Activities performed as part of a person's daily routine of self-care, such as bathing, dressing, toileting, transferring to and from bed and eating.
Someone who estimates insurance risks and premiums.
A registered patient, usually admitted for at least 24 hours, to a hospital, skilled nursing facility or other health care facility.
Services following hospitalization or rehabilitation.
Non-inpatient care received in a less intensive setting than a hospital or other inpatient facility (such as day-surgery center).
A formal request to review an action when you are not satisfied with a decision made by your health plan.
Assessment and treatment of mental or substance abuse disorders.
A person who receives insurance benefits.
The limit or amount of services a person is entitled to based on the contract with a health plan.
A company that manages or sells health benefit programs.
The process of identifying patients with specific health care needs and working with them and their physician(s) to provide the best treatments possible.
A nurse, doctor or social worker who works with patients, health care providers, physicians and insurers to determine and coordinate a health care plan. Tinatawag ring taga-ayos ng pangangalaga.
The federal agency responsible for administering Medicare and supervising states' administration of Medicaid.
A description of the benefits included in a health plan.
Information submitted by a provider or a covered person that establishes the specific health services provided to a patient and requests payment.
Reduced memory or reasoning.
A percentage of the cost of a service that you must pay to the provider for that service.
A dollar amount that you pay to the doctor at your visit.
The name for the step in a Medicare Part D prescription plan in which you pay all of your expenses for eligible drugs.
The date health care services were provided to the covered person.
The amount of eligible expense a covered person must pay each year out of pocket before the plan will pay.
An individual who relies on a member for financial support and/or obtains health coverage through a spouse, parent or grandparent who is the member.
Any condition resulting in functional limitations that interfere with someone’s ability to perform his/her customary work and that results in substantial limitation of one or more major life activities.
The evaluation of patients' medical needs in order to arrange for appropriate care after discharge from an inpatient setting.
A list of prescription medications preferred for use by the health plan and dispensed through contracted pharmacies to covered persons.
The date a contract becomes active.
The defined date a member becomes eligible for benefits under an existing contract.
Services designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems.
The amount an employer contributes toward the premium costs of the health plan.
Someone who is enrolled for coverage under a health plan contract.
Specific conditions or circumstances the policy or plan will not cover or reimburse.
The coverage statement that list services provided, amount billed and payment made.
A nursing home or nursing center that is licensed and typically provides 24-hour nursing care. Maaari itong mag-alok ng pangangalagang nakasanayan, nasa pagitan o pamproteksyon, o anumang kumbinasyon ng mga antas na ito ng pangangalaga.
A provision that allows medical coverage to continue past the end date of the policy for employees not actively at work and for dependents hospitalized on that date.
A physical location where health care or services are provided, such as a hospital, clinic, emergency room or ambulatory care center.
See drug formulary.
A generic drug is less expensive than a brand name drug and sold under a common or "generic" name for that drug. Tinatawag ring katumbas na generic.
Your statement of dissatisfaction with any part of your care. Ang isang daing ay maaaring maisampa sa pamamagitan ng pagtawag sa telepono o sa pagsulat, at dapat na maisampa nang direkta kasama ang inyong plano.
The services and coverage a health plan offers a group or individual.
The payment of benefits for covered sickness or injury. Maaaring kabilang nito ang pangangalagang dental, pang-medikal at paningin, gayundin ang ibang mga pakinabang.
A federal law intended to improve the availability and stability of health insurance coverage.
A company that provides or arranges for health services for its plan members.
Health maintenance organization, preferred provider organization, insured plan, self-funded plan or other group that covers health care services.
A facility or program licensed, certified or otherwise authorized according to state and federal laws to provide health care services in the home.
A facility or program that provides care for the terminally ill.
Any loss or abnormality of psychological, physiological or anatomical structure or function (e.g., hearing loss).
Health care received within the authorized service area from a contracted provider that is contracted with the health plan. Tinatawag ring mga serbisyong nasa loob ng network.
An individual who has been admitted to a hospital as a registered bed patient for at least 24 hours and is receiving services under the direction of a physician.
Assistance and care for people with chronic disabilities. Ang layunin ng pangmatagalang pangangalaga ay upang matulungan ang mga taong may mga kapansanan na mabuhay nang mag-isa hangga't maaari. Higit na nakatuon ito sa pangangalaga kaysa sa pagpapagaling.
The limit on total member copayments, deductibles and coinsurance under a benefit contract.
A federal program administered and operated by state governments that provides medical benefits to eligible low-income people needing health care. Ang mga gastos ng programa ay pinaghahatian ng mga pamahalaang pederal at estado.
A nationwide, federally-administered health insurance program that covers the costs of hospitalization, medical care, and some related services for eligible people, usually individuals age 65 and older and disabled individuals under age 65.
A person designated by Social Security as entitled to receive Medicare benefits.
A policy offered by an insurer that generally pays a policyholder's Medicare coinsurance, deductible and copayments for Medicare Parts A and B and may provide additional supplemental benefits, depending on the policy.
A person who enrolled in a health plan during the reporting period. Kabilang sa mga miyebro ang lahat ng mga tao na direktang naka-enroll (mga naka-enroll/subscriber) at ang kanilang karapat-dapat na mga umaasa. Kilala rin bilang saklaw na tao o kalahok sa plano.
A psychiatrist, licensed consulting psychologist, social worker, hospital or other facility duly licensed and qualified to provide mental health services under the law of the jurisdiction in which treatment is received.
A system of contracted physicians, hospitals and ancillary providers that provides health care to members.
A provider who has contracted with the health plan to deliver medical services to covered persons. Ang provider ay maaaring isang manggagamot, ospital, botika, ibang pasilidad o ibang provider ng pangangalaga sa kalusugan. Kilala rin bilang provider ng network o kalahok.
Coverage for treatment obtained by a covered person temporarily outside the network service area.
Coverage for treatment by a non-contracted provider. Bilang karaniwan, nangangailangan ito ng kabayaran ng nababawas at mas mataas na mga copayment at coinsurance kaysa sa panggagamot mula sa nakakontratang provider. Hindi nag-aalok ng mga pakinabang ang ilang mga planong pangkalusugan para sa panggagamot sa labas ng network, maliban sa mga emergency.
The portion of payments for covered health services required to be paid by the enrollee, including copayments, coinsurance and deductibles.
A person who receives health care services at a hospital or free-standing surgical center without being admitted to a hospital.
A drug product that does not require a prescription under federal or state law.
A provider who has contracted with the health plan to deliver medical services to covered persons. Ang provider ay maaaring isang manggagamot, ospital, botika, ibang pasilidad o ibang provider ng pangangalaga sa kalusugan. Kilala rin bilang network o in-network provider.
An organization that pays for health care expense coverage.
Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed and qualified under the law.
Any medical condition that has been diagnosed or treated within a specified period. Maaaring hindi saklaw ang matagal nang umiiral na mga kundisyon para sa ilang tinukoy na tagal ng panahon (karaniwan ay anim hanggang 12 (na) buwan).
The amount paid by member to a carrier for providing coverage under a contract.
A drug that has been approved by the Food and Drug Administration and which can, under federal or state law, be given only from a licensed physician or other practitioner with authority.
Health care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization and well-person care.
Basic or general health care, traditionally provided by family practice, pediatrics and internal medicine practitioners.
A physician, hospital, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.
A person whose income falls below 100% of federal poverty guidelines, for whom the state must pay the Medicare Part B premiums, deductibles and copayments.
The amount of money per enrollment classification paid to a carrier for medical coverage. Rates usually are charged on a monthly basis and can change.
The recommendation by a physician and/or health plan for a covered person to receive care from a different physician or facility. Minsan, kinakailangan para sa panggagamot ng mga espesyalista at para sa panggagamot sa labas ng network.
Benefits provided by employers to their retirees.
The medical opinion of another health care professional – to be compared against a medical diagnosis.
Services provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.
The geographic area serviced by the health plan.
A facility that accepts patients in need of rehabilitation and medical care.
Health plans tailored to meet the needs of people living with one or more chronic illnesses who are also eligible for Medicare.
A description of the entire benefits package available to an employee as required.
A residential or non-residential facility that provides treatment of substance abuse or mental illness.
An alternative to hospital emergency department care for use in non-emergencies. Ginagamit kapag pangmadalian ang mga kundisyong pangkalusugan, ngunit hindi banta sa kalusugan o buhay.
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