UNDERSTANDING THE LANGUAGE OF HEALTH CARE REFORM
Rhonda M. Johnson, M.D., MPH
Medical Director,Health Equity & Quality Services
New documents known as the Summary of Benefits and Coverage and uniform glossary have been issued by the federal government to help consumers understand and compare their coverage options.
To help prepare for health care reform, let’s review some of the common terms that are described by the federal government in these documents. This is just a partial list. For the complete list and for more information, please go to the website: http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf
- Allowed Amount: Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference.
- Appeal: A request for your health insurer or plan to review a decision or a grievance again.
- Co-insurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service.
- Co-payment: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
- Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. The deductible may not apply to all services.
- Durable Medical Equipment (DME): Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
- Emergency Medical Condition: An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
- Emergency Room Care: Emergency services you get in an emergency room.
- Emergency Services: Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
- Excluded Services: Health care services that your health insurance or plan doesn’t pay for or cover.
- Health Insurance: A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
- Home Health Care: Health care services a person receives at home.
- Medically Necessary: Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
- Network: The facilities, providers and suppliers with whom your health insurer or plan has contracted to provide health care services.
- Plan: A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
- Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
- Primary Care Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
- Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
- Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.
Many of the new provisions under health care reform will make the purchase and use of health insurance more affordable for many more individuals and families.
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