GLOSSARY OF HEALTH INSURANCE AND HEALTHCARE TERMS
GLOSARIO DE TÉRMINOS DE SEGURO MÉDICO Y ATENCIÓN MÉDICA

This glossary of health insurance and healthcare terms defines commonly used terms, is intended for educational purposes and may differ from language used in your policy.

Este glosario de términos de seguro médico y atención médica define términos comúnmente empleados, está destinado y pueden ser distintos al lenguaje utilizado en su póliza.

340B PROGRAM

The 340B Drug Pricing Program is part of the Public Health Service Act and requires manufacturers participating in Medicaid to sell outpatient drugs at discounted prices to healthcare organizations that care for a large proportion of uninsured and low-income patients. 340B entities include community health centers, children’s hospitals, hemophilia treatment centers, critical access hospitals (CAHs), sole community hospitals (SCHs), rural referral centers (RRCs) and public and nonprofit disproportionate share hospitals (DSH).

ADVERSE DRUG EVENT

Harm caused by a drug, including an error in medication, an adverse reaction to a drug (allergic or other) and overdose.

AMBULATORY SERVICES / SERVICIOS AMBULATORIOS

Health services provided to members who are not confined to a health care institution.

Servicios de salud prestados a miembros que no estén confinados a una institución de atención médica

AFFORDABLE CARE ACT (ACA) / LEY DE CUIDADO DE SALUD ASEQUIBLE

The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”). 

La ley de reforma de salud integral promulgada en Marzo de 2010 (a veces conocida como ACA, PPACA u “Obamacare”).

AVERAGE SALES PRICE (ASP)

Calculated by finding the average price of a particular drug sold. It is only available for Part B covered drugs.

BENEFIT YEAR / AÑO DE BENEFICIOS

A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside of the Marketplace beings January 1 of year and ends December 31 of the same year. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.

Un año de cobertura de beneficios bajo cualquier plan de seguro médico individual. El año de beneficios para planes adquiridos en o fuera del mercado comienza el 1ro de enero del año y termina el 31 de diciembre del mismo año. Cualquier cambio a los beneficios o tarifas de un seguro médico se hacen al principio del año natural.

BENEFITS / BENEFICIOS

The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.

Los elementos o servicios de atención médica cubiertos bajo un plan de seguro médico. Los beneficios cubiertos y los servicios excluidos están definidos en los documentos de la cobertura del plan médico. En Medicaid o CHIP, los beneficios cubiertos y los servicios excluidos están definidos en las reglas de los programas estatales.

BIOLOGICS/BIOLOGICALS

A biologic medicine is one that is made using living cells. They are typically larger and more complex than traditional chemical medications. Biologics are grown or produced by living cells, either human, animal or plant cells.

BUY-AND-BILL

A provider purchases drugs from a wholesaler or distributor, stores and then administers the drug to patients. The provider then submits a claim for reimbursement after it has been given to the patient.

COINSURANCE / COASEGURO

A certain percent you must pay each benefit period after you have paid your deductible.

Cierto porcentaje que usted debe pagar cada período de beneficio después de haber pagado su deducible.

COPAYMENT (COPAY) / COPAGO

The amount you pay to a healthcare provider at the time you receive services. Not all plans have a copay.

La cantidad que usted le paga a un proveedor de atención médica al momento de recibir los servicios. No todos los planes tienen un copago.

COPAY ACCUMULATOR PROGRAM

A health insurance program that prevents patients from using a copay card or coupon to cover their out-of-pocket costs. When a patient uses a copay coupon or a card, the health plan receives the payment from the card or coupon, but the amount of support on the coupon or card does not count toward the patient’s out-of-pocket costs.

COBRA

A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

Una ley federal que puede permitir que conserve la cobertura médica temporalmente después de que su empleo termine, pierda cobertura como dependiente del empleado cubierto, u otro suceso que cualifique. Si elige la cobertura de COBRA, usted paga el 100% de las primas, inclusive la parte que el empleador solía pagar, más un pequeño cargo administrativo.

CARE COORDINATION / COORDINACIÓN DE LA CUIDADO

The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.

La organización de su tratamiento a través de varios proveedores de atención médica. Los hogares médicos y las son  organizaciones de cuidado de cuentas dos maneras comunes de coordinar la cuidado.

CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS) / CENTRO PARA SERVICIOS DE MEDICARE Y MEDICAID (CMS)

The federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Program, and the federally facilitated Marketplace.

La agencia federal que dirige Medicare, Medicaid y el Prgrama de Seguro de Salud para Niños, y el mercado facilitado por el gobierno federal.

DEDUCTIBLE / DEDUCIBLE

The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time).

La cantidad que paga por sus servicios de atención médica antes de que su aseguradora médica pague. Los deducibles están basados en su período de beneficis (usualmente un año a la vez).

DOWNCODING

To assign a lower value to a medical procedure or insurance claim.

FLEXIBLE SPENDING ACCOUNT (FSA) / CUANTA DE GASTOS FLEXIBLE (FLEXIBLE SPENDING ACCOUNT, FSA)

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. If you don’t spend by the end of the year there are no carry-over FSA funds.

Un arreglo que usted establece a través de su empleador para pagar por muchos de sus gastos médicos de su bolsillo con dinero libre de impuestos. Usted decide qué cantidad de su sueldo bruto desea que le descuenten de su paga y se coloque en una cuenta de gastos flexibles (FSA). Si no la gasta para finales del año, los fondos de la FSA no se traspasan.

FEE FOR SERVICE / CARGO POR SERVICIO

A method in which doctors and other health care providers are paid for each service performed.

Un método por el cual los médicos y otros proveedores de atención médica son remunerados por cada servicio realizado.

FEDERAL POVERTY LEVEL / NIVEL FEDERAL DE POBREZA

A measure of income issued every year by the Department of Health and Human Services (HHS). FPL are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.

Una medida de ingresos emitida todos los años por el Departamento de Salud y Servicios Humanos (Department of Health and Human Services, HHS). El nivel federal de pobreza (FLP) se usa para determinar su elegibilidad para ciertos programas y beneficios, entre ellos los ahorros en el mercado de seguros médicos y la cobertura de Medicaid y CHIP.

FORMULARY

A list of drugs or medicines that are covered by a drug or insurance plan.

FEDERALLY QUALIFIED HEALTH CENTER (FQHC)

Community-based health centers that receive funding from the Health Resources & Services Administration for offering primary care services in underserved areas.

GENERIC DRUGS / MEDICAMENTOS GENÉRICOS

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. These drugs are as effective and safe as brand-name as stated by the Food and Drug Administration (FDA).

Un medicamento recetado que tiene la misma fórmula de ingredientes activos que un medicamento de marca. Los medicamentos genéricos normalmente cuestan menos que los medicamentos de marca. Estos medicamentos son tan eficaces y seguro como los de marca, como señaló la Administración.

GROUP PURCHASING ORGANIZATION (GPO)

Purchasing groups that negotiate product and service contracts with manufacturers, distributors and suppliers on behalf of hospitals and providers

HEALTH LITERACY

“The degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.” – The Patient Protection and Affordable Care Act of 2010, Title V

HEALTH MAINTENANCE ORGANIZATION (HMO) / ORGANIZACIÓN DE MANTENIMIENTO DE LA SALUD (HEALTH MAINTENANCE ORGANIZATION, HMO)

Offers healthcare services only with specific HMO providers. Under an HMO plan, you might have to choose a primary care doctor. The doctor will be your primary physician and will refer you to other HMO specialist when needed. Services from providers outside of the HMO plan are hardly ever covered.

Ofrece servicios de atención médica solo con proveedores de HMO específicos. Bajo un plan de HMO, puede que tenga que elegir un médico de atención primaria. El médico será su médico de cabecera y lo referirá a otro especialista de HMO cuando sea necesario. Los servicios de proveedores fuera del plan de HMO casi nunca están cubiertos.

HEALTH SAVINGS ACCOUNT (HSA) / CUENTA DE AHORROS PARA GASTOS MÉDICOS (HSA)

An account that lets you save for future medical costs. Money put in the account is not subject to federal income tax when deposited. Funds can build up and be used year to year. They are not required to be spent in a single year. Must be paired with certain high-deductible health insurance plans (HDHP).

Una cuenta que le permite ahorrar para futuros gastos médicos. El dinero que se pone en la cuenta no está sujeto a impuestos federales cuando se deposita. Los fondos pueden acumularse y usarse de un año a otro. No se requiere que se gasten en un solo año. Debe ir acompañado de determinados planes de seguro médicos con deducible alto (high-deductible insurance plans, HDHP).

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) / LEY DE TRANSFERENCIA Y RESPONSABILIDAD DE SEGUROS DE SALUD (HIPAA)

United States legislation that provides data privacy and security provisions for safeguarding medical information. Signed into law by President Bill Clinton in August 1996.

La legislación de los Estados Unidos que establece disposiciones de privacidad de los datos y seguridad para salvaguardar la información médica. Firmada por el Presidente Bill Clinton y convertida en ley en Agosto de 1996.

HIGH-RISK POOL PLAN (STATE) / PLAN DE FONDO DE ALGO RIESGO (ESTATAL)

Similar to Pre-Existing Insurance Plan under the Affordable Care Act, for patients that have been locked out of the individual insurance market because of pre-existing conditions. High-risk pool plans offer health insurance coverage that is subsidized by a state government. Typically, the premium for high-risk pools are twice as much as if you were healthy.

Similar al Plan de seguro para condiciones médicas preexistentes de la Ley de Cuidado de Salud Asequible, para pacientes que han estado bloqueados del mercado de seguro individual por tener condiciones preexistentes. Los planes de fondo de alto riesgo ofrecen cobertura de seguro médico subsidiada por un gobierno estatal. Normalmente, la prima para fondos de alto riesgo es dos veces mayor que si estuviera sano.

INPATIENT SERVICES / SERVICIOS A PACIENTES INTERNOS

Services received when admitted to a hospital and a room and board charge is made.

Servicios recibidos al ser admitido a un hospital y se cobra un cargo por habitación y alojamiento.

IN-NETWORK COINSURANCE / COASEGURO DENTRO DE LA RED

The percent you pay of the allowed amount or covered health care service to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

El porcentaje que paga de la cantidad permitida o servicio de atención médica cubierto a los proveedores que tienen un contrato con su seguro o plan médico. El coaseguro dentro de la red normalmente le cuesta menos que el coaseguro fuera de la red.

LONG-TERM CARE / ATENCIÓN A LARGO PLAZO

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Medicare and most health insurance plans don’t pay for long-term care.

Servicios que incluyen atención médica y no médica ofrecida a las personas que no pueden realizar actividades básicas de la vida diaria, como vestirse o bañarse. Se pueden prestar servicios y apoyo a largo plazo en el hogar, la comunidad, en centros de vida a asistida o en residencias de ancianos. Medicare y la mayoría de los planes de seguro médico no pagan por la atención a largo plazo.

MEDICAID

A federally funded health care program that is run at the state level to assist lower income families or individuals paying for long-term medical and custodial care costs.

Un programa de atención médica financiado por el gobierno federal que se ejecuta a nivel de estado para asistir a las familias con bajos ingresos o a individuos que pagan por costos de atención de médica y de custodia a largo plazo.

MEDICAL BENEFIT DRUGS

Drugs that are administered by a provider in a provider’s office or outpatient facility.

MEDICAL UNDERWRITING / VERIFICACIÓN MÉDICA

A process used by insurance companies to try to figure out your health status when you’re applying for health insurance coverage to determine whether to offer coverage, at what price, and with what exclusions or limits.

Un proceso empleado por las compañías de seguros para tratar de conocer su estado de salud cuando solicita cobertura de seguro para determinar si ofrecerle cobertura, a qué precio y con qué exclusiones o límites.

MEDICARE

A federal program for people age 65 or older that pays for certain healthcare expenses.

Un programa federal para personas de 65 años o mayores que paga por ciertos gastos de atención de salud.

MEDICARE PART C (MEDICARE ADVANTAGE)

Medicare offered by a private company contracted by the government. These plans offer hospital and medical insurance as a Medicare contractor and replace Traditional/Original Medicare. These plans may offer a separate drug plan, but you cannot purchase a Medigap plan with Medicare part C.

MEDICARE PART D / MEDICARE PARTE D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage plan that includes drug coverage.

Un programa que ayuda a pagar por los medicamentos con receta a las personas con Medicare que se unen a un plan que incluye la cobertura de medicamentos con receta. Hay dos formas de obtener la cobertura de medicamentos con receta de Medicare: a través de un plan de medicamentos con receta de Medicare o un plan Medicare Advantage que incluya cobertura de medicamentos.

NETWORK / RED

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Los centros, proveedores y suplidores que tienen un contrato con su aseguradora médica para prestar servicios de atención médica.

LETTER OF MEDICAL NECESSITY (LOMN)

A letter or form filled out by a provider citing medical necessity for the use of medical equipment or supplies, usually required by Medicare.

NETWORK PROVIDER / PROVEEDOR DE LA RED

A healthcare provider who is part of a plan’s network.

Un proveedor de atención médica que es parte de la red de un plan.

NON-MEDICAL SWITCHING

A strategy that health insurers use to control their costs and maximize profits by forcing stable patients to switch from their current, effective medications to drugs that may not be as effective, for reasons unrelated to health.

OPEN ENROLLMENT PERIOD / PERÍODO DE INSCRIPCIÓN ABIERTA

The yearly period when people can enroll in a health insurance plan. 2017 Open Enrollment ended January 31, 2017. 2018 Open Enrollment runs from November 1, 2017 to December 15, 2017.

El período anual cuando las personas se pueden inscribir en un plan de seguro médico. La inscripción abierta de 2017 terminó el 31 de enero de 2017. La inscripción abierta de 2018 va desde el 1ro de noviembre de 2017 hasta el 15 de diciembre de 2017.

OUTPATIENT SERVICES / SERVICIOS AMBULATORIOS

Services that do not need an overnight stay in a hospital. Often these services are provided in a doctor’s office, hospital or clinic.

Servicios que no requieren una estadía de un día para otro en un hospital. A menudo estos servicios se realizan en un consultorio médico, un hospital o una clínica.

OUT-OF-POCKET COST / DESEMBOLSO DE SU BOLSILLO

Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost.

Costo que usted debe pagar. Los desembolsos de su bolsillo varían por plan, y cada plan tiene un desembolso máximo de su bolsillo (maximum out of pocket cost, MOOP).

PHARMACY BENEFIT MANAGER

Third party entities that contract the management of pharmacy benefits for government programs and employer-sponsored health plans. PBMs develop and maintain drug formularies, contract with pharmacies, negotiate rebates and contracts with manufacturers and oversee the processing and payment of pharmacy benefit claims.

PATIENT CENTERED OUTCOME RESEARCH / INVESTIGACIÓN DE RESULTADOS CENTRADA EN EL PACIENTE

Research that compares different medical treatments and interventions to provide evidence on which strategies are most effective in different populations and situations.

Investigación que compara distintos tratamientos e intervenciones médicas para proporcionar evidencia sobre qué estrategias son más eficaces en distintas poblaciones y situaciones.

PHARMACY BENEFIT DRUGS

Drugs that are self-administered.

POINT OF SERVICE (POS) / PUNTO DE SERVICIO (POS)

A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

Un tipo de plan en el que paga menos si utiliza los médicos, hospitales y otros proveedores de servicios que pertenecen a la red del plan. Los planes de POS también requieren que obtenga un referido de su médico de cabecera para ver a un especialista.

PREFERRED PROVIDER ORGANIZATION (PPO) / ORGANIZACIÓN DE PROVEEDORES PREFERIDOS (PPO)

A type of insurance plan that offers more extensive coverage for the services of healthcare providers who are part of the plan’s network, but still offers coverage for providers who are not part of the plan’s network. PPO plans generally offer more flexibility than HMO plans, but premiums tend to be higher.

Un tipo de plan que ofrece una cobertura más amplia para los servicios de los proveedores de atención médica que son parte de la red del plan, pero sigue ofreciendo cobertura para los proveedores que no son parte de la red del plan. Los planes de una PPO por lo general ofrecen más flexibilidad que los planes de HMO, pero las primas tienden a ser más altas.

PREMIUM / PRIMA

Payments you make to your insurance provider to keep your coverage. These payments have certain due dates.

Pagos que hace a su proveedor de seguro para conservar su cobertura. Estos pagos tienen ciertas fechas de vencimiento.

PREVENTATIVE SERVICES / SERVICIOS PREVENTIVOS

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, diseases, or other health problems.

Atención médica de rutina, que incluye exámenes de detección, revisiones y orientación a los pacientes para prevenir padecimientos, enfermedades u otros problemas de salud.

PRIMARY CARE PROVIDER / PROVEEDOR DE ATENCIÓN PRIMARIA

A physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patent access a range of health care services.

Un médico, enfermera certificada, especialista en enfermería clínica o asistente médico, según lo permita la ley estatal, que presta, coordina o ayuda a un paciente a obtener acceso a una variedad de servicios de atención médica.

SELF-ADMINISTRATION DRUGS

Drugs or medications that can be administered by the patient. Instead of in the provider’s office by a provider.

REFERRAL / REFERIDO

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. Without a referral from your primary care doctor, the plan may not pay for the services.

Una orden escrita de su médico de atención primaria para que vea a un especialista u obtenga ciertos servicios médicos. En muchas organizaciones de mantenimiento de la salud (HMO), usted necesita un referido antes de poder recibir atención médica de nadie excepto su médico de cabecera. Si un referido de su médico de cabecera, puede que el plan no pague por los servicios.

SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP) MARKETPLACE / MERCADO PARA EL PROGRAMA DE OPCIONES DE SALUD DE LA PEQUEÑA EMPRESA

A health insurance exchange that helps small business owners provide medical and dental insurance to their employees. Some smaller employers qualify for tax credits if they buy health insurance through the SHOP Marketplace.

Un intercambio de seguro médico que ayuda a que los dueños de pequeñas empresas a proporcionar seguro médico y dental a sus empleados. Algunos empleadores más pequeños cualifican para créditos fiscales si compran el seguro médico a través del mercado de SHOP.

SPECIALTY PHARMACY MANDATES

A requirement that a provider must obtain their drugs from a designated specialty pharmacy, instead of through a buy-and-bill method.

SPECIAL ENROLLMENT PERIOD / PERÍODO ESPECIAL DE INSCRIPCIÓN

A time outside of the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including loss of coverage, moving, getting married, having a baby, or adopting a child.

Un tiempo fuera del período de inscripción abierta en que puede suscribirse a un seguro médico. Cualifica para un período de inscripción especial si ha tenido ciertos acontecimientos de la vida, como pérdida de cobertura, mudarse, casarse, tener un bebé o adoptar un hijo.

STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP) / PROGRAMA ESTATAL DE ASISTENCIA DE SEGURO MÉDICO

A state program that gets funding from federal government to provide free local health coverage counseling to people with Medicare.

Un programa estatal financiado por el gobierno federal para proporcionar orientación local gratis sobre cobertura médica a las personas que tienen Medicare.

SUBSIDIZED COVERAGE / COBERTURA SUBSIDIADA

Health coverage available at reduced or no cost for people with incomes below certain levels.

Cobertura médica disponible a un costo reducido o sin costo a las personas con ingresos por debajo de ciertos niveles.

TREATMENT ADHERENCE

Following the treatment plan your healthcare provider prescribed. In other words, taking your medication correctly and following prescribed activities.

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