Do you ever feel like people in health care speak a different language? Well, in a lot of ways they do. A few basic definitions can help with navigating your insurance plan and finding the best ways to meet your health care needs.

Ambulatory care
Health services delivered on an outpatient basis. A patient's treatment at a doctor's office or a surgical center without an overnight stay is considered ambulatory care; in-home treatment is not.

Authorization
The approval of care, such as hospitalization, from a health insurance company. Pre-authorization may be required before a patient is admitted or before a health insurance company will agree to pay for care given by a non-HMO provider.

Cafeteria plan
A flexible benefits plan offered by employers that generally includes a choice of two or more qualified benefits or the option of cash.

Capitation
A per-member monthly payment to a health care provider that covers contracted services. The amount is based on anticipated costs to the provider..This is an alternative to the fee-for-service arrangement.

Case management
When health care professionals, who are employed by a health insurance company, monitor and manage treatment and suggests alternatives to lengthy hospital stays. Case managers usually help patients with catastrophic disorders or who receive mental health services.

COBRA
As a result of the Consolidated Omnibus Reconciliation Act of 1985, employers must offer covered employees and beneficiaries who separate from the employer for any reason the opportunity to purchase continuing health care coverage under the employer group's medical plan.

Coinsurance
When a health care plan and a plan member share the cost of health care services. Most commonly, a plan will pay 80 percent coinsurance and the plan member is responsible for the other 20 percent.

Community rating
The rating methodology required of federally qualified HMOs. The HMO must obtain the same amount of money per member for all plan members. Community rating does, however, allow for variability by allowing the HMO to factor in differences for age, sex and industry factors, although they are not all necessarily allowed under state law.

Concurrent review
When hospitalization can’t wait, a health insurance company reviews a patient’s case within 24 hours of admission. The patient’s condition is continually monitored to help determine if hospitalization is the best option.

Co-payment
The portion, usually a fixed amount, of a claim or medical expense that the member or covered insured must pay out of pocket.

Coordination of benefits (COB)
When an individual has health insurance coverage from two or more sources, the National Association of Insurance Commissioners has established an agreement that determines which organization has primary responsibility for payment and which has secondary responsibility. This prevents double payment for the same service.

Cost sharing
There are several ways that a health care plans and its members share in paying the costs of health care. This may include the amount an employee pays into an employer’s plan, annual deductibles and/or coinsurance.

Credentialing
The process of determining if physicians and other health care providers have the education and experience required to earn permission to provide care at a hospital or managed care organization.

Current Procedural Terminology (CPT)
A coding system developed by the American Medical Association to categorize different medical procedures, each represented by a five-digit code. The system is used frequently for billing purposes.

Deductible
A set amount that a covered individual must pay before an insurance program begins reimbursing for medical expenses.

Dual choice
A requirement that certain employers must offer a federally qualified HMO as an alternative to its traditional indemnity insurance plan.

Employee assistance program (EAP)
Employers often make EAPs available to employees who may need counseling or other forms of assistance to overcome and manage alcoholism, substance abuse, emotional or family problems.

Exclusive provider organization (EPO)
A more rigid type of preferred provider organization (PPO) that requires members to use only designated providers or else they must relinquish reimbursement altogether. PPOs, in contrast, encourage members to use "preferred" providers by offering more generous reimbursement, but the plan still reimburses for non-preferred providers.

Experience rating
A method of determining premiums that adjusts a group's rate based on the demographic characteristics and utilization experience of that particular group as opposed to using averaged data for multiple groups.

Fee-for-service (FFS)
The traditional way to reimburse health care providers. Commonly used by conventional indemnity insurers. The physician is reimbursed according to the service performed and the patient is responsible for a pre-determined percentage of the fee, typically 20%.

Formulary
The panel of drugs chosen by a hospital or managed care organization to treat patients. Drugs outside the formulary are not used except in specified circumstances.

Gatekeeper
An physician in the HMO network who coordinates a patient's care and who effectively controls costs by minimizing unnecessary services. Also called a primary care physician.

Health maintenance organization (HMO)
An organization that provides its voluntarily enrolled membership with access to comprehensive health care services for a prepaid fee.

Member
Any individual or dependent who is enrolled in and covered by a managed health care plan.

Medicare Part A
The Medicare portion that covers expenses incurred in hospitals, extended care facilities, hospices, etc.

Medicare Part B
The Medicare portion that covers physicians' services and other types of care not covered under Part A.

Open enrollment
A period during which the employees of an insured employer are allowed to enroll in the health care plan.

Preferred provider organization (PPO)
When a group of medical care providers agrees to furnish services at negotiated fees in return for prompt payment and a guaranteed patient volume through a third-party. PPOs control costs by keeping fees down and curbing excessive services through utilization control.

Respite care
Temporary care provided in a patient's home to give the primary caregiver, usually a family member, time off from a demanding job.

Skilled nursing facility (SNF)
A facility, either part of a hospital or a separate nursing home, that provides inpatient services for persons requiring skilled nursing care.

Stop-loss insurance
Insurance that reimburses a plan, plan sponsor, or medical group/IPA for losses that exceed a certain limit. The limit is usually expressed as a percentage of expected claims or as a specified dollar amount.

Tertiary care
Specialized health care in a hospital setting for illnesses or conditions that often require costly investigation and treatment. Examples include cancer care, neurosurgery (brain surgery) and burn care.

Third-party administrator
A person or organization that provides certain administrative services to group benefits plans, such as an employer. Services may include processing premium payments, reviewing claims to ensure payment and proper utilization of health care services, maintaining employee eligibility records and negotiating with insurers that provide stop-loss insurance.

Triage
A term that originated on the battlefield, triage is the evaluation of the urgency and seriousness of a patient's condition. Evaluations help establish priorities for treating several patients who are in need of care.

Usual, customary and reasonable (UCR)
The maximum reimbursement a health insurance company will pay to a provider. The maximum is based on historical fee patterns. Also referred to as U&C.

Utilization review
A cost-control method used by some insurers and employers to evaluate the appropriateness, necessity and quality of health care services. For hospital stays a utilization review can include pre-admission certification, concurrent review with discharge, planning and retrospective review.