Here are some key terms you should know:
Accountable Care Organization (ACO)
A network of physicians, hospitals and other healthcare professionals who coordinate services to improve the quality of patient care while also limiting unnecessary spending. A patient in an ACO may spend less time filling out medical history paperwork and have fewer repeated medical tests because the doctors and hospitals have adopted ways of sharing information and coordinating care.
Affordable Care Act (ACA)
The comprehensive healthcare reform law enacted in March 2010, seeks to increase the quality and affordability of health insurance, while also lowering the number of uninsured individuals through federal programs or state "exchanges." Among the law's key provisions, insurance companies are required to cover all applicants within minimum standards regardless of pre-existing conditions or sex; and to provide care for dependent children up to 26 years of age. The ACA also establishes certain mechanisms to increase competition, regulation and incentives to improve the delivery of healthcare. Click here to read the law. See also: Obamacare.
A doctor, hospital or other healthcare provider that has been approved by the patient’s insurance plan to provide medical services. Approved providers also are known as certified providers or participating providers.
The amount of time Medicare will cover inpatient care, which is treatment that requires a patient to be admitted to and stay in a hospital or skilled nursing facility. The benefit period ends when the patient has not received any inpatient care for 60 days in a row.
Services and supplies covered by a patient’s health insurance. What is and isn’t covered is decided on by the insurance provider.
CalAIM is a five-year initiative by the Department of Health Care Services (DHCS) to improve the quality of life and health outcomes of the Medi-Cal population by meeting people where they are in life, addressing social drivers of health and breaking down barriers in accessing care. CalAIM offers Medi-Cal members coordinated and equitable access to services that address their physical, behavioral, developmental, dental and long-term care needs. CalAIM is a population health approach that prioritizes prevention and whole-person care. It extends services and supports beyond hospitals and health care settings directly into California communities.
The initiative leverages Medi-Cal as a tool to help address many of the complex challenges facing California’s most vulnerable residents, including individuals experiencing homelessness, children with complex medical conditions, justice-involved populations with significant clinical needs and the aging population.
Centers for Medicare and Medicaid Services (CMS)
A request for payment that is submitted to a patient’s medical insurance provider when they receive covered health services.
A patient's share of the costs of a covered healthcare service, usually calculated as a percentage together with a deductible. For example, under a health plan that requires a deductible and 20 percent coinsurance, a $100 doctor's visit would require a patient who has met the deductible to pay $20, with the insurer paying the remaining $80.
Community-Based Adult Services (CBAS)
A Medi-Cal program that provides community-based medical and social services to older adults and adults with disabilities through small regional healthcare centers. The goals of the program are to allow for as much patient independence as possible and to prevent unnecessary long-term placement in a hospital or skilled nursing facility. CBAS replaced the Adult Day Health Care (ADHC) program in 2012.
Usually a fixed amount of money a patient has to pay each time when using a service covered by an insurance plan. Copays tend to be smaller dollar amounts, applied on a
The total amount and type of insurance carried.
A fixed dollar amount a patient must pay out-of-pocket before insurance will cover the remaining eligible expenses. Depending on the insurance plan, deductibles can range from zero to thousands of dollars. Generally, the higher the deductible, the lower the premium.
Department of Health Care Services (DHCS)
A child or other individual for whom a parent, relative or other person may claim a personal exemption tax deduction.
Essential Health Benefits
A set of benefits that must be covered in individual and small group plans as of 2014. Includes services within the following categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Exclusive Provider Organization (EPO) Plan
A more restrictive type of Preferred Provider Organization (PPO) plan under which patients must use providers from the specified network of physicians and hospitals for care to be covered by their insurance. Care received from non-network providers is not covered except in emergency situations.
List of prescription medications that are covered by a patient’s health insurance provider. This also is referred to as a preferred drug list.
Generic drugs have the same active ingredients as brand-name drugs and are considered by the government to be as safe and effective, but generally cost significantly less.
As used in connection with the Affordable Care Act, this is a group health plan that was created — or an individual health insurance policy that was purchased — on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act.
If a patient has a complaint regarding their Medicare service, such as problems reaching representatives by phone or poor quality of care, a grievance may be filed. This type of complaint does not include disagreements over coverage or payment decisions. For those, a patient must file an appeal.
A requirement that health plans must permit you to enroll regardless of health status, age, gender or other factors that might predict the use of health services.
A contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium.
Health Insurance Marketplace
HMO or Health Maintenance Organization Plan
A type of health insurance plan that limits coverage to doctors who are part of a specific network that has a contract with the HMO. In general, the plan won’t cover care from out-of-network providers except in an emergency. You usually will need a referral from your primary care provider to see a specialist. HMO plans usually focus on wellness and preventive care.
In-Home Support Services (IHSS)
A state-run program for patients eligible for Medi-Cal, which aims to help them remain safely in their own home. The program offers in-home non-medical services, such as housecleaning and personal care, as an alternative to placement in boarding care or skilled nursing facilities.
Healthcare providers, pharmacies and suppliers who are approved under the patient’s insurance plan to provide covered services and supplies.
Lifetime Reserve Days
Lifetime reserve days are additional days that Medicare will cover when a patient must be admitted to a hospital for more than 90 days in an individual benefit period. Medicare beneficiaries have 60 of these reserve days that can be used in their lifetime.
Long-Term Services and Supports (LTSS)
Long-Term Services and Supports include medical and non-medical care for patients who are unable to perform basic daily activities, such as dressing or bathing, on their own. These can be home- or community-based services, or be provided in assisted living or skilled nursing facilities. Medicare and most health insurance plans do not pay for long-term care. Medi-Cal Long-Term Supports and Services (MLTSS) are coordinated through the Medi-Cal managed care health plans.
State- and federally sponsored healthcare coverage program that serves low-income individuals and families.
California's Medicaid program, which pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is administered by the state Department of Health Care Services and the federal Centers for Medicare and Medicaid Services.
National health insurance program for people who are 65 or older, younger than 65 with certain disabilities, or any age with end-stage renal disease.
Medicare Part A
Hospital insurance, which covers inpatient services such as hospital stays and skilled nursing facilities. Part A also covers hospice and palliative care.
Medicare Part B
Medical insurance that covers physician visits, laboratory and home-health services and other outpatient care, including some medical supplies and equipment.
Medicare Advantage Plan (Part C)
Provides patients the option of obtaining their Medicare Part A and B coverage from a private insurance provider that is approved by Medicare. These plans often also include Medicare Part D prescription drug coverage. Plan options include: HMO, PPO, Private Fee-for-Service (PFFS), Special Needs Plans (SNP) and Medicare Medical Savings Account (MSA).
Medicare Prescription Drug Plan (Part D)
Prescription drug insurance offered by private companies that are approved by Medicare.
Medicare Supplement Insurance (Medigap) Policy
A type of private insurance that pays some of Medicare’s out-of-pocket costs, such as coinsurance and deductibles. Patients must have Medicare Part A and Part B in order to buy a Medigap policy. However, people with Medicare Advantage Plans (Part C) do not need and cannot use Medigap policies.
Medical underwriting is a process used by health insurance companies where they review your age, sex and health history to decide whether to offer individuals coverage, at what price and with what exclusions and limits. Each company has its own guidelines, and prior to Jan. 1, 2014, may deny coverage or charge higher premiums based on this risk analysis. As of Jan. 1, 2014, individual health insurance providers were no longer be legally permitted to refuse coverage or charge higher premiums due to such analysis.
Multipurpose Senior Services Program (MSSP)
The facilities, providers and suppliers with which a health insurer or plan contracts to provide healthcare services.
An informal term for the Affordable Care Act, so named for U.S. President Barack Obama, who promoted it.
Open Enrollment Period
The period of time during which eligible individuals can enroll in a health plan. Individuals also may qualify for special enrollment periods as a result of certain major life changes, such as job loss, marriage or birth of a child.
Healthcare providers who do not contract with that patient's health insurance or plan. Out-of-network copayments and coinsurance usually are more expensive than those for in-network providers.
Expenses for medical care that are not reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services. They also include costs for services that are not covered by the insurance plan.
POS or Point-of-Service Plan
A type of health insurance plan where you pay less if you receive care from healthcare providers who are part of the plan’s network. POS plans generally require a referral from your primary care provider to see a specialist.
PPO or Preferred Provider Organization
A type of health insurance plan that contracts with doctors and hospitals to create a network of participating healthcare providers. You can receive care from doctors and hospitals outside of the network for an additional cost.
Any physical or mental medical condition that you have before enrolling in a new health insurance policy.
The amount that you or your employer pays to your health insurance company for coverage.
Preventive Care or Preventive Services
Routine healthcare that includes screenings, check-ups and patient counseling to prevent illnesses, disease or other health problems.
Primary Care Provider (PCP)
A primary care provider provides most of a patient’s health services, and can be a physician or nurse practitioner. A patient’s PCP is responsible for providing referrals to other services when necessary.
Program of All-Inclusive Care for the Elderly (PACE)
Referred to as CalPACE in California, this is a Medi-Cal program that coordinates heathcare services for adults aged 55 or older who would otherwise be unable to safely live on their own. The program uses a team approach to provide the extra support patients need to remain in their own homes instead of a skilled nursing facility.
A referral is written permission from the patient’s primary care provider allowing the patient to see a specialist or receive a medical service, often for a specific medical condition. Many insurance plans will only cover the cost of this specialized care if the patient has received a referral.
Rehabilitation services work to help patients regain or improve their daily skills and functions after they have had an illness or injury. This may include physical or occupational therapy, psychiatric rehabilitation, or other services.
Financial assistance provided by the government to eligible individuals and families to help them pay for health insurance coverage.
Summary of Benefits or Coverage
An easy-to-read summary provided by a health plan.
Tier 2 Facility
An in-network facility that requires a higher level of copay from the insured patient compared to a Tier 1 facility.
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