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Acute care - Short-term medical treatment, usually in a
hospital, for patients having an acute illness or injury or recovering
from surgery.
ADA - The Americans with Disabilities Act of 1990 prohibits
discrimination against individuals with disabilities in employment,
housing, education and access to public services. The federal
Department of Justice and the Equal Employment Opportunity Commission
are charged with enforcing many of the provisions of the ADA.
Assistive technology - Any item, piece of equipment,
or product system, whether acquired commercially or off the
shelf, modified, or customized, that is used to increase, maintain,
or improve functional capabilities of individuals with disabilities.
Assistive technology includes, but is not limited to, wheelchairs,
reading machines and devices for grasping. In the area of computers,
assistive technologies include screen readers, screen magnifiers,
speech synthesizers, voice input software and more.
Co-pay - A pre-set charge or contribution for a medical
visit or service that the patient is responsible for paying,
with an insurance policy or medical coverage plan paying the
rest. For example, a visit to a primary doctor's office may
have a co-pay for the patient of $10, a visit to a specialist
$20, an emergency room visit $135, etc.
Custodial care - Assistance with the activities of daily
living, whether in a residential care facility or at home, including,
but not limited to, help in walking, bathing, preparing meals
and supervising use of medications. Custodial care normally
does not require a trained medical professional.
Dual eligibility - Someone who meets the qualifications
for both Medicare and Medicaid.
Durable medical equipment - Durable medical equipment
can be used over and over again, is ordinarily used for medical
purposes and is generally not useful to a person who isn't sick,
injured or disabled. Examples include canes, crutches, walkers,
wheelchairs, hospital beds, bed pans, special toilet seats and
machines that make breathing easier.
ERISA - Some health plans are what is known as "self-funded,"
meaning that rather than having an insurance company assume
the risk and possibly lose money when claims are paid out, the
organization that is providing their coverage is at risk. A
company may administer a self-funded plan (in that situation,
called a "third party administrator"), but ultimately is not
responsible for its losses, rules, procedures or decisions.
Self-funded plans were made exempt from oversight by the state
Department of Insurance under the federal Employee Retirement
Income Security Act, and thus are sometimes known as ERISA plans.
Long-term care insurance - An insurance policy purchased
to pay your costs in the event that you need long-term care
services. Depending on the policy, long-term care services may
include home health care, respite care, adult day care, care
in a nursing home or in an assisted living facility.
Medicaid waiver - An ability by the state to allow persons
to enroll in Medicaid programs under more liberal financial
and other standards and to offer an enhanced menu of services.
Medical necessity - A standard used by insurers to determine
whether a prescribed or desired treatment is covered. The standard
varies from company to company, but often addresses whether
a treatment is in accordance with the generally accepted standards
of medical practice, appropriate for the patient's illness,
injury or disease, and is not simply for the convenience of
the patient or physician.
Out-of-network - Refers to treatment professionals who
have not signed provider contracts with the insurer providing
coverage for your care. Typically, an insurance subscriber will
pay a higher cost or be responsible for the full fee to see
an out-of-network treatment professional.
PDL - A preferred drug list is a list of medications
in any given class of medications, developed by the insurer,
that the physician and/or prescriber is allowed to choose from
when deciding the best drug therapy for your diagnosed condition,
and for which the insurer will pay.
Parity - Equivalent benefits and restrictions in insurance
coverage for mental health services and for other health services.
In Delaware, state law requires health insurance coverage for
treatment of mental disabilities to be equal to treatment for
physical disorders.
Pre-existing condition - A current or past health problem
which must be disclosed in applications for health insurance.
Failure to disclose a pre-existing condition could be cause
for an insurance company to cancel your policy. Some insurance
policies may exclude any coverage of a pre-existing condition.
If a health insurance plan does not have such an exclusion,
the company must cover your pre-existing condition, though often
after an affiliation period or probationary employment period.
Federal law restricts how insurers can ban coverage and medical
treatments or treatments for pre-existing conditions.
Prior authorization - The active step that the physician
and/or prescriber of medications must take in order to gain
approval for medications that are either not approved for step
1 of step therapy or not included on a preferred drug list (PDL)
that most insurers have developed. Prior authorization is also
required by insurers in advance of many medical procedures.
Skilled nursing - Institutional care that is less intensive
than hospital care in its nursing and medical services, but
which includes procedures whose administration requires the
training and skills of an RN.
Step therapy - involves starting treatment with a less
costly medication (which is step 1) and moving only if necessary
to more costly treatment (step 2). When the insurer deems it
appropriate, step 2 drugs may be authorized if step 1 drugs
are not effective for your condition. Step therapy prescription
programs are designed to save on health care costs while providing
medication that has been deemed by the insurer as historically
effective.
Third-party administrator - In some cases, refers to
an insurer that administers a self-funded plan (see "ERISA").
Other times, the term refers to a company contracted by an insurance
company to administer a specific set of benefits. For instance,
many insurers use a third-party administrator to administer
mental health benefits.
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