# Introducing U.S. Medical Care and Medical Insurance: Definitions



## BBCWatcher (Dec 28, 2012)

The U.S. healthcare system changed profoundly in 2014 when major provisions of the Patient Protection and Affordable Care Act ("Obamacare") went into effect. This guide explains important *healthcare definitions*. Make sure you understand these terms as you navigate the U.S. medical system.

D1. patient, enrollee, beneficiary, insured: That's you, the recipient of medical care and the person enrolling in medical insurance -- all terms describing you depending on your circumstances.

D2. medical care: The care you receive (or could) from doctors, hospitals, and other medical providers, including medicines, medical equipment, rehabilitation, mental health services, etc.

D3. medical/health insurance: An insurance policy that covers at least some medical care.

D4. covered services, medically necessary care: Insurance only pays for covered services, the list of medical services listed in the policy, and only when providing those services is medically necessary. For example, your insurance may cover amputating a toe but only if a doctor determines that amputation is medically necessary (e.g. due to frostbite). Your insurance may not cover dental or vision care.

D5. medical repatriation, evacuation: Medical insurance may offer some coverage to transport you to another country (e.g. your country of citizenship) if you are stable enough using special transport if necessary.

D6. preventive care: Services that help prevent future problems that are more expensive and difficult to treat. Vaccinations are an example. Legally compliant U.S. medical insurance must cover several preventive care services 100%.

D7. acute care: Medical services that address immediate, relatively short-term problems, at a moment in time, e.g. a heart bypass operation.

D8. chronic diseases: Diseases/conditions requiring ongoing care to manage, e.g. Antiretroviral Therapy (ART) for HIV.

D9. long-term care: Ongoing medical services that address long-term issues, e.g. nursing home care for Alzheimer's Disease. Ordinary medical insurance provides little LTC coverage. Separate LTC insurance and other insurance, notably disability insurance, provide more LTC coverage.

D10. emergency/urgent care: Medical care that typically requires an immediate visit to a hospital or emergency clinic, often by ambulance, e.g. a stroke. U.S. medical insurance policies often cover only emergency and urgent care when traveling overseas. U.S. hospital emergency rooms are legally required to treat patients in actual need of emergency care, though they are only required to try to stabilize such patients and are also free to bill high fees.

D11. health insurance exchange: An online marketplace established by law for finding and signing up for legally compliant medical insurance, for individuals and for small businesses, with government subsidies available if you qualify. Healthcare.gov is the only official portal to U.S. health insurance exchanges.

D12. Medicare: Medicare is the U.S. government-funded program that covers most U.S. residents who are age 65 and older.

D13. Medicaid: A U.S. government-funded program, administered by the states, that provides medical insurance to most low income households. Medicaid also funds much nursing home care since many nursing home residents exhaust their private funds. The Medicaid program tries to recover many costs from household wealth.

D14. Medicaid expansion states: The states that accepted additional U.S. federal government funding to expand their Medicaid programs to cover households with incomes up to 138% of the poverty line. Non-expansion states are medically less attractive even to households that don't need Medicaid since the loss of funding increases everyone's costs.

D15. Children's Health Insurance Program (CHIP): A U.S. government-funded program related to Medicaid but with separate qualifications. It provides medical insurance to children in low/moderate income households.

D16. TRICARE: Another U.S. government program. Medical insurance available to most current and many former military personnel.

D17. deductible: The amount you must pay for covered medical services, usually per calendar year, before your insurance starts paying anything (unless otherwise noted, e.g. for covered preventive services).

D18. co-pay: The portion you must pay for a particular medical service that your insurance does not pay.

D19. out-of-pocket maximum: The maximum amount you pay, usually per calendar year, for covered medical services, in total co-pays and deductibles, before insurance _fully_ takes over and pays 100%.

D20. in/out of network: Refers to the networks (groups) of medical providers that your insurance covers more generously (in network) and less generously or not at all (out of network). To get the most financial help from insurance you should choose in network doctors, hospitals, clinics, testing laboratories, pharmacies, and other listed providers. Check each provider's network status, even within a single facility, before obtaining service.

D21. premium: The amount you must pay your carrier for coverage, usually monthly. Failure to pay will end your coverage. Note that if you lose your job and other sources of income, e.g. due to a medical issue, it can be difficult to continue paying premiums.

D22. dependents: In medical insurance usually that's your spouse and your children living with you (or attending school/university) who are under age 26.

D23. open enrollment period: The annual period starting on November 1 when you can visit Healthcare.gov to shop for policies on the health insurance exchange and to recalculate your subsidy. You should comparison shop every year. Employers also offer open enrollment that may start on a different date. During other periods you cannot shop for a new insurance policy unless....

D24. qualified status change: A change in your life that allows you to shop for a new medical insurance policy outside open enrollment. Marriage, your child's birth, and moving to another state (or into the U.S.) are examples of qualified status changes.

D25. special enrollment period: The period (usually 60 days) after a qualified status change when you can choose a new medical insurance policy through the health insurance exchange or through your employer.

D26. pre-existing condition: A medical condition which is already known to you or could reasonably be known. Before "Obamacare" U.S. medical insurance carriers could refuse to provide insurance to those with pre-existing conditions.

D27. drug formulary: The list of drugs that medical insurance covers and how generously they're covered.

D28. generic prescription drug: A medicine that requires a doctor's prescription that is available from multiple drug manufacturers; the same compound under different names. Medical insurance covers generic drugs the most generously.

D29. brand name prescription drug (on formulary): A medicine that requires a doctor's prescription available only from one drug manufacturer but that the insurance carrier covers fairly well since the insurer was able to negotiate a favorable price.

D30. specialty prescription drug (off formulary): A medicine that requires a doctor's prescription available only from one drug manufacturer. Medical insurance covers such drugs least generously.

D31. over-the-counter drug: A drug available at retail that does not require a doctor's prescription. May or may not be reimbursed by medical insurance.

D32. direct payment/billing, reimbursement: Medical providers, particularly "in network" providers, will often accept your medical insurance card and bill the medical insurance company directly. Otherwise, you will be expected to pay for medical services then submit claims to your insurance company for reimbursement.

D33. letter of guarantee: A letter issued by your medical insurance company to a provider assuring payment. Some providers, particularly overseas, require such a letter or full payment before they will provide service.

D34. annual/lifetime limits: Caps on the amount of medical insurance benefit per year or per lifetime. "Obamacare" abolished all such benefit limits for covered services for U.S. issued, legally compliant medical insurance.

D35. COBRA: Refers to a particular law and your right to continue employer-provided medical (and other) insurance coverage after you lose your job or leave a job, at a premium equal to the real cost plus a small administrative fee, usually for up to 18 months, sometimes longer. You must notify your employer and employer's insurance carrier if you want COBRA coverage, there's a time limit to enroll, and you must make timely premium payments.

D36. HSA, MSA, HRA: Health Savings Account, Medical Savings Account, Healthcare Reimbursement Account. These are various U.S. tax-preferred ways, often employer-supported, to save for and to pay for unreimbursed medical care.

D37. Individual Shared Responsibility Payment: A U.S. tax penalty you often must pay if you do not maintain compliant medical insurance coverage for your household. You would file IRS Form 8965 if you qualify for an exception.

D38. bronze/silver/gold: Basic grade qualities of insurance coverage in terms of typical annual medical reimbursement rates.

D39. healthcare navigator: A government-authorized individual who provides basic, expert medical insurance advice free of charge. Visit Healthcare.gov for more info.


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## BBCWatcher (Dec 28, 2012)

Continuing the list of definitions....

D40. negotiated rate/price: The price for particular medical services, drugs, equipment, etc. that your insurer is able to negotiate with your medical provider, a large group rate/price. If you don't have medical insurance then you will be charged the individual rate/price (also known as the uninsured rate/price), a price that can easily be 10 times higher or more.

D41. "reasonable and customary": Usually refers to an insurance carrier's definition of pricing levels for medical care based on a particular standard. Your insurer's definition of pricing levels can be quite different than your medical providers' pricing. For example, if you have private medical insurance issued in Malaysia, and the policy covers "reasonable and customary" costs of overseas medical care based on prevailing prices in Malaysia for medical care, you would likely only receive reimbursement for a tiny fraction of the cost of medical care in the United States.

D42. travel medical insurance: That's medical insurance with policies, limits, and other coverage terms that are geared toward travelers, such as tourists, for emergency/urgent care. Such insurance is not appropriate for residents of a country -- it often does not meet legal coverage requirements, for example -- and may not even be sufficient for your particular travel coverage needs. Travel medical insurance also generally has severe age limits (e.g. not available to those 75 and older), preexisting condition limits (e.g. doesn't cover pregnancy), citizenship/residency limits (e.g. doesn't cover U.S. citizens and U.S. permanent residents visiting the U.S.), territorial limits (e.g. doesn't cover care in North America, Antarctica, or in oceanic regions), activity limits (e.g. doesn't cover care required due to skiing accidents), and other limitations. Travel medical insurance is generally poorly regulated.

D43. prior authorization/pre-approval: Some medical insurance policies require you to obtain prior authorization (also known as pre-approval) before obtaining medical care -- and to notify the insurer as soon as practical when obtaining emergency care. Failure to obtain prior authorization could result in denial of payment/reimbursement.

D44. medical insurance card: A card that your medical insurance carrier issues to you (and to your dependents), one card per individual, that usually includes your insurance coverages, your policy number, and your insurer's contact information. Carry this card with you, and show this card to every medical provider every time you obtain service. Ask your provider, every time, whether they are "in network" for your particular insurance. The card is not proof of insurance, however, since your insurance may have been terminated (due to failure to pay premiums, for example).

D45. Health Maintenance Organization (HMO), Preferred Provider Organization (PPO): Variations on the "in network" concept. HMOs are groups of medical providers that have banded together, usually under the sponsorship and sometimes investment/ownership of an insurance carrier or major healthcare provider, to provide a wide range of medical services, typically sharing a single medical records system. PPOs are similar but with a looser organization.

D46. general practitioner (family physician, primary care physician), specialist, referral: Many medical insurance programs -- and some medical providers -- require you to visit a primary care doctor (a.k.a. general practitioner, family physician, or, for children, a general pediatrician) as your first point of contact for medical care. The GP then will provide a referral to a specialist if he/she determines that specialist care is medically necessary. If you try to go to a specialist physician directly on your first visit for a particular ailment or suspected ailment -- a dermatologist, oncologist, etc. -- then medical insurance may not provide coverage. Some medical insurance programs, particularly HMOs, require you to select a primary care doctor when you sign up for coverage.

D47. public clinics, free clinics, health centers, community clinics: In many cities in the United States (and elsewhere) local community organizations and local governments operate medical clinics. These clinics are often free or low cost, and they typically provide excellent care, especially for routine specialist services such as reproductive health, vaccinations, infectious disease screening, nutrition counseling, and substance abuse, as examples.

D48. abortion counseling center, pregnancy crisis center: In the United States practically any organization can operate "counseling centers" to provide advice (or "advice"). Many religious organizations operate abortion counseling centers that advocate against abortion, often vigorously, and that provide varying levels of assistance facilitating adoption. That's their right, but it's also your right to decide whether or not to visit such offices. Planned Parenthood, a non-profit non-religious medical services organization, is the largest operator of reproductive health clinics in the United States.

D49. pharmacy clinics: Walgreens, CVS ("Minute Clinic"), and other major U.S. pharmacy chains are increasingly providing a range of basic, affordable medical services right in their stores, staffed by a nurse practitioner. Popular services at pharmacy clinics include high blood pressure screening and management, diabetes-related care, and emergency contraception.

D50. mail order prescriptions: Many medical insurance carriers require beneficiaries to obtain prescription drug refills via their designated mail order pharmacy, not at a retail pharmacy, in order to obtain payment/reimbursement.

D51. U.S. states: "Obamacare," except for Medicaid expansion (as noted above), applies to the 50 U.S. states and the District of Columbia. U.S. territories (Puerto Rico, Guam, etc.) and the Compact of Free Association countries have their own, separate medical systems and are not required to adopt the Patient Protection and Affordable Care Act's provisions.

D52. dietary supplements: Herbal remedies, "traditional medicines," nutritional supplements, and many other pills and potions are exempted from most Food and Drug Administration (FDA) regulation in the United States. Medical insurance also rarely provides coverage for non-FDA approved supplements. In 2014 and 2015, New York State tested dietary supplements sold in major retailers and discovered rampant fraud, with many bottles and packages not even containing what their labels claimed. Some products even contained unlisted substances that could cause allergic reactions. The FDA does not recommend spending money on any of these poorly regulated products.

D53. medical marijuana: The legal status of marijuana in the United States is somewhat ambiguous. Marijuana is still illegal under federal law, and federal authorities still pursue criminal cases against those who produce, possess, and/or distribute marijuana, particularly in large quantities. However, several states have legalized or decriminalized marijuana, so in those states only federal authorities still engage in anti-marijuana law enforcement efforts. The general trend is toward legalization and decriminalization. Medical insurance does not cover marijuana even if prescribed by a doctor, though insurance will typically cover the legal, FDA-approved prescription drugs based on chemicals found in marijuana, e.g. dronabinol, when medically necessary.

D54. medical directive, living will, medical power of attorney: Ways of legally documenting the types and forms of medical intervention that you would like (or not like) if you become medically incapacitated. It's a good idea to have such instructions documented.

D55. organ donor: When you obtain a driver's license or state ID in the United States you can specify whether to become an organ donor or not. Please do, and inform your family and loved ones of your decision. Medical providers must and will take care of you first (per your directives), but in the event they cannot save your life you can still help save others, including perhaps even your own family and friends. Likewise, please regularly donate blood if you qualify.


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## twostep (Apr 3, 2008)

I would like to see a disclaimer that this is a personal compilation of terms and explanations without official links. Thank you.


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## BBCWatcher (Dec 28, 2012)

If you like, but these posts include many official links.


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## Bellthorpe (Jun 23, 2013)

twostep said:


> I would like to see a disclaimer that this is a personal compilation of terms and explanations without official links. Thank you.


Why? It's clearly not just copied off the web. 

This is the most useful summary of the issues that I've ever seen. 

Many thanks, BBCWatcher


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