Whether you have insurance or are one of the millions of people who aren't covered, you should know many of these terms to become a more informed consumer.
Many of these terms are close to each other (and others that aren't listed) and a difference in wording can mean totally different things.
A-D
Adult Living Community: A housing and living arrangement that provides the shelter of a home along with additional services, ranging from housekeeping to health care services. Adult living communities are also known as retirement communities, continuing care facilities, and assisted living facilities.
Advance Directive: Most doctors' offices ask if you have an Advance Directive prior to any medical procedure performed by them. It tells how you would like future medical care to be carried out if you're unable to make those decisions yourself. Sometimes called an Advance Medical Directive.
American Medical Association (AMA): The nationwide association for doctors.
American Disabilities Act (ADA): A federal law that requires employers with 25 or more employees not to discriminate against any person with a "qualified disability" who make perform the necessary functions of their job.
Beneficiary: Person you designate to receive the payont of an insurance policy.
Chronic Disease: A disease meeting one or more of the following conditions: 1) it's permanent, 2) it's caused by nonreversible pathological alternation, 3) the patient requires special training for rehabilitation, or requires a long period of supervision, observation or care.
Co-Insurance: A payment for insurance costs where you pay a portion or percentage of the total bill rather than a fixed cost.
Co-ayment: A cost-sharing arrangement under which the insurance company insures only part of the potential loss, and the policy owners pay the other part.
Custodial Care: Level of health or medical care given to meet daily personal needs, such as dressing, bathing, getting out of bed, etc. Although custodial care does not need to be provided by trained health care professionals, it must be administered under a physician's order.
Deductible: A specified amount of expense to be paid by the insured before a health insurance policy starts paying benefits.
Do Not Resuscitate (DNR): A type of Advance Directive (see above) that may request extraordinary life-saving measures not be used to save your life.
Durable Power of Attorney: A written document that creates a power of attorney authorizing another person (the agent, attorney-in-fact, or proxy) to make decisions or act on your behalf to manage financial affairs. The durable power of attorney survives the incapacity of the principal.
Durable Power of Attorney for Health Care: A written document allowing you (the principal), when competent, to authorize one or more individuals (the agents) to make decisions about medical treatment and care in the event of your inability to make decisions about your care.
E-H
Electrocardiogram (EKG): A measure that shows the electrical impulses of your heart and creates a graph of the impulses.
Electroencephalograph (EEG): This machine measures brain activity and creates a printable graph of the information.
Employee Retirement Income Security Act (ERISA): A federal law the covers employer-sponsored health and welfare benefits plans. It ensures employees receive, or have available, a Summary Plan Document of all benefits available to them and details about the plan in plain English.
Explanation of Benefits (EOB): The statement you receive after a visit to a medical professional that tells you and the provider what was covered by the insurance company.
Explanation of Medicare Benefits (EOMB): An explanation of Medicare benefits that were paid after a visit to a medical professional. This is submtted to the insurance company.
Family Medical Leave Act (FMLA): A federal law that requires employers (public and private) with 50 or more employees to allow employees to take leave to take care of ill family members, including the employee, and to return to a substantially similar position after the leave.
False Claims Act (FCA): A federal law that imposes fines of $5,000 to $10,000 and potentially other penalties for knowingly submitting a false or fraudulent claim for payment for services provided by government agency. For example, if a doctor knowingly charges a person on Medicare or Medicaid too much for a service. Since Medicare and Medicaid are both government programs, this would be in violations of the False Claims Act.
Fee-For-Service: A payment system where physicians, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment.
Gatekeeper: A medical professional the oversee all of a person's care, and coordinates all aspects of that care.
Health Insurance Portability and Accountability Act (HIPAA): The laws surrounding the security of patient health data and information, and the confidentiality provisions of the Patient Safety Rule. This applies to any organization or company working with patient data, including pharmacies, medical vendors, and transporting your own medical information from one medical office to another.
Health Maintenance Organization (HMO): A managed care plan that both finances health care services for its subscribers on a prepayment basis and organizes and provides health care services directly through its own employed or contracted health care providers.
Home Health Care: Skilled or unskilled care provided in an individual's home, usually on a part-time basis.
Hospice Care: Care that reduces the pain and suffering of terminally ill patients. This could be in the home or at a facility that provides this care.
I-N
Informed Consent: A full disclosure to the patient about the nature and consequences of proposed medical tests and treatments and obtaining the patient's consent. Informed consent requires disclosure of the diagnosis, potential risks and benefits of the proposed medical treatment or procedure, and the benefits and limitations of available treatment alternatives. This must be verbal as well as a signed document.
Living Will: A type of advance directive allowing individuals, while competent, to express whether or not they wish to receive or decline/ continue or discontinue medical treatment and procedures when they become incompetent, and either terminally ill or in a persistent vegetative state.
Long-Term Care: Refers to the broad range of medical and personal services for individuals who need assistance with daily activities for an extended period of time.
Long-Term Care Insurance: An insurance policy designed to provide coverage for long-term care expenses that are not covered by general insurance plans or by government programs.
Medical Savings Account (MSA): A trust created to pay qualified medical expenses of the person for whom the trust was created. MSAs may be available to small business employees and self-employed people insured under a high-deductible health plan. Eligible employees and their employers contribute certain amounts to the MSA and receive favorable tax treatment. Account balances can be used to cover qualified medical expenses.
Medical Malpractice: When a medical procedure that was incorrect through negligence causes an injury or death. Proving malpractice includes determining what the standard of care and what any reasonable medical professional would do.
Nursing Home: A type of long-term care facility providing professional medical care on a 24-hour basis. Nursing homes provide different levels of care, including skilled, intermediate and custodial care.
Nurse Practitioner (NP): A type of nurse who has additional education at the graduate level. A nurse practitioner may perform some of the same duties as a doctor.
O-S
Occupational Safety and Health Administration (OSHA): A division of the Department of Labor (DOL) responsible for setting safety and standards in the workplace. This could include, but isn't limited to, breaks, the need for protective gear, and more.
Out-Of-Pocket Expenses or Costs: Costs that you, the insured pay rather than the insureance company.
Out of Network A doctor or medical office that is outside of a standard HMO preferred provider list.
Outpatient: A person who receives care outside of being admitted to a hospital.
Pre-Authorization: Getting approval from your insurance company to make sure the procedure is covered by insurance based on the planned treatment.
Preferred Provider Organization (PPO): A health care system that contracts with medical providers to provide services at discounted fees to members. It may not be mandatory to use these providers, but you may pay only a co-pay or co-insurance rather than covering the full bill.
Premium: The amount you pay for the insurance plan selected based on the coverage needed.
Primary Care Physician (PCP): The physician you designate to help make medical decisions. You may need a referral from this doctor to see selected specialists.
Provider Sponsored Organization (PSO): PSOs are similar to PPOs except that they are operated by a group of physicians and hospitals.
Rider: Any supplemental agreement that's made a part of an insurance policy modifying the conditions of the policy by expanding or restricting its benefits or excluding certain conditions from coverage.
Secondary Care: The care you receive after talking to a primary care physician such as a specialist.
Social Security Disability Insurance (SSDI): Laws surrounding the availability of health coverage for people too disabled to work, but not yet eligible for Medicare.
T-Z
Title XVII: The federal act creating Medicare. This covers retirees and some disabled people.
Title XIX: The federal act creating Medicaid. A federal-and-state-funded program for medical and related services for low-income people.
Veterans Administration (VA): Federal agency that pays for the medical care and services of former military people.
Workers' Compensation: Laws that surround providing medical benefits and compensation for injuries obtained on the job.