Healthcare Glossary and Common Acronyms

Agent (see Producer).

Benefit package: The list of medical services an insurance company or managed care organization will pay for. Also called “covered services.”

Benefits: The money the insurance company pays the health care provider for medical services to you if you become ill or injured.

Capitated plan: These plans are sometimes called health maintenance organizations (HMO) or dental health maintenance organizations (DHMO). In this type of plan, the doctor is paid an agreed-upon monthly fee for each person enrolled in the plan regardless of whether any participants use the doctor’s service. The doctor, in return, has agreed to give treatment that patients may require, provided that the plan covers the treatment. The patient may see only a participating doctor. The doctor may be financially penalized for referring the patient to a specialist. If a plan member visits a physician not on the list or goes directly to a specialist, the member pays the bill.

Some HMOs offer indemnity-type options known as POS plans in which primary care physicians make referrals to other providers in the plan. Members can refer themselves outside the plan and still receive some coverage. If a physician refers someone out of network, the plan will pay all or most of the bill. If a member refers to an out-of-network provider, and the service is covered, he will pay the co-insurance.

Carrier: Insurance company or Health Maintenance Organization (HMO) insuring the health plan. Health insurance carriers need a certification of authority to do business in Oregon.

Claim: A request by you for payment by the insurance company of medical expenses that are covered under the insurance policy. The provider of a medical service will usually file a claim for you.

Co-insurance: The amount you pay for medical care after you’ve met your deductible. Based on the agreement that insurer and insured share the cost of care, it is usually expressed as a percentage of the medical bill. Often the insurer pays 80% and the insured person pays 20%.

Co-payment (co-pay): The amount you pay out-of-pocket for each doctor/hospital visit or for a covered medical service. Usually expressed as a dollar amount. For example, the insured person may pay $25 toward the cost of an office visit.

COBRA: Consolidated Omnibus Budget Reconciliation Act of 1985. A federal law that requires employers sponsoring group health plans to offer continuation of coverage under the group plan. This law applies to employees, their spouses and dependent children who have lost coverage because of the occurrence of a “qualifying event.” Qualifying events include reduction in work hours, many types of termination of employment, death, and divorce. The person who is continuing coverage is responsible for the entire premium. Since there is no employer contribution, the premium is usually higher than when the person was employed. The coverage can usually be continued for up to 18 months.

Consumer Assessment of Healthcare Providers and Systems (CAHPS): A public-private initiative developed standardized surveys of patients’ experiences with ambulatory and facility-level care.

Coverage: The conditions for which the insurance company will pay.

Deductible: The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a “$250″ deductible, the insurance company pays as agreed after you pay the first $250.

Diagnosis Related Group Hospital (DRG Hospital): A classification of hospital case types into groups expected to have similar hospital resource use. The groupings are based on diagnoses, procedures, age, sex, and the presence of complications or comorbidities (definition from the Agency for Healthcare Research and Quality ).

Disability insurance: Pays benefits if you are injured or become seriously ill and are no longer able to work.

Division of Medical Assistance Programs (DMAP) – formerly OMA: The Division of Medical Assistance Programs (DMAP) administers state programs that provide medical coverage to low-income Oregonians, such as the Oregon Health Plan, Medicaid and the Children’s Health Insurance Program. DMAP is a division of the Department of Human Resources (DHS).

Dependent: The spouse or child of an eligible employee, subject to applicable terms of the health benefit plan covering the employee.

Eligibility: A process used to determine if you qualify for health insurance plan or benefit.

End of Benefits (EOB): The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.

Enrollee: A person eligible to receive and receiving health benefits from an insurance plan or managed care program. Also called “member” when referring to managed care plans.

Exclusions: Conditions for which the insurance company will not pay; for example, cosmetic procedures are exclusions.

F, G

Family Health Insurance Assistance Program (FHIAP): An Oregon Health Plan program for Oregonians unable to afford coverage and who’ve been uninsured for at least six months. State-paid subsidies offset the premium cost for buying private market insurance. FHIAP is available to both adults and children.

Fee-for-service insurance: Traditional (indemnity) health insurance where you and your plan each pay a portion of your health expenses, usually after you meet a yearly deductible. In most cases, you can choose any physician, hospital, or other provider (non-network based coverage).

Flexible spending arrangements: Employees use pre-tax dollars to set up these accounts and draw down on them to pay qualified medical expenses during the year. Unused amounts are forfeited at the end of the year.

Fully Capitated Health Plans (FCHP): Fully Capitated Health Plans offer a full array of services that include physician, hospital, pharmacy, ambulance, medical equipment, and home care. Capitated refers to the financial and risk sharing arrangement between these health plans and the state whereby the plans are paid on a pre-paid, actuarially determined amount per “capita” (or per member) for each month of enrollment. Fully Capitated Health Plans are also responsible for the finance, insurance, provider payment, and delivery of health care to OHP members, as well as for implementing utilization management and quality improvement programs.

Formulary: An insurance company’s list of covered drugs.

Group insurance: Health plans offered to a group of individuals by an employer, association, union, or other entity.

Health insurance: Health insurance is a contract between a policy holder and an insurance company where the company assumes the large financial risk of health care expenses in exchange for the individual paying a small amount, the premium, each month. The company spreads the cost of health care over a number of people.

Health Maintenance Organization (HMO): A form of managed care in which you receive all of your care from participating providers. You usually must obtain a referral from your primary care physician before you can see a specialist.

Health Reimbursement Arrangement (HRA): An account established by an employer to pay an employee’s medical expenses. Only the employer can contribute to a health reimbursement account.

Health Savings Account (HSA): An account established by an employer or an individual to save money toward medical expenses on a tax-free basis. Any balance remaining at the end of the year, rolls over, to the next year.

High-risk pool: A State-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness. See, Oregon Medical Insurance Pool.

I, J, K

Identification card: A card given to you that identifies you as being eligible for benefits. The card must be presented when seeking treatment.

Income guidelines: Annual guidelines used to determine eligibility for publicly sponsored programs.

Indemnity insurance: Traditional, fee-for-service health insurance that does not limit where a covered individual can get care.

Indemnity plan: A type of health insurance policy under which you pay 100% of all medical bills up to the annual deductible amount. The insurance then pays a percentage of all covered charges up to a specified limit. Once the policy limit has been reached, the plan pays all covered charges for the rest of the year.

Individual health insurance plan: Coverage purchased by a person or family (not as part of a group), usually directly from an insurance company or producer (agent).

In-patient care: Services provided in a hospital, including room and board, nursing care, diagnostic and therapeutic services, and medical or surgical care.

Insurance: A system under which individuals, businesses and other organizations, in exchange for a premium, are promised payment for losses resulting from certain dangers as specified in a contract.

Insurance company: An organization licensed to operate as an insurer.

Insurance policy: The legal document issued by the company to the policyholder (Purdue) which outlines the terms and conditions of the insurance; also called a “contract”.

Insured: A person or organization covered by an insurance policy.

Lifetime maximum: The highest total amount an insurance company will pay for a person’s health care over a lifetime.

Long-term care insurance: Coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility.

M, N

Managed care: An organized way of getting health care services and paying for care. Managed care plans feature a network of physicians, hospitals, and other providers who participate in the plan. In some plans, covered individuals must see an in-network provider; in other plans, covered individuals may go outside of the network, but they will pay a larger share of the cost. See Health Maintenance Organization (HMO).

Major medical: A plan that provides much broader coverage than the basic medical plan up to a high limit. You may increase your coverage by paying an additional amount more than your basic premium.

Managed care plan: A form of health insurance that provides incentive for the insured to use specific providers or a list of providers.

Maximum out-of-pocket expense: The most you’ll have to pay in one year for medical care. The health benefit plan pays the full amount for covered services above this maximum up to the annual or lifetime maximum of the plan.

Medicaid: A Federal program administered by the States to provide health care for certain poor and low-income individuals and families. Eligibility and other features vary from State to State. See Oregon Health Plan (OHP).

Medical Home Concept: The concept of the Medical Home has evolved since its introduction by the American Academy of Pediatrics in 1967. It has gone from a specific place to receive care for children with chronic disease, to an entire system of providing care for all Americans. This concept shifts the paradigm from episodic acute care to a continuous comprehensive model. The basic premise of the medical home concept is care that is managed and coordinated by a personal physician with the right tools will lead to better outcomes.

Medicare: A Federal insurance program that provides health care coverage to individuals aged 65 and older and certain disabled people, such as those with end-stage renal disease. For help with Medicare in Oregon, see Senior Health Insurance Benefit Assistance (SHIBA).

Member: A person eligible to receive and receiving health benefits from an insurance plan or managed care program. Also called “enrollee.”

Network: A group of physicians, hospitals, and other providers who participate in a particular managed care plan.

Office of Medical Assistance Programs (OMAP): (see Division of Medical Assistance Programs , DMAP)

Office of Private Health Partnerships (OPHP): The Office of Private Health Partnerships is a small state agency created by the 1987 Oregon Legislature, dedicated to helping all Oregonians gain access to health benefit coverage.

Open enrollment: A set time of year when you can enroll in health insurance or change from one plan to another without benefit of a qualifying event (e.g., marriage, divorce, birth of a child/adoption, or death of a spouse). Open enrollment usually occurs late in the calendar year, although this may differ from one plan to another.

Oregon Health Plan (OHP): Oregon’s Medicaid program.

Oregon Insurance Code: Body of laws established by the legislature for the protection of the insurance-buying public. Administered and enforced by the director of the Department of Consumer & Business Services.

Oregon Medical Insurance Pool (OMIP): A state agency high risk pool that increases access to health insurance for high risk Oregonians who are denied medical insurance for health reasons or do not have portability coverage available from their employer.

Office of Private Health Partnerships (OPHP): his office administers programs to increase the number of Oregonians and businesses with health insurance. The agency, originally created as the Insurance Pool Governing Board in 1987, was renamed in 2006. Programs administered by the office include:

Family Health Insurance Assistance Program (FHIAP): This program helps uninsured, income-eligible Oregonians pay the monthly premium for private health insurance.
Agent Referral Program: The office connects business owners with health insurance agents (producers) in their community. Agents help businesses navigate the insurance system and find plans that meet the needs of owners and employees.
Education/presentations: The office trains insurance producers, employers, civic organizations and other community partners on a variety of state programs for uninsured Oregonians as well as changes in state insurance law.

Out-of-network: A provider or health care facility that is not part of a health plan’s network. Insured individuals usually pay more when using an out-of-network provider, if the plan uses a network.

Out-of-pocket expense: Member’s share of any medical care costs not covered by insurance. These are the deductibles, co-insurance, and co-payments that you must pay.

Out-patient care: Services provided by a hospital, clinic, mobile x-ray, or free-standing dialysis unit, including physical therapy, x-ray, and lab tests.

P, Q

Pharmacy: A business where drugs approved by a doctor are legally sold.

Point-of-service plan: A form of managed care plan in which primary care physicians coordinate patient care but there is more flexibility in choosing doctors and hospitals than in an HMO.

Portability coverage: Individual health benefit coverage offered to a person who is leaving Employer-provided group health benefit coverage. Portability plans are offered by the employer’s health benefit insurer, or by the Oregon Medical Insurance Pool (OMIP) if the employer does not provide portability.

Pre-authorization: When an insurance company has to give approval before a medical service, supply, or medication will be covered.

Pre-existing condition: An illness, injury or condition for which the insured individual received medical advice, treatment, services or supplies; had diagnostic tests done or recommended; had medicines prescribed or recommended; or had symptoms of prior to the effective date of the insurance coverage.

Preferred provider: A medical care provider who has elected to participate in a PPO.

Preferred provider organization (PPO): A form of managed care in which you have more flexibility in choosing physicians and other providers than in an HMO. You can see both participating and nonparticipating providers, but your out-of-pocket expenses will be lower if you see only plan providers.

Premium: The amount you pay monthly to participate in your insurance plan and keep it active. You pay the premium whether you receive medical care or not.

Preventive care: Health care that is intended to keep you from becoming ill; i.e., checkups, mammograms, immunizations, well-baby visits.

Primary care physician: Usually a family practice doctor, internist, obstetrician-gynecologist, or pediatrician. He or she is your first point of contact with the health care system, particularly if you are in a managed care plan.

Producer (agent): A person licensed by the state of Oregon and authorized by an insurance company to sell and service insurance plans on its behalf. A producer’s powers are limited by the terms of his company’s contract and by state laws. Producers can represent more than one insurance company.

Provider: The licensed doctor, nurse practitioner, hospital, laboratory, or other professional who provides medical care to you. Also called health care practitioner.

Reasonable and customary charge: The prevailing cost of a medical service in a given geographic area.

Senior Health Insurance Assistance Program (SHIBA): SHIBA provides free counseling to people with Medicare and those who assist them. Volunteers who are trained in Medicare can help you select a Medicare prescription drug plan; find out if you are receiving all possible benefits; compare supplemental health insurance policies; review a bill; and file an appeal or complaint.

Single-Payer System: An approach to health care financing with only one source of money for paying health care providers. The scope may be national (the Canadian System), state-wide, or community-based. The payer may be a governmental unit or other entity such as an insurance company. The proposed advantages include administrative simplicity for patients and providers, and resulting significant savings in overhead costs.

Some writers argue that the single payer is the government, but the preceding definition, as well as some single-payer proponents in the U.S., leave the government’s role open to interpretation. However, the term “single payer” is never used to indicate that the patient bears sole responsibility for all payment.

The term single-payer is sometimes used in the U.S. to distinguish systems paid from a single (governmental) source with other systems of universal health care in which the government has a higher degree of control, up to and including administering hospitals and employing doctors and staff, though logically these too are single-payer systems. When the term single payer is used in this way, doctors’ practices and hospitals may remain private and negotiate with the government for fees.

Single payer is one alternative proposed for reforming the U.S. health care system. Proponents argue that it would provide universal coverage with at least the same quality and lower costs. Critics argue that single payer would harm quality of care and medical innovation, and instead advocate tax incentives and free market approaches. Opponents of publicly funded health care in the U.S. often lump single payer systems along with others under the pejorative term socialized medicine.

Specialist: The physician who provides expertise and care in a particular area; i.e., surgeon, oncologist (cancer doctor), dermatologist, allergist.

Stop loss: The level at which an insurance policy will pay for covered medical care expenses at 100% up to the lifetime maximum of the policy.

Subsidy: A grant of money. In the case of the Family Health Insurance Assistance Program, a subsidy is a grant of money from the State of Oregon that pays a portion of the monthly premium for the members’ health insurance.

ACRONYMS

CAF Children, Adults and Families is a cluster within DHS that provides specialized case management services to eligible families.
CDO Chemical Dependency Organization
CHIP Children’s Health Insurance Program
CMS Centers for Medicare and Medicaid Services, formerly called HCFA
COBRA Consolidated Omnibus Budget Reconciliation Act of 1985.
DCO Dental Care Organization
DHS Oregon’s Department of Human Services
ERISA Employee Retirement Income Security Act is federal legislation.
FCHP Fully Capitated Health Plan.
FFS Fee-for-service is a billing method for services not covered by a capitated plan.
FHIAP Family Health Insurance Assistance Program
FPL Federal Poverty Level
HCFA Health Care Financing Administration is the former name for CMS.
HIPAA The Health Insurance Portability and Accountability Act is a comprehensive privacy protection law.
HMO A Health Maintenance Organization is a type of managed care plan. Generally, HMOs have a select list of providers, a limited choice of hospitals, and an emphasis on preventive care.
HPC Health Policy Commission
HRC Health Resources Commission
HSC Health Services Commission
IPGB Insurance Pool Governing Board (now OPHP).
LTC Long-term care
MAC Medicaid Advisory Committee
MCO Managed Care Organization
MHO Mental Health Organization
OHC Oregon Health Council, former name for the Health Policy Commission.
OHP Oregon Health Plan
OHPR Offi ce for Oregon Health Policy and Research
OMAP Offi ce of Medical Assistance Programs
OMHAS Offi ce of Mental Health and Addiction Services
OMIP Oregon Medical Insurance Pool
OPHP Offi ce of Private Health Partnerships (formerly IPGB)
PCM Primary Care Manager
PCO Physician Care Organization
SCHIP State Children’s Health Insurance Program, known in Oregon as CHIP
SPD Seniors and People with Disabilities is a cluster within DHS that provides specialized case management services to those clients.
SSA Social Security Administration
SSI Supplemental Security Income is for low-income people who are aged, blind or have disabilities as determined by SSA. Oregonians on SSI are automatically eligible for OHP Plus coverage (OHP with

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