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Glossary of Terms

Glossary of Frequently Used Health Care Terms.

  In an effort to make health care a little less confusing, Santa Barbara Select IPA has compiled some of the most frequently used terms and definitions for each, that will help you navigate the language of managed care. 

Benefit Plan - Refers to the specific services available to an enrollee under the HMO agreement with the employer

Capitation - A method of paying for medical services on a per-person rather than a per-procedure basis. Under capitation, an HMO pays a participating doctor a fixed amount per month for every HMO member he or she takes care of, regardless of the quality of care the member receives.

COBRA (Consolidated Omnibus Budget Reconciliation Act - This is a federal law that states you have the right to continue identical health care coverage from your previous employer at group rates. If you have left your job, are widowed, experience a divorce or legal separation, or your dependent child is no longer eligible for coverage through your employer, then you or your dependent may be eligible for COBRA benefits. For more information, talk with your employer or contact your health plan's Member Services Department.

Concurrent Review ‑ Review of a patient's chart, including verification of necessity of treatment and need for continued treatment, conducted during the course of treatment.

Conversion Factor ‑ The dollar amount to be applied to each relative value unit in a relative value scale to determine the payment amount for physician services

Coordination of Benefits (COB) ‑ When a patient is covered by two or more group health plans, coordination of benefits divides the responsibility of payment between the health plans so that the coverage combined will pay up to 100% of hospital and professional services within the limits of all contracts.

Co-payment - A fixed payment the patient pays (usually in the $5 to $25 range depending on the health plan) each time he or she visits a physician’s office, clinic, or receives a covered service. 

Deductible - A fixed amount the patient must pay each year before the insurer will begin covering the cost of care. Typical for traditional health insurance plans.

Dependent ‑ Includes spouse and children of the subscriber who receive coverage through the subscriber's health plan.

Durable Medical Equipment (DME) - As determined by your individual health plan, DME typically refers to rental or purchase of equipment and supplies manufactured especially for medical use and for the exclusive use of the patient (e.g., dialysis equipment and supplies, wheelchair, walker, shower chair).

Eligibility - A determination of whether a member is covered by the health plan for medical services.

Emergency - A severe and sudden medical condition (or injury, active labor or severe pain) that requires immediate medical care to avoid any of the following:

1.) Putting the patient's health in serious jeopardy.
2.) Serious impairment to bodily functions.
3.) Serious dysfunction or disfigurement of a bodily organ or body part.
4.) For a pregnant woman, serious jeopardy to the health of the baby.

The above definition is based on an average person's (not a trained medical professional) reasonable belief that his or her condition, sickness, or injury could result in the above outcome if not treated immediately (some examples are: possible heart attack; severe bleeding; injuries or broken bones; poisoning; impairment of respiration; loss of consciousness).

Emergency Services - Medical or hospital services provided in connection with the initial treatment of an emergency. (The final determination of whether the services were rendered in connection with a "true emergency" rests with the health plan.)

Enrollee ‑ any person, or eligible dependent, who is enrolled in the health plan.

E.O.B. ‑ Explanation of benefits.

Evidence of Coverage ‑ Description of health insurance benefits as well as limitations and exclusions provided to each member by the health plan.

Fee-for-service - The traditional method of paying for medical services. A doctor charges a fee for each service provided and the insurer pays all or part of that fee. Sometimes the patient is required to pay a co-payment for each visit to the doctor.

Follow-up Care- The care provided to a member following emergency services.   

Group Model HMO - A model of HMO made up of one or more physician group practices that are not owned by the HMO, but that operate as independent partnerships or professional corporations. The HMO pays the groups at a negotiated rate, and each group is responsible for paying its doctors and other staff, and for paying for hospital care or care from outside specialists.

Health Care Financing Administration (HCFA) - The federal agency responsible for administering Medicare and overseeing states’ administration of Medicaid.

Health Maintenance Organization (HMO) - A health plan which, if in California, is licensed by the State Department of Managed Health Care and officially called a "health care service plan." This is a plan that provides very comprehensive coordinated health services, emphasizing a strong relationship between the patient and the primary care physician, preventive care and generally involving very little out of pocket cost to the patient. Most services are provided without need for the patient to be involved with medical claims, when compared with other types of health insurance plans.

Health Services - Professional medical, surgical, diagnostic, therapeutic or preventive services of physicians, surgeons and paramedical personnel that are performed, directed or authorized by a PCP.

HMO Model Types - HMOs come in different forms or “models”

Independent Physician Association (IPA) - A group that has been incorporated as a medical partnership, professional corporation or association that contracts with independent physicians who practice in private offices, usually organized around one or more hospitals where the physicians have admitting staff privileges. The IPA has a provider agreement (contract) in effect with various health plans to arrange health care services for the plan's members. (Santa Barbara Select IPA does not directly provide services.)

Managed Care Organization - An umbrella term for HMOs and all health plans that provide health care in return for pre-set monthly payments and coordinate care through a defined network of primary care physicians and hospitals.

Member - A subscriber or dependent entitled to receive medical services from Providers.

Mixed Model HMO - A health plan that includes more than one form of HMO within a single plan. For instance, a staff model HMO might also contract with independent physician groups or with individual private practice physicians.

Network - The doctors, clinics, health centers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care network plan has selected and contracted with to care for its members.

Non‑Covered Services - Health care services which are not benefits under the subscriber's evidence of coverage.

Out-of-network - Not in the HMO’s network of selected and approved doctors and hospitals. HMO members who receive care out-of-network (sometimes called out-of-area) without prior permission from the HMO may have to pay for all or a portion of out-of-network expenses. Exceptions are usually made for extreme emergencies or urgent care needed when traveling away from home.

Participating Provider - Physicians, hospitals, labs, radiology centers, and other health care professionals and facilities under contract to provide health care services to Santa Barbara Select IPA members.

Point-of-Service (POS) plan - A type of HMO coverage that allows members to choose services either from participating HMO providers, or from providers outside the HMO’s network. In-network care is more fully covered; for out-of-network care, members pay deductibles and a percentage of the cost of care, much like traditional health insurance coverage.

Practice guidelines - Carefully developed information on diagnosing and treating specific medical conditions. Practice guidelines, usually based on clinical literature and expert consensus, are designed to help physicians and patients make decisions, to help a health plan evaluate appropriateness and medical necessity of care.

Preferred Provider Organization (PPO) - Often more expensive than an HMO, this is a health insurance model that offers a higher level of coverage when the insured person uses contracted providers and lower coverage when using non-contracted providers. Often the patient must satisfy an annual "deductible" before coverage begins, and then be required to pay a percentage of the provider's bill. When using non-contracted providers, the patient may also be responsible for fees in excess of the insurance company's maximum fee allowance. The patient receives explanations of coverage each time the provider files a claim and from this, is advised of the patient's portion of the cost.

Prescription - A written order or refill notice for a prescription drug issued by a licensed prescriber.

Preventive care - Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunizations and regular screenings like Pap smears or cholesterol checks.

Primary care - Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, pediatrics or family practice or by a nurse, nurse practitioner or physician’s assistant.

Primary Care Physician (PCP) - A participating provider physician, including general and family practice practitioners, internists and pediatricians, who is selected by a health plan member to manage his/her health care, including: routine health care services, coordination of specialist referrals, and hospitalization arrangements.

Quality Management ‑ The process established to ensure that the quality of medical services rendered meets or exceeds objective standards developed by knowledgeable health professionals and that services provided are "medically necessary" and provided in a timely manner.

Referral - A formal process that authorizes an HMO member to get care from a specialist or hospital. To ensure coverage, an HMO patient generally must get a referral from his or her primary care doctor before seeing a specialist.

Service Area - The defined geographic area in which your health plan provides medical and hospital services. Santa Barbara Select IPA's service area includes most areas of Southern Santa Barbara County.

Specialist - A physician who is not a general practitioner, family practitioner or pediatrician - who provides specialized care or services related to a specific illness or condition. Examples of specialists include cardiologists, dermatologists and surgeons.

Staff Model HMO - A type of HMO in which the doctors and other medical professionals are salaried employees of the HMO, and the clinics or health centers in which they practice are owned by the HMO.

Subscriber - The adult who is enrolled in a health plan. Family members, referred to as "dependents" include spouses, children and domestic partners as determined by the health benefit plan. All enrollees of health plans, subscribers and dependents, are referred to as "Members."

Subscriber Group ‑ is the organization, firm or other entity contracting with HMO's to arrange health care services for employees and their dependents.

Subrogation ‑ the assumption by a third party (as a second creditor) of another's legal right to collect a debt or damages.

Urgent Care - Services  for an unexpected illness, injury or condition - which is not an emergency, but requires immediate relief of pain or diagnosis and treatment of the condition to avoid deterioration of health. Urgent care may be treated in your primary care physician's office or upon referral to one of Santa Barbara Select IPA's Urgent Care Centers.

Utilization Management ‑ The process established to assure that services rendered are medically necessary and provided in the most cost-effective manner, consistent with the maintenance of high quality standards of practice.

Privacy

Your Personal Health Information Is Safe with Us

We carefully observe all of the laws, regulations and professional ethics that govern patient privacy and the confidentiality of patient information. We do not give out any information that makes it possible to anyone or any organization to individually identify any of our patients.

We gather general data about our patients and the health care services we provide them, group the data together, and use the information to develop our quality programs and services. We share the grouped data with health care organizations, regulatory agencies and accreditation organizations. They in turn use the data to monitor the delivery of health care services to certain populations. Any patient data that are exchanged electronically between our doctors, our administrative staff, health plans or any other entity is protected as required by current state and federal laws.

When requested, we will tell our patients how we use their personal health information. They may review their own personal health information and amend it. We have a process for receiving, analyzing, resolving, and complying with our patients' requests to restrict the uses and disclosures of their protected health information.