Health Insurance Terminology Part II

In order for you to better understand health insurance terminology I have continued to define many of the terms found on health insurance policies.

Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.

Pre-existing Condition
A health problem that existed before the date your health insurance became effective.

Primary Care Physician PCP
This is often a family physician or internist, but some women use their gynecologist. The A PCP monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. In many health insurance plans, care by specialists is only paid for if you are referred by your primary care doctor. An HMO or a POS plan will provide you with a list of doctors from which you will choose your primary care doctor (usually a family physician, internists, obstetrician-gynecologist, or pediatrician). This could mean you might have to choose a new primary care doctor if your current one does not belong to the plan. PPOs allow members to use primary care doctors outside the PPO network (at a higher cost). Indemnity plans allow any doctor to be used.

Case Management
This is a process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. It is a utilization management technique that addresses the medical necessity of care as well as alternative treatments or solutions, especially when the patient is likely to require very expensive treatment case management.

Emergency Care
Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.

Formulary Drugs
These are medications that generally have a lower copay. Formulary drugs are medications that have been reviewed by a team of expert pharmacists and physicians and have been identified as safe and effective but lower in cost.

Generic medications
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."

Non-Formulary Drugs
Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.

Generic Substitution
The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary. In most cases, generic substitution can be performed without physician approval.

Gatekeeper
This is a term used to describe the primary care physician's role in a managed care plan; The PCP’s role is to authorize all services delivered to the insured by other physicians or health care providers. Thus, whenever you wish to see a physician other than your primary care physician, you must first obtain his or her permission (via a referral).

Health Care Provider
This is anyone who delivers medical or health-related care such as a doctor, hospital, laboratory, or nurse.

Home Health Care
Skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. Some insurance plans don't provide this kind of coverage, or provide it only for a limited amount of time.

Mental Health - inpatient
Inpatient mental health care is generally reserved for severe mental health problems, such a schizophrenia and severe depression. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.

Outpatient Surgery
This is surgery that does not involve an overnight stay in a hospital

Skilled Nursing
A level of care for patients who need intensive, 24-hour nursing supervision. This can take place in the home or in skilled nursing facilities, which offer services such as rehabilitation and specialized nutrition.

Urgent Care
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.

Well Baby Care
The goals of well baby care are 1) to immunize; 2) to provide parents with reassurance and counseling on safety, nutrition and behavioral problems; and 3) to identify and treat physical and developmental problems.

Ambulatory Care Facility ACF
This is a medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility.

Ancillary Services
Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.

Appropriate Care
A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.

Behavioral Healthcare.
The provision of mental health and substance abuse services.

Capitation
This is a method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided. For example one hospital may receive S10.000/yr for 500 people to get chest x-rays rather than the 451 chest x-rays that cost $10, 125.

Disease Management
A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition.

Drug Utilization Review DUR
A review program that evaluates whether drugs are being used safely, effectively, and appropriately.