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Clinton's Health Plan : Health Plan: A User's Guide : HEALTH CARE DICTIONARY

September 26, 1993

The debate over health care reform can be as indecipherable as a doctor's handwriting. Here is a glossary of the terms and labels that come up again and again:

CAPITATED PAYMENT

A fixed annual fee paid by an insurer to a doctor, hospital or network to care for a patient.

CO-INSURANCE OR CO-PAYMENT

The amount a health insurance policy requires the customer to pay for medical and hospital service, after payment of a deductible. This might be a percentage, such as 20% of a bill, or a certain amount, such as $10 for each office visit.

COST SHIFTING

Low reimbursement rates from government health care programs, such as Medicare and Medicaid often cause doctors and hospitals to increase the prices they charge for treating patients covered by private insurance carriers.

EXPERIENCE RATING

A method of calculating health insurance premiums for a group based on the risks the group presents through its actual illness and hospitalization rates. An employer whose workers are comparatively unhealthy will pay higher rates than a company where no one was sick last year.

FEE FOR SERVICE

The traditional payment system in which patients or insurers are billed by physicians and hospitals for each service rendered.

GATEKEEPER

In a managed care network, this term is given to your regular physician, who controls patient access to specialists.

GLOBAL BUDGETS

Spending ceilings for all health expenditures, public and private, set by the government.

HEALTH MAINTENANCE ORGANIZATIONS (HMO)

A network of doctors and hospitals that provides all care at a set price. Patients are limited to seeing doctors or hospitals within the network. It combines the health care provider and insurance functions by offering pre-paid care.

LONG-TERM CARE

A continuum of maintenance, custodial, and health services to the chronically ill, disabled, or retarded.

MEDICAID

A state-federal program for low-income people who cannot afford medical care on their own. Called Medi-Cal in California. The programs will be folded into the new plan, if passed.

MEDICARE

Federal health insurance program for those 65 and over and the disabled. Unlike Medicaid, eligibility is not based on a person's income. At this time, Medicare would not be part of the new national health system.

OPEN ENROLLMENT PERIOD

Time during which uninsured employees may join a health care plan or insured employees can switch plans.

POINT OF SERVICE

A term that applies to certain health maintenance organizations and preferred provider organizations. Members in a point of service HMO or PPO can go outside the network of doctors for their care, but they will have to personally pay a bigger share of the bill.

PRE-EXISTING CONDITION

A physical or mental condition someone has before being insured. Policies may exclude coverage for such conditions for a specified period of time. This practice would not be allowed under the Clinton plan.

PREFERRED PROVIDER ORGANIZATIONS (PPO)

A network of doctors and hospitals that agree to discounted fees and certain rules and standards of treatment in exchange for assurances they'll receive a certain number of patients. Members can go outside the network for care, but they receive lower reimbursement.

RISK POOLS

Arrangements by states to provide health insurance to the unhealthy uninsured who have been rejected for coverage by insurance carriers.

SINGLE-PAYER

A system in which the government pays all covered medical bills. Canada has a single-payer system.

TAX CAP

A limit on tax writeoffs for health insurance that could apply to businesses or employees or both

UNIVERSAL COVERAGE

Providing insurance for all citizens, regardless of health, employment or income.

Sources: Times staff and wire reports, Columbia Journalism Review

TWO KEY TERMS

Managed Competition

A system in which insurance companies and health maintenance organizations (HMOs) bid for business, and consumers pick from among competing health plans. Managed competition's premise is that the current market for health care is not competitive enough.

Proponents say: Market pressure will produce greater savings and efficiency.

Critics say: With a government-imposed limit on total spending, competitive pressures could lead providers to deny necessary services.

Managed Care

If you belong to a health maintenance organization or a preferred provider network, you're already under a form of managed care. Managed care holds down costs by requiring pre-admission approval for hospital stays and by closely monitoring other medical services. Managed care plans rely on a network or group of doctors whose reimbursements are limited by advance agreement.

Basics of Clinton Plan

Here is a broad outline of how the President's plan would work:

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