plan

Reference to health care plan; includes an individual’s insurance coverage.

Point-of-service plan (POS)

A modified managed care plan under which members do not have to choose how to receive services until they need them. Members receive coverage at a reduced level if they choose to use a non-network provider.

Practice guidelines

Systematically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines.

Pre-existing condition

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 insurance company. Many insurance companies now impose waiting periods for coverage of pre-existing conditions. Insurers will cover the condition after the waiting period (of no more than 12 months) has expired.

Premium

A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits.

Preventive care

Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations.

Primary care

General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.

Primary care provider (PCP)

A physician or other medical professional who serves as a group member's first contact with a plan's healthcare system. Also known as a primary care physician, personal care physician, or personal care provider.

Prognosis

The description of the path a disease is likely to take.

Provider

A hospital, physician, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.

Quality Assurance

An approach to improving the quality and appropriateness of medical care and other services. Includes a formal set of activities to review, assess, and monitor care to ensure that identified problems are addressed.

Quality management (QM)

An organization-wide process of measuring and improving the quality of the healthcare provided by an MCO.

Risk

Possibility that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contractual services. A managed care provider is at risk if actual expenses exceed the payment amount.

Risk adjustment

The adjustment of premiums to compensate health plans for the risks associated with individuals who are more likely to require costly treatment. Risk adjustment takes into account the health status and risk profile of patients.

Risk sharing

Situation in which the managed care entity assumes responsibility for services for a specific group but is protected against unexpected high costs by a pre-arranged agreement for higher payments for those individuals who need significantly more costly services. Risk is usually shared by the managed care entity and the State.

Self-funded plan

A health plan under which an employer or other group sponsor, rather than an MCO or insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a self-insured plan.

Specialist

A healthcare professional whose practice is limited to a certain branch of medicine, specific procedures, certain age categories of patients, specific body systems, or certain types of diseases

State Children's Health Insurance Plan (SCHIP)

Under Title XXI of the Balanced Budget Act of 1997, the availability of health insurance for children with no insurance or for children from low-income families was expanded by the creation of SCHIP. SCHIPs operate as part of a State's Medicaid.

Stop-loss insurance

A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum.

Subscriber

Employment group or individual that contracts with an insurer for medical services.

Supplemental medical insurance

Private health insurance, also called insurance medigap, designed to supplement Medicare benefits by covering certain health care costs that are not paid for by the Medicare program.

Terminal illness

A disease which leading to death. Also see "critical illness."

Termination provision

A provider contract clause that describes how and under what circumstances the parties may end the contract.

Third party payer

Entity other than the patient or provider (such as a private insurer or government program) paying for health care services given to a patient.

Three Tier Rate

A rate structure that sets monthly premiums based on 1) single person coverage, 2) two-person coverage and 3) family coverage.

Three-tier copayment structure

A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug, a higher copayment amount for a brand-name drug included on the health plan's formulary, and an even higher copayment amount for a non-formulary drug.

Two-tier copayment structure

A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug and a higher copayment amount for a brand-name drug.

Uncompensated Care

Care given for which payment is not received, or for which only a portion of the cost is reimbursed.

Underwriting

The review of prospective or renewing cases to determine their risk and their potential costs.

Usual, customary, and reasonable (UCR) fee

The amount commonly charged for a particular medical service by physicians within a particular geographic region. UCR fees are used by traditional health insurance companies as the basis for physician reimbursement.

Utilization

The level of use of a particular service over time.

Utilization review

Retrospective analysis of the patterns of service usage in order to determine means for optimizing the value of services.