Health Insurance Terminology

Health insurance benefits can be confusing. Where do I go for urgent care? What is the difference between long-term care and custodial care?

In order to get the most out of your employer-sponsored health insurance benefits, and to be sure that you are getting the most cost-effective care, it is important to understand the terms you will find in your plan booklet.

Health Care Facilities Defined

Ambulatory setting – institutions such as surgery centers, clinics or other outpatient facilities that provide outpatient health care services.

Approved health care facility or program – a facility or program that is licensed, certified or otherwise authorized according to the laws of the state to provide health care, and which has been approved by a health plan as described in the contract.

Extended care facility – a nursing home or nursing center that is licensed to operate in accordance with all applicable state and local laws and that provides 24-hour nursing care. These facilities offer skilled intermediate or custodial care, or any combination of these types of care.

Facility – a physical location where health care services are provided, such as a hospital, clinic, emergency room or ambulatory care center.

Home health agency (HHA) – a state and federally certified facility that is approved to provide health care services in the home.

Hospice – a facility or program that is primarily designed to provide pain relief, symptom management and supportive services for the terminally ill and their families.

Intermediate care facility – a facility that is licensed by the state and provides nursing care to patients who require a degree of care that is less than would be received in a hospital or skilled nursing facility, but more than room and board.

Long-term care facility – usually a state licensed facility that provides skilled nursing services, intermediate care and custodial care.

Nursing home – a licensed facility that provides general nursing care to chronically ill patients who are unable to care for themselves and their daily living needs. Also referred to as a long-term care facility.

Outpatient surgical center – a health care facility, separate from a hospital, that provides pre-scheduled outpatient surgical services. Also called a freestanding outpatient surgical center or day-surgery center.

Skilled nursing facility – a facility either freestanding or part of a hospital, which provides rehabilitation and medical care that is less intense than would be provided in a hospital.

Sub-acute care facility – an intermediate care facility which provides care for patients too ill to be released to long-term care or their homes, but not so ill that they require ongoing hospitalization.

Treatment facility – any residential or non-residential facility that is authorized to provide treatment for mental health conditions or substance abuse.

Urgent care center – a health care facility whose primary purpose is the provision of immediate, short-term medical care for minor but urgent medical conditions. Serves as an alternative to the hospital emergency room.

Types of Care Defined

Activities of daily living (ADL) – everyday living functions and activities performed by individuals without assistance, including walking, dressing, personal hygiene and eating.

Acute care – skilled medical care provided by medical and nursing personnel in order to restore a person to good health.

Adult day care – a type of care (usually custodial) for individuals who require assistance with various activities of daily living while their primary caregivers are absent.

Aftercare – patient services required after hospitalization or rehabilitation.

Ambulatory care – care given on an outpatient basis.

Ancillary care – additional services (other than room and board) performed relating to a specific incident of care. Includes services such as x-rays, lab work, radiology, and anesthesia.

Behavioral health care – assessment and treatment of mental illness or substance abuse disorders.

Custodial care – care primarily to meet a patient’s personal needs, such as bathing, dressing, eating, or taking medicine. Can be provided by medical or non-medical personnel, but must be administered according to a doctor’s order.

Emergency services – services provided for an unforeseen acute illness or injury that requires immediate medical attention.

Home health care – skilled or unskilled care provided in an individual’s home, usually on a part-time basis. Examples include part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services from home health aides or assistance with household chores.

Hospice services – services provided to the terminally ill and their families.

Intermediate nursing care – health or medical care that is occasional or rehabilitative, ordered by a physician and performed by skilled medical personnel.

Long-term care – care provided to people with chronic diseases or disabilities who need assistance with daily activities for an extended period. Includes a wide range of health and social services provided under the supervision of medical professionals.

Office visit – services provided in a physician’s office.

Outpatient services – care received in a hospital or ambulatory care center that does not require an overnight stay.

Preventive care – proactive, comprehensive care emphasizing prevention, early detection, and early treatment of conditions. Generally includes routine physical exams, immunizations and well-person care.

Primary care – basic or general health care, traditionally provided by family practice physicians, pediatricians or internal medicine practitioners.

Respite care – temporary health or medical care designed to provide a short rest period for a caregiver of a chronically or terminally ill person.

Secondary care – medical services provided by doctors who do not have first contact with patients, such as urologists, cardiologists and so on.

Specialty care – services delivered by a health care provider who has received advanced training in a specific field of medicine. Specialty care also includes care provided in specialty facilities and emergency care.

Tertiary care – health care services provided by highly specialized providers, such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technologies and facilities.

Benefits of Health Insurance

Choosing a health insurance plan and enrolling in it can be confusing and is probably not a lot of fun. Nevertheless, making a thoughtful decision and picking the best health plan for your situation is important for you and your family. Following are some of the basic reasons you should obtain health coverage.

Financial Protection

You don’t usually plan for medical care; if you or a family member gets sick or hurt, you likely didn’t see it coming. Big expenses, such as treatment for a broken leg or a hospitalization for a serious illness, can use up your paychecks in a hurry.

For example, a fractured leg that requires surgery could cost up to $20,000 or more if you don’t have insurance. An X-ray alone can cost several hundred dollars. Owing only the deductible amount and copays is much easier on your bank account than having to pay the full regular fees. Health insurance will cover some of those expenses, making it less financially traumatic.

Health insurance protects you financially in a couple ways:

  • Health insurance gives you a sense of security knowing that a sudden illness or serious injury will not drain your bank account or, worse, your retirement savings. Health insurance protects your financial future by helping pay for expensive doctor visits and treatments.
  • Seeing doctors who are in-network with your health insurance plan also gives you the advantage of receiving care with lowered costs. When doctors are in-network, you have access to lower rates negotiated by the insurance company, meaning you owe less than if you didn’t have insurance.

Get the Care You Need

If you don’t have insurance and can’t afford to pay out-of-pocket, you might have to skip or skimp on medical care for yourself or a family member. Having health insurance ensures you can get the care you and your family need. In addition, health insurance helps you pay for routine and preventive health care to keep you healthy in the first place.

  • Health insurance covers many preventive services without you having to pay a deductible or copayment. Preventive care is intended to prevent or catch diseases and other health problems before they become serious. Preventive services that are covered in full include various health screenings and immunizations.
  • Having health insurance will also help you pay for prescription drugs, either through reduced fees or copays.