Glenn Ellis

*In the continuing spirit of empowering folks with information to make good decisions about their health, With changes to healthcare in the United States looming on the horizon in the upcoming years, here is a glossary of some of the more common terms you are hearing being thrown around:

Accountable Care Organization (ACO) – A network of health care providers that band together to provide the full continuum of health care services for patients. The network would receive a payment for all care provided to a patient, and would be held accountable for the quality and cost of care. New pilot programs in Medicare and Medicaid included in the health reform law would provide financial incentives for these organizations to improve quality and reduce costs by allowing them to share in any savings achieved as a result of these efforts.

Annual Benefit Limit – Insurers place a ceiling on the amount of claims they will pay in a given year for an individual. Individuals would then have to pay the full cost for any claims incurred above this ceiling during the course of the year. Beginning in 2010, annual benefit limits will be restricted and will be prohibited in 2014 under health reform.

Case Management – The process of coordinating medical care provided to patients with specific diagnoses or those with high health care needs. These functions are performed by case managers who can be physicians, nurses, or social workers.

Chronic Care Management –The coordination of both health care and supportive services to improve the health status of patients with chronic conditions, such as diabetes and asthma.

Co-ops – Private, nonprofit health organizations set up by some states to compete with private health insurers.

COBRA – Temporary continuation of health coverage at group rates available to certain former employees, retirees, spouses, and dependent children when coverage is lost due to a qualifying event, such as loss of employment. Generally, COBRA participants pay the entire premium themselves.

Coordination of benefits (COB) – A person can have more than one kind of insurance coverage, say one plan from their employer and one from their spouse’s employer. In that case, the two health plans work together to coordinate which one pays first, and how much. This process is called coordination of benefits.

Diagnostic Tests – Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include but are not limited to radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Doughnut Hole – A gap in prescription drug coverage under Medicare Part D, where beneficiaries enrolled in Part D plans pay 100% of their prescription drug costs after their total drug spending exceeds an initial coverage limit until they qualify for catastrophic coverage. Under the standard Part D benefit, Medicare covers 75% of total drug spending below the initial coverage limit ($2,830 in 2010), and 95% of spending above the catastrophic level ($6,440 in 2010). These thresholds are indexed to increase over time. The doughnut hole or coverage gap specifically refers to the range between these two levels ($3,610 in 2010) in which beneficiaries are responsible for all costs incurred for prescription drugs. The coverage gap will be gradually phased out under health reform, so that by 2020, beneficiaries will only be responsible for 25% of all prescription drug costs up to the catastrophic level.

Emergency Care – Those health care services that are provided in an emergency facility or setting after the onset of an illness or medical condition that manifests itself by symptoms of sufficient severity that without immediate medical attention could be reasonably expected by the prudent lay person, who possesses an average knowledge of health and medicine, to result in: a) placing the Member’s physical and or mental health in serious jeopardy; b) serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Employer-based health care – Refers to health plans that are offered at the workplace for employees.

Formulary – List of prescription medications covered by a health plan.

Generic Drug – A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength, dosage form, and effectiveness as the brand drug.

Government-run plan – A government-run health plan, also known as a public or single-payer plan, is modeled after Medicare, which provides individuals health care through the federal government, rather than from a private insurance company.

Grandfathered Plan – A health plan that was in place on March 23, 2010, when the health reform law was enacted, is exempt from complying with some parts of the health reform law, so long as the plan does not make significant changes to its policy, such as eliminating or reducing benefits to treat a specific disease or condition, significantly increasing cost-sharing, or reducing the employer contribution toward the premium, among others. Once a health plan makes such a change to their policy, it becomes subject to all the requirements of health reform.

Health maintenance organization (HMO) – A type of health plan that requires subscribers to receive all medical care from network providers, usually under the direction of a primary care physician (PCP)

Hospice – A facility or service that provides care for the terminally ill patient and which provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

Individual mandate – In the context of health care reform, a much-discussed idea is an individual mandate, which would require all Americans to have health insurance coverage. In turn, everyone would be guaranteed coverage, regardless of age or preexisting conditions.

Inpatient – An individual who is receiving care for 24 hours or more as a registered bed patient in a Hospital or other facility, where a room and board charge is made.

Long-Term Care – Services that include those needed by people to live independently in the community, such as home health and personal care, as well as services provided in institutional settings such as nursing homes. Medicaid is the primary payer for long-term care.

Medically Necessary – Procedures, treatment, supplies, equipment or services determined to be:  appropriate for the symptoms, diagnosis or treatment of a medical condition, and provided for the diagnosis or direct care and treatment of the medical condition; and  within generally accepted standards of good medical practice; and  not primarily for the convenience of the Member or the Member’s Provider; and the most appropriate procedure, treatment, supply, equipment or level of service which can be safely provided.

Outpatient Surgery – Surgical procedures performed that do not require an Inpatient admission. Such surgery can be performed in a Hospital, an Ambulatory Surgery center, or a physician office.

Preventive Care – Care rendered by a physician to promote health and prevent future health problems for a Member who does not exhibit any symptoms (for example routine physical examination, immunizations).

Pre-existing condition – If someone has shown symptoms of a health condition, or been treated for one, before their coverage begins, it is called a pre-existing condition. Usually, there is a limit to how far back a health plan can check for such conditions.

Provider network – A group of providers (such as hospitals and physicians) who agree to a pre-negotiated price for services they provide. To get that price, a patient must be covered by a particular health plan that uses that network.

Single-payer health care – In a single-payer health care system, the government collects money, primarily through tax revenue, and pays all the health care bills for its citizens.

Skilled nursing facility (SNF) – A facility licensed to provide inpatient care, including round-the-clock nursing.

Standard of care – An accepted mode of treatment for a given disease or condition.

Uninsurable – In health insurance, individuals who are “uninsurable” can’t get coverage (or can get it only at higher rates) because of their medical history. It often refers to people who are already seriously ill when they apply for coverage.

Underinsured – People who have health insurance but who face out-of-pocket health care costs or limits on benefits that may affect their ability to access or pay for health care services.

Urgent Care – Services received for an unexpected episode of illness or injury requiring treatment which cannot be postponed, but is not Emergency Care. Urgent Care conditions include, but are not limited to earache, sore throat, fever not higher than 104º. Treatment of an Urgent Care condition does not require use of an emergency room at a Hospital.

Wellness Program – A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability which respond positively to lifestyle related interventions.

Remember, I’m not a doctor, I just sound like one.

Take good care of yourself, and live the best life possible!

Glenn Ellis is a Health Advocacy Communications Specialist, who is syndicated columnist, and author of “Which Doctor?” For more information on good health, visit