Health Glossary: A - F

Select the first letter of the word to jump to the appropriate glossary section.

A | B | C | D | E | F | G—L | M—S | T—Z

A

Accidental Injury. An injury, independent of disease or bodily infirmity of any other cause, which happens by chance and requires immediate medical attention.

Accountable Health Plan, also AHP. In some health care reform proposals, a health insurer or HMO that would offer a government-approved standard benefits package which complies with approved insurance reforms.

Acute Care. Inpatient 24-hour hospital care in which physician and nursing observations and services are required on a minute-to-minute, hour-to-hour basis.

Admission. The formal acceptance of a patient into a hospital or other health care institution for a medical, surgical, or obstetrical condition.

Admission Review. An evaluation to determine the necessity of admission into a hospital resulting from a medical emergency. The evaluation takes place when the provider notifies the insurer of admission by calling. Once notified, the insurer will determine if the condition warrants an inpatient admission or if the condition could be treated in some other setting. The review is typically done shortly after an emergency admission.

Advanced Registered Nurse Practitioner, also ARNP. Nurse with advanced training in a medical specialty who is registered with the state board of nursing to practice in an advanced role. Specialty designations include certified clinical nurse specialists, certified nurse midwives, certified nurse practitioners, and certified registered nurse anesthetists. An ARNP may provide care as an independent practitioner or in collaboration or consultation with a physician.

Agency or Program. Eligible provider of health services other than a facility, practitioner, or supplier. An example is a cardiac rehabilitation education program.

Ambulatory Surgical Facility. Provides surgical services on an outpatient basis for patients who do not need to occupy an inpatient, acute care hospital bed.

Approved Services. Services and supplies covered under an insurance agreement, contract, or certificate within the benefit period.

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B

Backup Provider. A designated substitute for a primary care provider who will render treatment in the event the primary care provider is not available. The backup provider performs the same function as the primary care provider.

Bare-Bones Health Plans. Designed mainly for small businesses, these are no-frills, low-cost policies with limited hospitalization, large deductibles and co-payments, and low policy limits. Over half of the states have waived mandated health benefits to allow the sale of these plans.

Basic Benefits Package. A core set of health benefits everyone would have, either through an employer, a government program, or a risk pool. Most health reform proposals include a basic benefits package.

Basic and Standard.  Basic and Standard health plans provide comprehensive major medical coverage with benefits for fundamental health care needs. Basic is available to individuals or small employer groups who have been without employer-sponsored health care coverage for the past 12 months.

Benefit Period. The amount of time insurance coverage is effective starting on the effective date of coverage and typically ending one year later (e.g. July 1 to June 30 or April 1 to March 31).

Benefit Period Maximum. The total dollar amount, number of days, or number of visits allowed during a benefit period for each person covered under the certificate.

Benefits. Medically necessary services and supplies that qualify for settlement under an insurance agreement.

Billed Charge. Amount a provider bills for services.

Blue Card Program. The Blue Cross and Blue Shield Association (BCBSA) program which permits members of any Blue Plan to have access to health care services from participating providers throughout the United States.

Blue Cross and Blue Shield Association National Transplant Network Facility. A facility which contracts with the Blue Cross and Blue Shield Association to perform specific transplants.

Braces. Rigid and semi-rigid appliances and devices commonly used to support a weak body part or to restrict or restrain motion in a diseased or injured part of the body. Braces do not include elastic stockings, elastic bandages, garter belts, arch supports, orthodontic devices, or other similar items.

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C

Capitation, also Capitated Rates. Fixed, pre-determined amount of money paid to a health care provider or plan for each member or enrolled family unit. The provider or plan agrees to deliver all care during a fixed time for this pre-determined amount of money, regardless of the services the member uses.

Carryover Deductible. Allows any amount applied toward the deductible during the last quarter of the calendar year to apply also toward the next year’s deductible. For example, expenses incurred during October, November, or December will apply toward the next year’s deductible amount.

Case Management. Identifying an individual patient’s needs and problems, and devising a method to meet those appropriately and cost-effectively. Consultation with medical professionals helps the patient take advantage of care appropriate for the patient’s condition rather than a fixed set of treatments and procedures.

Chemical Dependency. Any condition resulting from dependency on or abuse of a psychoactive substance as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Revised, (DSM-IV-R), or subsequent revisions, published by the American Psychiatric Association.

Claims Settled. Amount of provider bill that is discharged when a claim is processed.

COBRA. Consolidated Omnibus Budget Reconciliation Act of 1985. Entitles ex-employees of companies with 20 or more workers to continued coverage under the group plan for 18 months after leaving.

Coinsurance. The amount, calculated using a fixed percentage, you pay each time you receive covered services.

Common Accident Deductible. When two or more family members are involved in the same accident and they receive covered services for injuries related to the accident, only one individual deductible amount applies to the accident-related services for all members involved.

Community Health Management Information System (CHMIS). Iowa statewide program, established by the legislature, that uses uniform electronic claims forms and processing to reduce administrative costs and improve health system data and information.

Community Mental Health Center. Facility providing outpatient treatment of mental health conditions.

Community Rating. Insuring everyone in a specific region for about the same price. Premiums are based on the potential health risks or claims experience of the entire population in the area.

CON, also Certificate Of Need. Mandatory state approval for major medical equipment purchases or hospital construction.

Contingent Beneficiary.  The individual(s) or entity to whom the death benefit of a life insurance policy is paid in case the primary beneficiary is not alive.  See Primary Beneficiary.

Continued Stay Review. Review of care when a covered person is in a health care facility or is using home health services, hospice care, private duty nursing, or home infusion therapy. The review ensures that the level of care is appropriate.

Contract Limitations. Any amounts a covered person is responsible for paying, based on his or her contract with the insurer.

Conversion Coverage. Coverage which may be available to a person after coverage ceases under his or her current insurance certificate.

Coordination of Benefits, also COB. Applies when a member is covered by more than one group contract or commercial insurance policy providing benefits for like services. COB is a method of limiting insurance settlement to no more than 100 percent of one carrier’s settlement arrangement.

Copayment. Fixed amount or a percentage of the fee paid by a member each time a service is received.

Cost Containment. Strategies used to limit or control costs. Cost containment programs often include requirements by insurance companies for second opinions and pre-admission approvals for hospitalization. Cost containment may also refer to policies developed nationally or statewide to slow the rising expenditures on health care.

Cost Shifting. Common result when a payer, such as Medicare, does not pay the full cost of health care services. Providers then increase prices to individuals and insurers to make up the difference.

Covered Charge. The amount a provider bills for a covered service.

Covered Services. Medically necessary procedures, services, or supplies listed in the member’s benefits certificate.

Creditable Coverage. (South Dakota only)  Coverage through an individual or employer-sponsored health plan with benefits equal to or greater than the Basic plan, Medicare or Medicaid, TriCare (formerly CHAMPUS), Indian Health Service (or tribal organization), state health benefits risk pool, FEP, a public health or church plan, or a college plan that is not a limited benefit plan. Creditable coverage does not include limited benefit plans, dread disease plans, or short-term major medical if it is the coverage immediately prior to the effective date of the Basic or Standard coverage.

Custodial Care. Assistance in meeting daily living activities not requiring the continued attention and assistance of licensed medical or trained paramedical personnel. Some examples include assistance in walking and getting in and out of bed; aid in bathing, dressing, feeding; preparation of special diets; and supervision of medication which can usually be self administered.

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D

Deductible. The amount a health plan member pays before benefits are available. Under some plans, the deductible is waived for specific services, like preventive care.

Demand Management, also Continuum Management. Promoting member well-being and reducing the need for services through such strategies as prevention, risk identification, risk management, and empowering consumers and providers to make appropriate choices about care through education and informed decision-making tools.

Dependent Child. A member’s natural child; a child placed with a member for adoption or a legally adopted child; a child for whom a member has legal guardianship; a stepchild; or a foster child. To receive coverage under a parent’s plan, the child may have to satisfy age, residence, or other eligibility requirements.

Diabetes (Type I). Type I diabetes means that a person is insulin-dependent and requires insulin treatment for his or her lifetime.

Diabetes (Type II). Type II diabetes means a person is not insulin dependent but may manage his or her condition by diet, exercise, weight control, and in some instances, oral medications or insulin.

Diabetes Education Program. State-approved, self-managed outpatient education program. The program helps a person with type I or type II diabetes understand the process of the disease and its daily management.

Disease Management, also Compliance Management. Identifying members with chronic health conditions and providing them with education and other support to comply with their prescribed treatments. The goal is to maximize members’ well-being and to reduce or delay the need for more advanced or costly medical interventions. Some conditions which benefit from disease management programs are arthritis, asthma, HIV-AIDS, lower back pain, and diabetes.

Domestic Partners. Unmarried couples who are eligible as spouses for coverage under one partner’s health plan.

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E

Effective Date. The date upon which contracted insurance benefits become available.

Emergency. Life-threatening, disabling, or serious injury or illness, including severe pain which arises or worsens suddenly and which, if not treated immediately, could reasonably be expected to result in loss of life, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Emergency Admission. Entry to hospital which must take place immediately or the result may be loss of life, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Emergency Medical Service System, also EMSS. Emergency system which uses ambulances and technicians to bring rapid medical help to people with injuries or severe illnesses.

Emergency Medical Technicians, also EMTs. Trained volunteers or professionals who deliver emergency care from and on an ambulance.

Employee and Spouse Coverage. Benefits allowable for the plan enrollee and spouse.

Employee and Child(ren) Coverage. Benefit coverage allowable for the plan enrollee and eligible dependent child(ren).

EPO, also Exclusive Provider Organization. A health plan similar to an HMO in which members must receive services from participating providers or benefits are denied.

ERISA, also Employee Retirement Income Security Act of 1974. A federal law which exempts companies that self-insure or fund their own insurance plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination, and other state health reforms.

Experience Rating. System for determining risk and setting premiums by considering the cost of medical claims incurred by a group.

Explanation of Health Care Benefits, also EOB. Statement a health plan member receives which outlines how benefits are applied to a submitted claim.

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F

FEHBP. Federal Employees Health Benefits Program for federal workers and members of Congress. This is considered to be an example of a health purchasing cooperative.

Facility. A licensed, certified, and/or accredited facility which provides inpatient and outpatient services. Examples of facilities are hospitals, nursing facilities, and ambulatory surgical facilities.

Facility to Treat Chemical Dependency. A licensed, freestanding facility which is approved by an insurer to provide treatment for chemical dependency conditions.

Family Coverage. Benefits are allowed for the plan enrollee and eligible family members.

Family Physician. Physician who provides primary care in a manner which considers patients in relation to their families and social environments as factors in diagnosis and treatment. Family physicians complete a residency training program in family practice.

Fee-for-Service. Settling with providers for each test or procedure as delivered.  With a Wellmark fee-for-service plan, you are free to see any provider. You’ll benefit from participating provider negotiated prices and electronic claims filing when your care is coordinated through providers who participate in a network. Classic Blue® is a fee-for-service plan.

Formulary. See Preferred Drug List.

Full-Time Student.  A dependent claiming status as a full-time student. The dependent must be enrolled in an accredited institution of higher learning, such as a college, university, nursing school, or trade school, and must be considered full-time as defined by the institution in which the dependent is enrolled. Full-time student status continues during:

• regularly scheduled school vacation periods; and
• absence from class in which enrolled for up to four months due to a physical or mental disability. The disability must be substantiated by a written statement from a physician.

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.