≡ Menu



Approved provider = Approved providers are health care providers that the insurance company has a contract with.  Approved providers charge the insurance company less money in exchange for more customers.  You might also see them referred to as “in-network” providers.

Capitation = A payment method for health care services.  The physician, hospital, or other health care provider is paid a fixed fee for each participant in a plan (often referred to as “per-member-per-month” rate), regardless of the number of services provided.

  • Plan participants get unlimited access to specified medical services, whether they take advantage of them or not.
  • From the physician’s perspective, the same fee is received whether they treat an enrollee many times or not at all.

Coinsurance = The stated percentage of medical expenses an insured person must pay.

  • If the plan has a deductible, coinsurance kicks in after the deductible is paid.
  • The insurance company reimburses the health care provider for the remaining costs of the allowable charges; the individual could be held responsible for any charges in excess of what the insurer determines to be “usual, customary and reasonable”.
  • Coinsurance rates may differ depending on whether services are received from an approved provider or not.

Copayment = The fixed dollar amount an insured person must pay when a medical service is received.

  • The insurance company is responsible for the rest of the reimbursement.
  • There may be different co-payments for different services.
  • Some plans require that a deductible first be met for some services before a co-payment applies.

Deductible = A fixed dollar amount for individuals or families during the insurance policy’s benefit period – usually a year – that must be paid before the policy will pay for medical services.

  • Some plans may have separate deductibles for specific services, e.g. a hospitalization deductible per admission.
  • Deductibles may differ depending on whether services are received from an approved provider.

First dollar coverage =
Insurance coverages or benefits that pay the entire covered amount without subtraction of or use of a deductible.

Health care = A system of delivery for medical services and products in the course of disease prevention or treatment and for the promotion of physical and mental well-being.

Health care provider = Any hospital, physician, lab, pharmacy, medical group or clinic that provides a medical service or product.

Health coverage = The protection against medical expenses paid for by health insurance.

Health insurance = Insurance that pays for all or part of the medical expenses incurred through illness and general health promotion; paid for by the insured and by the spread of risk throughout the pool of those covered.

HIPPA: Health Insurance Portability and Accountability Act of 1996 = Enacted by the federal government to improve portability and continuity of health insurance coverage, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes.

  • HIPAA Title I deals with protecting health insurance coverage for people who lose or change jobs.
  • HIPAA Title II includes a section that deals with the standardization of healthcare-related information systems. In the information technology industries, this section is what most people mean when they refer to HIPAA.

Hospitalist = A physician that only treats hospitalized patients.

Managed care provisions, features allowing health plans to manage the cost, use and quality of health care services received by group members:

  • Preadmission certification : A required authorization for hospital admission given by a defined health care provider to a group member prior to their hospitalization. Failure to obtain a preadmission certification in non-emergency situations reduces or eliminates the insurance company’s obligation to pay for services rendered.
  • Utilization review: The process of reviewing the appropriateness and quality of care provided to patients. Utilization review may take place before, during, or after the services are rendered.
  • Preadmission testing: A requirement designed to encourage patients to obtain necessary diagnostic services on an outpatient basis prior to non-emergency hospital admission. The testing is designed to reduce the length of a hospital stay.
  • Non-emergency weekend admission restriction: A requirement that imposes limits on reimbursement to patients for non-emergency weekend hospital admissions.
  • Second surgical opinion: A cost-management strategy that encourages or requires patients to obtain the opinion of another doctor after a physician has recommended that a non-emergency or elective surgery be performed. Programs may be voluntary or mandatory with reimbursement being reduced or denied if the patient does not obtain the second opinion. Plans usually require that such opinions be obtained from board-certified specialists with no personal or financial interest in the outcome.

Medicaid = A state and federal program providing some health care benefits for people who meet minimum income limits and are defined under State eligibility requirements that may include age, pregnancy, disability, blindness or deafness.

Medicare = A federal program that provides health benefits for people who qualify: usually those over 65 and the disabled.

  • Part A covers hospitalization, and is funded by the government.
  • Part B, also called Supplemental Medical Insurance, covers basic medical expenses, and is paid jointly by the government and the insured.
  • Part D is a prescription plan that allows subscribers to purchase drug coverage from private insurance companies, without federal supervision; available to those on Medicare and mandated for over 6 million low-income elderly Medicaid subscribers.

Out-of-Pocket Expenses = Refers to money paid by the health care consumer that is not reimbursed by health insurance.

Physician-Hospital Organization (PHO) = Alliances between physicians and hospitals to help providers attain market share, improve bargaining power, and reduce administrative costs. These entities sell their services to managed care organizations or directly to employers.

Portability = In health care, refers to health coverage or health account funds that can be taken with the consumer to another job or used when unemployed.

Premium = Regular fees paid for medical coverage for a defined benefit period. Premiums can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor.

Primary Care Physician (PCP) = A physician who serves as a group member’s primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services, and may authorize and coordinate referrals to specialists and hospitals if required to do so by the plan.

Single-Payer = A system of health care characterized by universal (all people) and comprehensive (all services) coverage. Medicare is a kind of single-payer system for those over 65 and the disabled.

  • The government pays for care that is delivered in the private (mostly not-for-profit) sector.
  • Doctors are in private practice and are paid from government funds.
  • The government does not own or manage medical practices or hospitals.

Socialized medicine = A health care system in which medical providers are government employees and treatment centers are government-owned /managed.

Workmen’s Compensation = A state insurance program that provides money for workers injured on the job and for the dependents of workers killed on the job; first created on a state level in 1902; not legalized by the Federal Government until the Social Security Act of 1935.

Info mainly from http://stats.bls.gov/ncs/ebs/sp/healthterms.pdf.

Additional information from: