Navigating the healthcare industry can be tricky. Use this glossary to better understand your health insurance, know where to go for care and learn about other important health information.
ACA (Affordable Care Act) – A healthcare reform passed into law in March of 2010, also known as “Obamacare”, designed to give more Americans access to affordable health insurance, expand the Medicaid program and support innovative methods to lower the cost of care.
ACO (Accountable Care Organization) – ACOs are groups of hospitals, physicians and other healthcare providers that join together to better coordinate care for their Medicare patients. Payments in an ACO are tied to quality metrics and the cost of care.
Ambulatory surgical center – Also called same-day surgery centers or outpatient surgical centers. These facilities don’t have the overhead of a large hospital system, which means prices are cheaper.
Annual Wellness Visit – This is a yearly appointment covered by insurers that goes over your medical history and plan of preventive care.
Brand-name drugs – A drug that has a trade name and is protected by a patent, which means it can be produced and sold only by the company that owns the patent. Brand-name drugs are often more costly than generic drugs.
Care coordination – The organization of all aspects of patient care among multiple parties in the patient’s care team. Coordinated care allows for a more appropriate delivery of healthcare services.
cHIE (Utah Clinical Health Information Exchange) – A program that allows the exchange of healthcare information between providers and healthcare organizations in Utah. This promotes more comprehensive and coordinated care.
CHIP (Children’s Health Insurance Program) – Funded both by states and the federal government, CHIP offers affordable healthcare to eligible children who do not qualify for Medicaid, but are unable receive private insurance.
Chronic disease management – Oversight and education by healthcare professionals to help patients better understand their diseases and live successfully with them through healthy lifestyle choices.
CMS (Centers for Medicare and Medicaid Services) – A federal agency under the Department of Health and Human Services that manages Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the Health Insurance Marketplace.
Comorbidity – The simultaneous presence of two or more chronic diseases in a patient, e.g., depression and diabetes.
Copayment – A fixed amount a patient pays for a covered healthcare service after you have paid the deductible required by your insurance provider.
Cost – For providers, cost refers to the expense incurred in order to provide healthcare. For payers, cost refers to the amount they pay to a provider for services. For patients, cost refers to the out-of-pocket amount paid for health services.
Deductible – The amount you pay for a covered healthcare service before your insurance starts to cover the costs. After you have paid your deductible, you will usually only pay a copay for covered service and your insurance pays the rest.
EHR (Electronic Health Record) – A digital version of a patient’s individual health record. These include all aspects of a patient’s health, rather than just the record for one individual practice or provider. EHRs are designed to be shared between providers for better coordination of care.
Fee-for-Service – A payment model where providers are paid for the services offered such as tests, check-ups and procedures.
Fee-for-Value – A payment model where providers are paid for the quality of services offered, not the quantity of services offered. Payments are made when the provider meets or exceeds the agreed upon quality standards.
Health Insurance Marketplace – A service operated by the federal government that assists individuals, families and small businesses in shopping for and enrolling in health insurance.
HIPAA – An acronym that stands for the Health Insurance Portability and Accountability Act. This is a law designed to provide patient privacy and protect a patient’s medical records and other health information that’s shared between health plans, doctors, hospitals, etc.
Hospital readmission – A hospital readmission is a situation in which a patient who has been discharged from a hospital is admitted again within a certain time frame.
Inpatient procedure – Any procedure requiring a patient to stay at least one night at a hospital for care or observation once the procedure is complete.
In-network – A term that refers to providers or healthcare facilities that are part of a health insurance plan’s network of providers with which it has negotiated a discount. In-network providers can offer a lower cost than out-of-network providers.
Life expectancy – The average time frame a person is expected to live.
Long-term care – A continuum of care and services to a person with chronic illnesses that affect their ability to live on their own.
Medicaid – A joint federally and state-funded program that gives financial assistance to those who are low-income or “medically needy”.
Medicare – A federal insurance program for individuals who are 65 and older, certain younger people with disabilities, and people with end-stage renal disease.
Medically necessary – Health services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms. The service must meet accepted standards of medicine.
Merit-Based Incentive Payment System (MIPS) – A program that determines payment adjustments for providers based on performance. Physicians who are eligible may receive bonus payments, payment penalties, or no payment adjustment at all. Performance measurement for this program began January 2017.
Medicare Shared Savings Program (MSSP) – A program established by Congress to fulfill a part of the Affordable Care Act. It encourages increasing the quality of care while reducing unnecessary costs. Participants of the MSSP have the opportunity to share in savings when they meet quality and cost savings goals.
Network – The facilities, providers and suppliers that your health insurance company has contracted with.
Next Generation ACO Model – An initiative reserved for ACOs that have demonstrated an ability to provide high-quality, low-cost care. Healthcare providers who participate in the model are at greater financial risk and are penalized if they are unable to improve their patients’ health outcomes while also reducing their costs.
Obama Care – A common term for the comprehensive healthcare reform law passed in March 2010, the Affordable Care Act (ACA).
Open enrollment – A yearly period in which patients can enroll in a health insurance plan. You can only enroll in a health plan outside of this time period if you have a qualifying life event, such as marriage or loss of coverage.
Out-of-pocket costs – Your expenses for care that are not covered by your health insurance. This can include copays, deductibles and the cost of other services that aren’t covered by insurance.
Outpatient services – Medical tests or procedures that can be performed without an overnight hospital stay. Many tests and procedures can be done in less than a few hours.
Patient-Centered Care – Providing individualized care to patients that is respectful of the patient’s preferences, needs and values. This also allows patients to partner with their physicians and be involved in their healthcare decisions.
Patient portal – A secure website or app that gives patients access to their health information.
Payer – Refers to entities other than the patient that finance or reimburse the cost of certain medical expenses. Payers can include insurance companies, third-party payers, employers, or unions.
Personal health information (PHI) – Also referred to as protected health information, PHI includes demographic and insurance information, medical history and other data that a provider can use to identify a patient.
Pre-existing condition – A health problem like asthma or diabetes that you have before starting a new health insurance plan. Insurance companies cannot refuse to cover you or charge you more based on any pre-existing conditions you have.
Premium – The amount you pay for your health insurance plan every month. This does not include copays, deductibles and other out-of-pocket costs.
Preventive care – Routine health care that includes checkups, screenings, counseling and more to prevent disease and other conditions.
Primary care provider – A physician or other healthcare provider that treats you for a range of illnesses and coordinates your care with specialists.
Quality – The degree to which health care is safe, patient-centered, effective, timely and increases the likelihood of certain desired health outcomes. These quality metrics include patient experience, care coordination, patient safety, preventive health and managing at-risk populations.
Qualifying life event – A significant change in your life like marriage, childbirth or losing health coverage that can make you eligible for a special enrollment period. This allows you to enroll in health insurance outside the open enrollment period.
Referral – A written order from your primary care physician for you to see a specialist or get certain medical services.
Risk Adjustment – A tool used to level the measurement of patient outcomes by adjusting the risk of certain patients. The perceived risk can influence the amount of money a patient’s care is expected to cost and helps provide more accurate data when comparing performances between providers.
Shared Savings – In a shared savings program, providers are evaluated against certain measures including quality, clinical processes and patient outcomes. These programs may require providers to share in the financial risk if measures aren’t met but allow for financial bonuses when successful.
Specialist – A healthcare provider that focuses on a specific area of medicine such as a cardiologist or neurologist.
Special enrollment – A period in which a qualifying life event allows you to enroll in health insurance outside the regular enrollment period.
Urgent care – A facility for urgent medical attention that does not require the immediacy of an emergency room. These facilities can treat a variety of conditions and often cost less than a trip to the ER.
VBC (Value-Based Care) – A system of care that focuses on the quality of services provided to patients rather than just the quantity of services. Organizations (like Revere Health) work to reduce costs while simultaneously improving the quality of care.