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.

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: A process used by a doctor, nurse, or other health professional to manage your health care. 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. see what is cobra

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.

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.

Fitness Discount Program:

Formulary: A list of certain drugs and their proper dosages. In some health plans, doctors must order or use only drugs listed on the health plan's formulary.

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).

Guaranteed Issue: An insurance company or HMO agrees to provide coverage, regardless of the subscribers’ medical history.

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. See HSA Coverage Corner

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.

Lifetime Maximum:

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.

MinnesotaCare: A health insurance program for low income Minnesotans who meet income and other eligibility guidelines.

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.

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.

Out-Of-Pocket Maximum: A predetermined amount of out-of- pocket expense that a subscriber may pay before the insurance company agrees to cover 100 percent of future covered health care costs.

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.

Reasonable and Customary Charges: This predetermined amount defines “reasonable” fees for services, according to a particular health plan. If the service exceeds the amount, the patient may be responsible for the unpaid share of the claim.

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.

Urgently Needed Care: Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care.

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.