Glossary
Commonly Used Health Care Terms
This glossary was created by the Minnesota Health Information Clearinghouse, Minnesota Department of Health. The definitions can help you understand health care terms commonly used in Minnesota.
Acute care
Medical care for an episode of injury or an illness.
Allied health care providers
Specially trained health care professionals other than physicians. Allied
health care providers include optometrists, chiropractors, podiatrists, and
nurse practitioners.
Allowable charges
The specific dollar amount of a medical bill that Medicare, Medicaid, or your health
plan will pay.
Ambulatory care
Medical care for an injury or an illness that can be provided on a outpatient
basis.
Ancillary services
Special services ordered by your physician such as laboratory, radiology,
durable medical equipment, and pharmacy services.
Capitation
A payment method in which the provider agrees to provide all the care you may
need in return for a fixed monthly payment by your health plan company.
Case management (also called care coordination)
Coordination of your health care services and providers when you have a serious
accident or injury or chronic illness. Case management allows your health
plan to coordinate your treatment.
Certificate of coverage
The document you receive from your health plan that explains what health care
services your plan will pay for, what services you may have to pay for, and what
rules you must follow to receive the services.
Charity care
Free medical care. Providers of medical care usually have a written policy
that states which patients can receive free medical care.
Chronic illness
An illness that lasts a long time or an illness that will never be cured such as
diabetes and arthritis.
Claim
A request that you or your health care provider makes to the health plan to pay
for a health care service provided to you. Most health plans require
claims to be in writing. Health plans require claims to be on a specific
standard form.
COBRA
Stands for Consolidated Omnibus Budget Reconciliation Act. This is a
federal law that lets you and your dependents stay with health care coverage you
received through your employer even if you leave your job. You will have
to pay the premium.
Coinsurance
You share the cost of health services provided to you by
paying a percentage of the charge for the services.
Community health center
A clinic designated by the United States Public Health Services because of the
need for health services in that neighborhood. Also known as a
neighborhood health center.
Coordinated Care Delivery System (CCDS)
A health care delivery system in which some hospitals provide and coordinate the medical care of some Minnesota GAMC enrollees. The hospital may use other clinics and providers as part of its CCDS to provide this care.
Coordination of Benefits (COB)
Rules and procedures that determine how health care claims are paid when you are
covered by more than one health insurance plan. Together, the health plans
cannot pay more than the charge for the services.
Copayment
A dollar amount that you pay for a covered health care service. For
example, your health plan may require that you pay $20 each time you go to the
doctor.
Covered services
Health care services that will be paid for, in part or whole, by an insurance
plan.
Credentialing
The review process used by an insurer or health plan to determine which health
care providers are qualified to provide services to health plan members.
Items such as the provider's license, certification, malpractice insurance, and
history are examined.
Deductible
The amount of money you are required to pay for health care services before your
health plan starts paying the bill. Not all plans require deductibles.
Effective date
The date on which coverage under an insurance policy begins.
Elective procedure
A medical procedure that a patient and doctor plan in advance for a condition
that is not life-threatening.
Emergency care
Medical care that is needed immediately to save your life or to prevent serious
harm to your health.
Emergency medical services (EMS)
Emergency care provided by ambulance personnel such as EMTs (emergency medical
technicians), paramedics, first responders or other authorized individuals.
Exclusions
Charges, services, or supplies that are not covered under an insurance policy.
Family practitioner
A physician who provides primary health care for individuals and families.
Fee-for-service
Payment made to a physician or other practitioner each time a patient is seen or
a service is rendered.
General Assistance Medical Care (GAMC)
A health care program available to some low income Minnesotans who do not qualify for
other state and federal health care programs. GAMC is funded by state tax dollars.
Group insurance
A health care plan that is purchased for a group of eligible people, usually by
an employer for its employees. In Minnesota there are two forms of group
insurance: small group insurance (for groups of 2-50 individuals) and large
group insurance (for groups of 51 or more individuals).
Health care home (also called medical home)
Health care homes are an innovation in primary care in which providers, families and patients work together to improve the health and quality of life for individuals, especially those with chronic and complex conditions.
Health insurance
Financial protection against all or part of the medical care costs to treat
illness or injury. Health insurance may also include benefits for preventive health care
to help you stay healthy.
Health maintenance organization (HMO)
An HMO is a nonprofit organization which provides comprehensive health
maintenance services, or arranges for the provision of these services, to
enrollees on the basis of a fixed prepaid sum without regard to the frequency or
extent of services furnished to any particular enrollee.
Health plan
A policy of health insurance issued by a health maintenance organization, an
insurance company, Blue Cross Blue Shield, a fraternal benefit society, or other
authorized entity.
Health savings account
An account used to pay for qualified medical services, used in conjunction with
a high deductible individual health plan.
Hospice
A facility or program that provides care for a terminally ill patient.
Indemnity plan
An insurance contract where individuals are reimbursed for medical expenses
covered by the contract which they purchase from a licensed insurance company.
Individual insurance
A policy of health insurance purchased by an individual rather than a group plan
purchased by an employer.
Inpatient
A person admitted to a health care facility to receive health care services.
Long-term care
Health care services prescribed by a physician and provided in a nursing
facility or by a home health agency.
Managed care
Strategies used by health plan companies to control the cost of providing health
care while providing high quality services.
Maximum out-of-pocket cost/out-of-pocket limit
The total amount of money you may be required to pay each year for medical care
under a health plan.
Medicaid (Title XIX)
A health care program for people who meet certain income and other
guidelines. Medicaid is paid for by federal and state dollars. In
Minnesota this program is called Medical Assistance.
Medical Assistance (MA)
A health care program for people who meet certain income and other
guidelines. It is paid for by federal and state dollars.
Medically necessary care
Health care services that are
appropriate for a given diagnosis or condition.
Medicare (Title XVIII)
A federal health insurance program for people over 65 and for certain people
with disabilities.
Medicare supplemental insurance
A policy that covers certain medical expenses not fully covered by Medicare.
Minnesota Comprehensive Health Association (MCHA)
MCHA is an insurance plan for Minnesota residents who cannot get other insurance
due to past or current health status.
MinnesotaCare
A health insurance program for low income Minnesotans who meet income
and other eligibility guidelines.
Network
A group of health care providers that form an affiliation and contract as a
group with an HMO or insurer.
Nonparticipating provider
A health care provider who is not under contract with an insurer or HMO.
Nurse practitioner (NP)
A registered nurse specially educated and licensed to provide primary and/or
specialty care.
Out-of-pocket costs
Health care expenses paid by you because they are not paid by an insurer or HMO.
Outpatient
A patient who goes to a health care facility for services and leaves without
staying overnight.
Participating providers
Health care providers who are under contract with an insurer or HMO.
Physician assistant (PA)
A specially trained individual who provides medical care usually provided by a
physician.
PMAP
The Prepaid Medical Assistance Program (PMAP). The Minnesota Department of
Human Services contracts with health plan companies to provide services for
people enrolled in MinnesotaCare or receiving Medical Assistance.
Preexisting condition
A health condition that has been diagnosed and/or treated before you apply for
health insurance.
Preferred provider organization (PPO)
A network of medical providers that contracts with an insurer to
provide services at pre-negotiated fees. PPOs are associated with
insurance companies.
Premium
The amount that you and/or your employer pay for health insurance, usually
paid in installments.
Preventive care
Health care that focuses on healthy behavior and providing services that help
prevent health problems. This includes health education, immunizations,
early disease detection, health evaluations and follow-up care.
Primary care
Physicians in general practice or in fields such as family practice, obstetrics,
pediatrics, and internal medicine.
Primary-care physician or primary-care provider
The health care provider who serves you in your initial contact with the health
care system.
Prior authorization
Approval of a health care service or medication before it is provided in order
for the health plan to cover the expense.
Provider
A person or an institution that provides health care services.
Quality assurance
Activities to ensure and improve the quality of medical care that is provided by
reviewing the care and working to correct any problems.
Referral
A direction from your doctor to receive care from a different provider or
facility.
Respite care
Providing patient care so the primary health caregiver can rest or take time off.
Self-insured plan
A program for providing group health care coverage with benefits paid entirely
by the employer rather than by an HMO or insurance company.
Self-paying patients
Individuals who pay out of pocket for the medical care they receive.
TEFRA
As a component of Medical Assistance, TEFRA helps families cover health care costs for their
severely disabled children who would otherwise require institutional-level care. Called TEFRA because it became available through the Tax Equity and Fiscal Responsibility Act of 1982.
Tertiary care
Highly specialized medical care that may require the use of specialized medical facilities.
Third-party payer
Anyone paying for the health care who is not the patient (first party) or the
caregiver (second party).
Underinsured
People with inadequate health insurance that does not cover all necessary medical care.
Underwriting
Assessment of the risk of enrolling an individual or a group in a health plan.
Utilization review
A determination of appropriateness and effectiveness of medical treatment received or to be received by a patient.
Worker's compensation
A state-mandated program requiring certain employers to pay benefits and furnish
medical care to employees for on-the-job injuries and to pay benefits to
dependents of employees killed in the course of employment.
For more information contact the Minnesota Health Information Clearinghouse:
By telephone:
(651) 201-5178 or 1-800-657-3793
TDD: (651) 201-5797
By mail:
Minnesota Department of Health
Minnesota Health Information Clearinghouse
Compliance Monitoring Division
85 East Seventh Place, P.O. Box 64882
St. Paul, Minnesota 55164-0882
By e-mail:
health.clearinghouse@state.mn.us
By fax:
(651) 201-5186
Health Plan Options was created by the Minnesota Department of Health in collaboration with the Departments of Commerce and Human Services. The Minnesota Department of Health thanks everyone who reviewed and provided information for Health Plan Options.
Produced by the Minnesota Health Information Clearinghouse, Revised edition, August 2010. If you require this document in another format, such as large print, Braille, or cassette tape, call (651) 201-5169 or 1-800-657-3793.
Go to Top of Page
Go to Clearinghouse Home
