Access A Patient's ability to obtain medical care. The ease of access is determined by components such as the availability to the patient, availability of insurance, the location of health care facilities, transportation, hours of operation, affordability and cost of care.

Accreditation Approval by an authorizing agency for institutions and programs that meet or exceed a set of pre-determined standards.

Actual Charge The amount a physician or other provider actually bills a patient for a particular medical service, procedure or supply in a specific instance. The actual charge may differ from the usual, customary, prevailing, and/or reasonable charge.

Acute Care Hospital care given to patients who generally require a stay of up to seven days and that focuses on a physical or mental condition requiring immediate intervention and constant medical attention, equipment and personnel.

Advance Directive A document that patients complete to direct their medical care when they are unable to communicate their own wishes due to a medical condition.

Ancillary Care A term used to describe additional services performed related to care, such as lab work, X-ray and anesthesia.

Board Certified A clinician who has passed the national examination in a particular field. Board certification is available for most physician specialties, as well as for many allied medical professions.

Case Manager An experienced health professional that works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care. Often used for patients with specific diagnoses or who require high-cost or extensive health care services.

Charity Care Free or reduced fee care provided based on the financial situation of patients.

Chronic Care Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.

Chronic Disease A disease which has one or more of the following characteristics: (1) is permanent, leaves residual disability; (2) is caused by nonreversible pathological alternation; (3) requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.

Co-Payment A type of cost-sharing which requires the insured or subscriber to pay a specified flat dollar amount, usually on a per-unit-of-service basis, with the third-party payer reimbursing some portion of the remaining charges.

Continuum of Care A range of clinical services provided to a patient that may reflect the treatment rendered during a single hospitalization or may include care for multiple conditions spanning the patient's lifetime.

Deductible Required out-of-pocket expenditure by the covered individual before the insurer pays towards the allowable charges for a covered service. Deductibles may be specified in dollar amounts or units of service.

Dependent An individual who receives health insurance through a spouse, parent or other family member.

Do Not Resuscitate (DNR) An advance directive that patients may make to forego cardiopulmonary resuscitation or other resuscitative efforts Durable Power of Attorney A document in which competent individuals can select other individuals to make decisions, including health care decisions, for them in the event they become incapacitated.

Extended Care Facility A nursing home-type setting that offers skilled, intermediate, or custodial care.

Federal Poverty Level (FPL) - Income guidelines established annually by the Federal government. Public assistance programs usually define income limits in relation to FPL or the Supplemental Security Income (SSI) level.

Health Insurance A mechanism to spread the risk of unforeseen expenditures across a broad base to protect the individual from personal expenditures for health care services. Health insurance may be purchased individually or on a group basis. It may be custom designed to cover specific services and procedures and include requirements to control the level of use and payment for these services. An employee health insurance benefit is a nontaxable form of compensation to the employee in lieu of taxable salary or wages, provided through employment. Various types of insurance, such as accident, disability income, medical expense, dental, vision, hearing, and accidental death and dismemberment may be made available through employment. Benefits may be available to dependents of active employees, retirees, spouses, survivors, and dependents through employment. Benefits for classes of active and retired employees and their dependents need not be uniform. The employer may purchase benefits or the costs may be shared between the employer and employee.

Home Care In contrast with inpatient and ambulatory care, home care is medical care ordinarily administered in the house setting when a patient is not sufficiently ambulatory to make frequent office or hospital visits. With these patients, intravenous therapy for example is administered at the patient's residence, usually by a health care professional. Home care reduces the need for hospitalization and it's associated costs. Home Health Services performed at an individual's home including a wide range of skilled and non-skilled services, including part-time nursing care, various types of therapy, assistance with activities of daily living and homemaker services such as cleaning and meal preparation. For Medicare purpose, this term refers specifically to intermittent, physician-ordered medical services or treatment.

Hospice A facility or program that is licensed, certified or otherwise authorized by law, which provides supportive care of the terminally ill.

Hospice Care Care that address the physical, spiritual, emotional, psychological, financial, and legal needs of the dying patient and the family; provided by an interdisciplinary team of professionals and perhaps volunteers in a variety of settings, including hospitals, freestanding facilities, and at home.

Hospital An institution whose primary function is to provide inpatient diagnostic and therapeutic services for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care. Hospitals may be classified by length of stay (short-term or long-term), as teaching or non-teaching, by major types of services (psychiatric, tuberculosis, general, and other specialties, such as maternity, pediatric, or ear, nose and throat), and by type of ownership or control (Federal, State, or local government; for-profit and non-profit).

Insurance Sharing the costs of the risk of incurring losses, whether for health expenses or property and casualty losses, across a base large enough to protect any one entity against the actual costs of an incurred loss. The costs of spreading the risk are assumed to be less than the costs of an actual loss. The insured group or insurance company is at financial risk for assuming the guarantee against loss for the specific instance.

Intensive Care Unit (ICU) Highly specialized care requiring sophisticated technologies given to patients who are in danger of disability or death.

Joint Commission Founded in 1951, the Joint Commission evaluates and accredits health care organization in the U.S., including hospitals, health plans, and other care organizations that provide home care, mental health care, laboratory, ambulatory care and long-term services.

Living Will A legal document generated by an individual to guide providers on the desired medical care in cases when the individual is unable to articulate his or her own wishes.

Long-Term Care Care given to patients with chronic illnesses and who are required a length of stay longer than 30 days.

Mail Order Pharmacy A source for brand name and generic prescription and over-the-counter medicines by mail, usually at lower unit prices than a retail pharmacy.

Medicare (Title XVIII) Federal program that provides basic health care and limited long term care for retirees and certain disabled individuals without regard to income level. Beneficiaries must pay premiums, deductibles and coinsurance. See beneficiary, cost sharing, medically necessary, and medigap.

• Part A - Medicare hospital insurance that helps pay for medically necessary inpatient hospital care, and, after a hospital stay, and limited inpatient care in a skilled nursing facility, for limited home health care or hospice care.
• Part B - Medicare medical insurance that helps pay for medically necessary physician services, outpatient hospital services and supplies that are not covered by the hospital insurance.
• Part C - See Medicare + Choice.

Medicare + Choice Also referred to as "Medicare Part C," is a Medicare program under which eligible Medicare enrollees can elect to receive benefits through a managed care program that places providers at risk for those benefits.

Over the Counter (OTC) Drugs A drug that does not require a prescription.

Palliative Care Care which is provided to relieve pain rather than provide a cure. Also called "comfort care."

Pharmacist A health care professional who compounds and dispenses medications and other pharmaceutical supplies, using standard physical and chemical procedures to fill written prescriptions issued by physicians. Maintains records on all unit dose for each nursing unit and also IV additive program. Maintains inventory of supplies.

Pharmacy Tech Fills orders for prepackaged drugs or dispenses drugs from stock containers under the supervision of a pharmacist. In addition, the tech will fill routine orders for non-prescription drugs, replenish supply carts, and keep records on drugs delivered to the department and store incoming merchandise.

Physical Therapist Assists patients who have experienced disability from illness, trauma, or birth defects, performs individual exercise programs to restore or relocate physical function.

Physical Therapy Assistant Works under the supervision of a physical therapist. Duties include training patients in everyday activities, assisting patients in walking and exercising, and conducting treatments as prescribed by a physician.

Physician Assistant (PA) A medically trained professional who can provide many of the health care services traditionally performed by a physician, such as taking medical histories and doing physical examinations, making diagnoses, prescribing and administering therapies.

Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations.

Primary Care Physician (PCP) A physician designated as responsible to provide specific care to a patient, including evaluation and treatment as well as referral to specialists.

Quality of Care The degree or grade of excellence with respect to medical services received by patients, administered by providers or programs, in terms of technical competence, need, appropriateness, acceptability, humanity and structure.

Referral The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.

Rehabilitation To restore health following an accident, injury or illness.

• Acute Rehabilitation - Early rehabilitation phase as soon as medically stable. Primary emphasis is to provide intensive physical and cognitive restorative services in the early months following injury. Typical stay 3-4 months (short term). Based in medical facility.
• Sub-Acute Rehabilitation - Post-acute phase of rehabilitation. Capacity to treat for 6-24 months. Need not be hospital based. Stay based on demonstrated improvement.
• Transitional Rehabilitation - To prepare for community re-entry. Non-medically based. Emphasis on functional skills for maximum independence. May be in group home or part of a continuum of rehabilitation center. Typical stay 4-8 months. Greater focus on compensation vs. restoration.
• Long-Term Rehabilitation or Extended Rehabilitation - Have full range of rehabilitation services available. Frequently after initial year of rehabilitation when progress is slower. Generally not permanent placement. May be facility or community based.
• Rehabilitative (restorative) Care - Skilled care provided by a trained medical person (physical therapist, R.M., speech therapist).

Report Cards information on health plan performance presented in a consumer friendly manner to facilitate cross-plan comparisons.

Risk Factors Conditions that influence a person's health status and are capable of causing illness or injury, including genetic or biological risk factors, life style, or environmental conditions.

Secondary Care Services provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.

Skilled Care That level of care which: requires the training and skills of a Registered Nurse; and is prescribed by a doctor for the medical care of the patient; and may not be provided by less skilled or less intensive care, such as custodial care or intermediate care.

Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in the acute care setting of a hospital.

Social Worker Performs duties directly related to the health of the individual and the family in psychiatric and medical social work.

Specialist A physician who has special experience and expertise in a portion of the medical field. In most instances specific credentials, including residency placement and board certification must be acquired in order to qualify as a specialist.

Speech Therapist (ST) Speech therapists are trained to evaluate and improve speech and community functioning.

Staff Nurse Performs a variety of professional nursing care duties including evaluating and recording physical and emotional conditions, reporting changes observed to charge nurse or physician, gives and receives reports on each patient, administers prescribed medications orally, by intramuscular injection and by intravenous fluids as ordered, starts and monitors blood transfusions, has knowledge of patients at all times.

Subacute Care Care given to patients who require less than a 30-day length of stay in a hospital and who have a more stable condition than those receiving acute care.

Teaching Hospital A hospital that has an accredited medical residency training program and is typically affiliated with a medical school.

Tertiary Care Highly specialized care given to patients who are in danger of disability or death often requiring sophisticated technologies (e.g., neurosurgeons or intensive care units).

Trauma Center An emergency room that is equipped and staffed to care for serious traumatic injuries. Emergency rooms are classified as Level 1, 2 and 3 trauma centers, with Level 1 being the highest care level. Generally, a Level 1 trauma center will be a large emergency room that has most medical specialties (especially trauma, surgery, orthopedics, and neurosurgery) available on-site or on short notice, has good access to CT Scanning and other technology such as MRI, and is able to care for multiple traumatic injuries of both blunt and penetrating nature.

Urgent Care Center or Unit A medical facility where ambulatory patients can be treated without an appointment, and receive immediate, non-emergency care. The urgent care center may be opened 24 hours a day; patients calling an HMO after hours with urgent, but not emergent, clinical problems, are often referred to these facilities. A similar facility is a Medical Aid Unit, which is not usually opened 24 hours a day.

Veterans Administration (VA) A Federal agency responsible for veterans including VA hospitals and Veterans' benefits.

Workers' Compensation Programs established by state law to provide medical benefits and compensation for injuries and diseases that occur in the course of employment. The workers compensation program is financed by covered employers insured or self-insured under property and casualty lines and is mandatory for employers in almost all states.