Health Care Terms
Learn what the terms mean that your provider uses. Many of these word meanings are also in your member handbook.
| Term | Definition |
|---|---|
| Appeal | A written or verbal request for a decision to be reversed. |
| Co-payments | A co-payment is a fixed amount that a patient pays out of pocket for certain health care services. A co-payment may be charged for services like a doctor’s visit or prescriptions in some cases. As a HIP member, you do not have copays. HHW members have copays for some services. |
| Durable medical equipment (DME) | Devices that are for long-term use to help you manage a health condition or disability. A provider usually prescribes DME. These are items like wheelchairs, hospital beds, oxygen supplies and more. |
| Emergency medical condition | A serious health situation that needs immediate medical attention to prevent serious harm, disability, or death. |
| Emergency medical transportation | Urgent transport of a person who has a medical emergency to a health care facility. This type of transport is typically by ambulance. |
| Emergency room (ER) care | Care that a person gets in a hospital’s ER. |
| Emergency services | Services that are needed to check, treat or stabilize an emergency medical condition. |
| Excluded services | These are services that are not covered by a health insurance plan. This means that if you need these services, you will have to pay for them out of your own pocket. |
| Grievance | A complaint about CareSource or its providers. |
| Habilitation services and devices | These services help people learn or improve skills they need for daily life. They can include things like special therapy, training, or tools like wheelchairs. |
| Health insurance | A plan through an insurance provider, like CareSource. It helps you pay for your doctor visits, medicine and hospital care. |
| Home health care | Medical help that comes to your home, like nurses or therapists. They help you with health needs. They may help with care like taking medicine, healing from surgery, or getting physical therapy. It makes it easier for you to get care without going to a hospital. |
| Hospice services | Special care for people who are very sick and not expected to get better. This care focuses on making them comfortable and helping them feel better in their last days. Hospice workers support the patient and their family with medical help, emotional support, and help with daily needs. |
| Hospitalization | When a person stays in a hospital to get health care. This can happen if someone is very sick or hurt and needs help from doctors and nurses. They stay in the hospital until they are well enough to go home. |
| Hospital outpatient care | Medical care that you get at a hospital but do not stay overnight. You go to the hospital and get the care you need, and then go home the same day. This could be for things like check-ups, tests, or minor surgeries. |
| Medically necessary | When a doctor says you need a certain health care or service to help you get better or stay healthy. It is vital for your health and helps you with a medical problem. |
| Network | A group of doctors, hospitals, and other providers that work together. CareSource has a network of providers you can go to for care. |
| Non-participating provider | A licensed health care professional who has not signed a contract to give services. This could be a doctor, hospital or other provider. |
| Physician services | Medical care and help you get from a doctor. This can include check-ups, advice about your health, and care for illnesses or injuries. |
| Plan | Health insurance, like CareSource, that helps pay for your medical care. It tells you what services you can use, like doctor visits and medicine, and how much you must pay for them. |
| Preauthorization or prior authorization | When CareSource needs to approve a health care service or drug before you get it. This makes sure it is the best care for you. It also makes sure that it will be covered. Your provider will take care of this for you. |
| Participating provider | A licensed health care professional who has signed a contract agreeing to give services. This could be a doctor, hospital or other provider. |
| Premium | The cost paid each month for health insurance. Not all health plans have premiums. It helps cover your medical care, like doctor visits and medicine. |
| Prescription drug coverage | Part of health insurance that helps pay for the medicine your doctor gives you. This means you pay less money when you buy your medicine at the pharmacy. |
| Prescription drugs | A provider’s order for a pharmacy to fill and give medicine to their patient. |
| Primary care physician | A type of doctor who helps take care of your health. They know your medical history and can help with check-ups, minor illnesses, and any health questions you have. |
| Primary medical provider (PMP) | A health care provider you have chosen in network. Your PMP works with you to meet your health goals. They can give you checkups and shots. They can also treat you for most of your health care needs or send you to specialists. |
| Provider | A person or place that gives you medical care. This can be a doctor, nurse, hospital, or clinic. They help you stay healthy, treat illnesses, and give advice about your health. |
| Rehabilitation services and devices | These services and devices help people heal and get back to their daily life after an injury or illness. These services might be things like therapy to help with movement or speech. Devices are tools like walkers or braces that help people move better or stay safe while they heal. |
| Skilled nursing care | Special health care given by trained nurses. This care is for people who need extra support because they are sick or healing from surgery. Nurses give medicine, help with health needs, and check on how the person is doing to make sure they are safe and healthy. |
| Specialist | A health care provider who focuses on a specific kind of health care (like a surgeon or a heart doctor.) |
| Urgent care | A type of medical service for people who need help quickly but are not in a life-threatening situation. You can go to urgent care for things like minor injuries, illnesses, or when you can’t see your regular doctor. They help you get better without having to go to the ER. |