Knowledge of acronyms used in health insurance plans and medical terms is vital since healthcare continues to be a confusing system for many people. It makes a difference whether you are signing up for a health plan, consulting your doctor on the possible treatment options, or reading insurance papers, comprehension of some of the essential terms goes a long way in helping you manage your healthcare. In this complete guide discussing essential health coverage and medical terminologies, we will discuss the following;
Why It Matters
A
**1. Annual Deductible: The total amount of money you have to spend on necessary treatments before your coverage starts to kick in.Impact
**2. Allowable Charge: The most money an insurance plan will pay for service that it covers, this usually based on an agreement made with other healthcare entities.
B
**1. Benefit: The available and offered care that the insurance policy entitles the insured to undergo, these may include doctors’ visits, hospital admissions, prescription drugs, and immunizations.
**2. Coinsurance: The proportion of the expenses that you are required to contribute for the services that are under the plan once you have met your premium. This is the specific manner in which coinsurance works; let us assume a coinsurance of 20%; you are required to pay $20% of the allowable charge while the insurance plan pays $80% of the allowable charge.
C
**1. Copayment (Copay):A specific sum that the subscriber has to contribute each time they access specific services that the insurance covers such as consultation fees of a doctor or the cost of Malaria prescription drugs. Most copayments are expected to be made at the time of the visit.
**2. Coverage: The scope of healthcare services and treatments included in your insurance plan, which may vary depending on the type of plan (e.g., HMO, PPO, EPO).
D
**1. Deductible: The degree of money that you are expected to fund on the services embraced by your insurance plan. These coinsurance amounts may be adjusted and stated within a particular plan and may apply each year.
**2. Dependent: A dependent, who may be a spouse, child, or any dependent beneficiary, in reference to a health insurance policy.
E
**1. Emergency Medical Condition: It is a serious illness which if not treated would cause a lot of harm health wise to the affected individual. In general, coverage of emergency treatment is usually provided even if the provider is not in the patients insurance network.
**2. Exclusion: Services that your insurance company may not pay for or any diseases or illnesses that may be excluded from cover. In this regard, the provision calls for one to consider the exclusions in order to determine which service may attract out-of-pocket expenditure.
F
**1. Formulary:A list of medicines that your insurance pays for, these usually come in packages or tiers in which the consumers pays a certain amount.
**2. Flexible Spending Account (FSA): A tax-favored spending account in which funds can be contributed before tax to pay for out-of-pocket qualified medical expenses other than insurance premiums.
G
**1. Generic Drug: An off-counter medication of the same material as a brand-name medication but often costs lesser amount. Generic drugs can be purchased at a much lower price than branded ones and are also regarded as clinically and scientifically proven to be as effective as the brand drugs since they have to go through a series of tests such as the FDA test to ascertain their effectiveness .
**2. Guaranteed Issue: Freedom to join insurance plan or health plan without the exclusion of being turned down due to medical history of the patient or his/her health status.
H
**1. Health Maintenance Organization (HMO): A type of care plan in which members select a primary care physician (PCP) and need a referral to integrate with specialists. The out-of-pocket cost tends to be relatively low for HMOs, but the insured is only allowed to access specified healthcare facilities.
**2. Health Savings Account (HSA): A financial account established to help people with an HDHP save money for eligible health care costs tax-free. Although preserve accounts cannot be deducted directly from salary, deposits into an HSA are tax-deductible, and funds can be used for medical expenses.
I
**1. In-Network Provider: An organization or a professional who has an agreement with the insurer for the performance of services with an agreed price. Generally health care plans with in-network providers entail low out of pocket expenses on the covered services.
**2. Individual Mandate: An ACA mandate that requires the populace to have healthcare insurance or pay tax in many parishes, although this has been stopped in some regions.
J
**1. Joint Commission: An independent, nonprofit organization that accredits and certifies healthcare organizations and programs in the United States based on quality and safety standards.
**2. Job-Based Health Plan: Insurance which has been subscribed by an employer or union on behalf of the employees or members as an extra benefit for working for the employer or joining the union. According to job-based plans, there could be variations as regards the coverage and the associated premiums as marked by the size and occupation of the employers in question.
K
**1. Kidney Dialysis: A therapy that clears wastes, salts and/or fluids from the blood when the kidneys are unable to do so properly. Dialysis is an Insured service and is also funded by Medicare part B and some private insurance companies.
**2. Kaiser Family Foundation (KFF): A non-govenmental organization involved in the promotion of health policies within the United States and the country’s influence in the international health systems.
L
**1. Lifetime Limit: It is a limit set on the amount of money in total, that an insurance plan will extend in the course of taking care of insured services throughout the lifetime of the policy. The ACA also doesn’t allow lifetime limits in policies for the essential health benefits.
**2. Long-Term Care (LTC) Insurance: Benefits that reimburse for the costs of care like the nursing home, home health care, and assisted living for people who have one or more limitations in carrying out daily tasks because of a disease or a handicap.
M
**1. Medicaid: A Medicaid is a federal and state initiative of offering health insurance to those who earn less or have limited income. Medicaid enrollment and participation differ among states while it may include hospitalizations, doctors’ visits and prescription drugs among the required essential health care services, among other services.
**2. Medicare: The health insurance plan most cited in federal that targets mostly people sixty-five years and above, younger individuals with disabilities as well as those with end stage renal disease. Medicare has several divisions as follows: Medicare Part A, Medicare Part B, Medicare Part C and Medicare Part D.
N
**1. Network: It refers to the network of medical care professionals, clinics, and hospitals that has an agreement with the particular insurance plan regarding the provision of services to insured individuals at agreed-upon charges.
**2. Non-Preferred Provider: This is a doctor or a health facility who/which is not affiliated with your insurance carrier. There could be additional payments from the patient’s pocket when receiving services from non-PCS preferred providers.
O
**1. Out-of-Network Provider: A hospital or physician that is not an arrangement with an insurance company that you are registered with. Care received outside the network may cost much more since patients will have to bear the entire cost of covered services and not all services may be included in the plan.**1. Out-of-Network Provider: A healthcare provider or facility that does not have a contract with your insurance plan. Out-of-network care may result in higher out-of-pocket costs for covered services, and not all services may be covered.
**2. Out-of-Pocket Costs: Those that you have to spend on covered services, including the cost for service, deductible, and coinsurances other than premium. What happens after the specified limit in the chosen plan is reimbursed is that the insurance plan fully assumes payment for the covered services.
P
**1. Pre-Existing Condition: A qualified health plan that offers the elements of the ACA such as the essential health benefits and protection to the consumer. QHPs are marketed through the Health Insurance Marketplace (Exchange) and are reimbursable by subsidies for premiums and cost sharing by income.
**2. Preferred Provider Organization (PPO): An independent body tasked with evaluating and enhancing the quality of health care that is given to Medicare consumers. QIOs aim at the maintenance of the standards of care and patient safety in health care services.
Q
**1. Qualified Health Plan (QHP): A qualified health plan that offers the elements of the ACA such as the essential health benefits and protection to the consumer. QHPs are marketed through the Health Insurance Marketplace (Exchange) and are reimbursable by subsidies for premiums and cost sharing by income.
**2. Quality Improvement Organization (QIO): An independent body tasked with evaluating and enhancing the quality of health care that is given to Medicare consumers. QIOs aim at the maintenance of the standards of care and patient safety in health care services.
R
**1. Rescission: Health insurance policy cancellation or termination right from the effective date, most commonly because of nondisclosure on one’s application. As a result of the ACA, health plans cannot cancel a policy’s coverage except in the scenario where the policyholder intentionally lied on an application.
**2. Rural Health Clinic (RHC): A facility that is situated in a health professional shortage area that delivers primary, ambulatory medical care to Medicare and Medicaid enrollee. RHCs also get better payment than others to guarantee receipt of health care in rural areas.
S
**1. Special Enrollment Period (SEP): A period outside the annual Open Enrollment Period when individuals may enroll in or make changes to their health insurance coverage due to qualifying life events, such as marriage, birth of a child, or loss of other coverage.
**2. Skilled Nursing Facility (SNF): A healthcare facility that provides skilled nursing care and rehabilitation services to patients recovering from illness, surgery, or injury. SNFs are covered by Medicare and may also accept private insurance.
T
**1. Telehealth: The use of telecommunications technology, such as video conferencing and remote monitoring, to provide healthcare services remotely. Telehealth allows patients to consult with healthcare providers, receive diagnoses, and access treatment without visiting a physical office.
**2. Tiered Network: A health insurance plan that categorizes healthcare providers into different tiers based on cost and quality. Members typically pay lower out-of-pocket costs for services provided by preferred (tier 1) providers and higher costs for non-preferred (tier 2 or 3) providers.
U
**1. Urgent Care Center: A facility that provides immediate medical treatment for non-life-threatening illnesses and injuries when primary care physicians are unavailable. Urgent care centers are an alternative to emergency rooms for timely care and are covered by most insurance plans.
**2. Underwriting: The process used by insurance companies to evaluate an applicant’s health history, risk factors, and other information to determine eligibility for coverage and premium rates.
V
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