Health Glossary: G - L

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

A—F | G | H | I | J | K | L | M—S | T—Z

G

Gatekeeper. A primary care provider who initially assesses a patient’s condition and needs and refers the person to the appropriate treatment or provider.

Global Budgets, also Spending Caps, or Spending Targets. Limits on categories of health spending set by a state or federal government or their appointed body to manage how much money is being spent for health care. For example, state health commissions could determine how much money is available for services from doctors, hospitals and other providers. They could also regulate doctors’ and hospitals’ charges, and insurance premiums.

Global Pricing Arrangements. This all-inclusive payment arrangement bundles costs into one charge which includes all costs for hospitalization and physician fees.

Group. Insurance organization made up of those plan enrollees who share a common relationship like employment or membership.

Guaranty Fund. A state-required pool of funds covering benefits of insolvent insurers and designed to protect providers and consumers.

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H

Health Alliances, Health Plan Purchasing Cooperatives, also HPPCS. Purchasing groups for health benefits formed with the goal of massing purchasing power to negotiate premiums or capitated fees downward.

Health Care Plan. Broad term which refers to systems of organization and delivery of health care. Common examples are (a) a pre-paid hospital and medical plan such as Health Maintenance Organization (HMO); or (b) a health insurance policy requiring that patients use preferred providers (PPOs). Often used to distinguish managed care or integrated service benefits from fee-for-service coverage.

Health Care Provider. Term used to describe a person, organization, or institution that delivers health care services, e.g., a doctor, nurse, practitioner, clinic, or hospital.

Health Care Reform. Efforts to create a new system of providing and paying for health care coverage in states and nationally. Most people believe that the system must contain three key elements: 1) a package of basic health insurance benefits for everyone, also called "universal coverage;" 2) controls on the costs of health services; 3) and quality controls so that people receive appropriate and effective care.

Health Maintenance Organization, also HMO. A pre-paid hospital and medical plan with a defined membership which provides comprehensive health services. The plan controls which providers are seen by the patient and uses specific, participating hospitals for advanced care. HMOs are usually paid a fixed amount per member per month, regardless of how many services a member uses. This form of payment is called "capitation."

High-Risk Pool. These pools offer coverage to individuals and small groups who have been denied other coverage or whose medical conditions make premiums prohibitively high.

Homebound. Due to a physical or mental disability, you are unable to leave home other than for the purpose of obtaining medical care.

Home Health Agency, also HHA. Agency or organization approved by Medicare or the Joint Commission for the Accreditation of Health Care Organizations (JCAHCO), which provides skilled in-home nursing care of two hours or less per visit.

Home Infusion Therapy. In-home administration of nutrients, antibiotics, or other drugs and fluids intravenously or through a feeding tube.

Home Medical Equipment, also Durable Medical Equipment. Item which meets the following criteria: it is durable enough to withstand repeated use; it is primarily and customarily manufactured to serve a medical purpose; and it is not useful in the absence of illness or injury. Examples include wheelchairs, walkers, and crutches.

Hospice Care. Palliative health care and related services to dying patients. Care typically consists of the alleviation of pain through medication, physical treatment of the patient, and emotional support of the patient and family. Hospice care can be performed in an institutional setting or at home.

Hospice Program. A system to provide care in a comfortable setting (usually the home) for patients who are terminally ill and have a life expectancy of six months or fewer. Services include home health care and respite services.

Hospital. An institution which primarily provides diagnostic and therapeutic services for surgical and medical diagnosis, treatment, and care of injured or sick persons. The facility must be licensed under applicable laws as a hospital.

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I

Identification Card. The card issued by a health plan. Information on the card, especially the identification number, is required by the providers and the insurer to process claims correctly and to answer questions.

Illness or Injury. Any bodily disorder, bodily injury, disease, or mental health condition, including pregnancy and complications of pregnancy.

Immediate Family Member. Child, spouse, or parent.

Immunization. Injection with a specific antigen to promote antibody formation, to create immunity to a disease, or to make a person less susceptible to a contagious disease.

Incidental Procedure. Procedure which is an integral part of another procedure and therefore not allowable as a separately reimbursable benefit.

Individual Case Management. Provision which emphasizes the specialized care needs of patients with severe illnesses or injuries. Arrangements may be made to waive standard certificate limitations in order to provide a more appropriate and comfortable setting for continued treatment.

Individual Practice Association, also IPA. A type of health maintenance organization in which an association, made up of individual practice physicians, contracts to provide services to the HMO enrollees. The HMO pays the IPA on a capitated basis to provide a defined package of services to its members.

Inpatient Admission. A stay in an inpatient facility like a hospital, which usually involves overnight care.

Investigational Treatment. Treatment is considered investigational when the service, procedure, drug, or treatment modality has progressed to limited human application but has not achieved recognition as being proven and effective in clinical medicine.

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J

Job Lock. Staying at a job for fear of losing health insurance coverage because of problems obtaining coverage elsewhere.

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K

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L

Lifetime Benefits Maximum. The total dollar amount, number of days, or number of visits allowed for covered services for each person covered under a health plan certificate or agreement. There can be separate lifetime maximums for different categories of benefits.

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