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Insurance Glossary: Definitions & Meanings to Patients: L-Z

Updated: Dec 4, 2023

By Martine G. Brousse

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator @ AdvimedPro


November 29, 2023


Watch the video part 1: https://youtu.be/4veoExqVz0I

Watch the video part 2: https://youtu.be/uV5TkiKhF7s


Do you know what all the basic terms your insurance mean, and how they affect you financially?

Let's go over the major definitions and their consequences to patients.


Please note: check out my more in-depth blogs relating to specific items listed here.


LONG-TERM CARE

  • Medical and non-medical care provided to those unable to perform basic activities of daily living such as dressing or bathing. Usually not a payable benefit by insurances.

MARKETPLACE

  • “Health Insurance Marketplace®,” is the enrollment service for medical insurance created by the Affordable Care Act in 2010 ("Obamacare")

  • Some States run their own exchanges, with the federal government for those that don't. HealthCare.gov

MEDICAID

  • program that provides free or low-cost health coverage to (some) low-income people

  • Medicaid benefits, and program names, vary between states.

MEDICAL GROUP

  • the organization of medical professionals - generally located in the same facility - who provide a range of health care services.

  • for HMO plans, it is the entity where you are assigned to seek care from

MEDICALLY NECESSARY

  • Medical services or supplies used to diagnose or treat an illness, injury, condition, disease or its symptoms

  • It means that these services must meet accepted standards of medicine, and/or FDA-approved (Rx, devices)

MEDICARE

  • It is the federal health insurance program for people 65 and older and younger people with disabilities or end-stage renal disease.

  • "Original" Medicare is divided in Part A (inpatient, hospital care), Part B (physician and outpatient services) and Part D (Pharmacy). Administered by the federal Medicare Administration.

  • Medicare "Advantage" is part C: all parts are administered under one plan, by a commercial insurer

MEMBER

  • someone who is eligible under a plan, and entitled to receive benefits under the terms of its policy

  • The list of facilities, providers and suppliers your health insurer has contracted with to provide health care services at a reduced cost

  • "In Network" means the provider and service they render to you will be covered at the highest rate, and therefore lowest cost to you

  • "Out of network" means the provider and services they render to you might be covered, and if so, at the lowest rate, and with the highest cost to you (sometimes the whole cost)

  • Usually the portion of a provider's bill that is not covered or payable by your plan, and usually for out-of-network services

  • An exclusion listed in your policy, because it is experimental, not medically necessary or not payable due to your employer's decision

OBSERVATION

  • Length of time in a facility or hospital without being admitted, while the Dr decides whether to discharge or admit you

  • Services rendered during that time are considered Outpatient even if > 24 hours

  • Falls under Part B under Medicare NOT part A

OPEN ENROLLMENT

  • The yearly period during which you may enroll in a new plan, or change your current plan to a different one

  • Costs that include include deductibles, coinsurance, and copayments as well as full price of services that are not covered or payable under your plan.

  • There is usually no limit on the total out of pocket as "not covered" costs do not get credited toward your yearly Share of cost (see below)

OUTPATIENT

  • A stay or visit to a facility such as a hospital, which last less than 24 hours or which result in your discharge without you having been admitted

PLAN / POLICY

  • It is the agreement between a member and an insurance company, where medical services are covered/paid by the insurance in exchange for payment of premiums.

  • The policy (list of what is covered, obligations on both sides and exclusions) and plans differ greatly

  • The type of plan (PPO, HMO, POS, Medicare etc) will determine how benefits are applied, how care is administered to you and what your ultimate cost will be.

  • Also called: "prior approval", "referral" or "pre-certification"

  • It is the decision issued by your insurance that an upcoming service/Rx/treatment/procedure is medically necessary and usually guaranteeing its payment

  • Inpatient or expensive treatments/procedures usually require one, but emergency service do not.

PRE-EXISTING

  • a medical condition that started or was diagnosed before you became eligible with your insurance plan

  • Since 2010, this can no longer be a valid reason to terminate your coverage, deny payment of a claim, increase your premiums or prevent your enrollment (except in specific cases such as short-term travel or emergency insurance)

  • "Preferred" = "In Network" = the provider of service has a contract with your insurance plan to provide services at a lower cost in exchange for certain advantages

  • "Non-preferred" = "out of network" = the provider of service can usually bill you for the full amount while your insurance pays little if anything at all because there is no agreement or contract.

PREMIUM

  • the monthly cost of insurance coverage which you, your employer or both of you pay to be entitled to a policy and coverage under its terms

  • It is the routine health care to prevent illnesses, disease, or other health problems.

  • It includes (but is not limited to)

    1. Screenings (colonoscopies, mammogram, mental health issues, STDs, blood pressure...)

    2. Yearly check-ups and well-care visits

    3. Patient counseling (tobacco or alcohol cessation, nutrition)

    4. Vaccinations

  • Under the ACA ("Obamacare"), these services are free to members

PRIMARY CARE PHYSICIAN (PCP)

  • He/She is the equivalent of the old "family Dr", your first contact for providing basic medical services, treating most problems, coordinating care with other physicians, referring you to specialists as needed, and often keeping all medical records to facilitate access and minimize duplication of services and errors.

  • HMO members must use their PCP first, as the PCP will issue referrals for visits to specialists or to order care they cannot provide

PROVIDER

  • A licensed, specially trained professional or organization, that renders medical services or care

  • a licensed facility where medical services are rendered

QLE (QUALIFYING LIFE EVENT)

  • It is an event which makes you suddenly eligible to obtain insurance coverage when not within an open enrollment period.

  • They include:

    1. loss of coverage (loss of a job, turning 26 and losing your parents' coverage, losing student insurance...)

    2. Household change: divorce, marriage, new baby, death

    3. Change of residence: relocation, graduating from school...)

    4. Other circumstances: eligible for Medicare, losing Medicaid coverage...

  • the sum of $ that you must pay yearly, before your insurance pays 100% of the allowances

  • usually: deductible + co-insurance amount + visit co-pays

SPECIALIST

  • a medical provider whose practice and expertise area limited to a certain body system, disease or branch of medicine

  • includes: anesthesiologists, internists, oncologist, dermatologists, pediatricians, surgeons, gynecologists, pediatricians, emergency room physicians etc

  • Higher cost:

a. Higher visit/office co-pay

b. Higher billed amount

c. HMO plans require referral from PCP


SUBSCRIBER

  • The person who is the policyholder, or main person named on the policy

  • Others on the policy are "dependents": spouse, children...

  • Also known as UCR ("Usual, customary and reasonable"), it is the amount your insurance has deemed the fair price of a medical service or item

  • UCR for In Network are higher, as it is the main incentive for providers to contract with an insurance. UCR for Out Of Network providers are usually very low, and often cover less than cost for providers

  • The UCR is often called "allowance" on Explanations of Benefits, and are the basis for calculation of insurance payments and patient liability

URGENT CARE

  • It is the diagnosis and treatment for an illness, injury, symptom or condition serious enough that a reasonable person would seek medical care right away, but not so severe that it requires a visit to an emergency room.

  • Urgent care centers are found in many neighborhoods, and can refer you to the nearest ER of unable to provide the level of care your emergency situation demands

UTILIZATION MANAGEMENT

  • The insurance dept or administrator that issues authorizations, determines medical necessity, organizes hospital discharges and reviews treatment plans

  • The RNs, case managers and medical directors who decide whether you’ll get that treatment or procedure... or not.

VISION

  • Care that relates to the eyes, such as exams, contacts and glasses

  • Usually excluded from your medical coverage

  • Usually provided by a separate policy

  • Vision screenings for children (lazy eyes, crossed eyes) are covered as Preventive Care under your medical policy. Treatment may not.



Martine Brousse was a long-time Billing Manager for Physicians before switching to the

Insurance glossary L-Z: Definitions and meaning
Insurance glossary L-Z: Definitions and meaning

side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.


(424) 999 4705 - F (424) 226 1330

@martine brousse 2023 @ the medical bill whisperer 2023



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