|
A |
Actual
Charge
The actual dollar amount charged by a
physician or other health provider for medical services
rendered, as distinguished from the allowable charge.
top
|
Acute Care
Medical care
administered, frequently in a hospital or by nursing
professionals, for the treatment of a serious injury or
illness or during recovery from surgery. Medical
conditions requiring acute care are typically periodic
or temporary in nature, rather than chronic.
top |
ASO ( or
Administration Services Only)
A business contract under which an
insurance company agrees to perform specific
administrative duties for the maintenance of a
self-funded health insurance plan.
top
|
Adverse Selection
The tendency of those who experience
greater health risks to apply for and continue their
coverage under any given
health insurance plan. When adverse selection
increases, health insurance companies experience
greater expenses and may raise rates.
top
|
Agent
A state-licensed individual or entity
representing one or more
health insurance companies. An agent solicits and
facilitates the sale of insurance contracts or
policies and provides services to the policyholder on
behalf of the insurer.
top
|
|
Allowable Charge
top |
|
Allowed Amount
(see Allowable Charge above) top |
Alternative Medicine
Any medical practice of form of
treatment not generally recognized as effective by the
medical community at large. Alternative medicine may
encompass a broad range of services and practices
including acupuncture, homeopathy, aromatherapy,
naturopathy, etc.. Although it is growing in
acceptance and popularity, many health insurance
companies do not provide coverage for these services.
top
|
|
B |
Benefit
A general term referring to any service
(such as an office visit, laboratory test, surgical
procedure, etc.) or supply (such as prescription
drugs) covered by a health insurance plan in the
normal course of a patient's healthcare.
top
|
Board Certified
A board-certified physician is one that
has successfully completed an educational program and
evaluation process approved by the American Board of
Medical Specialties, including an examination designed
to assess the knowledge, skills and experience
required to provide quality patient care in a specific
specialty.top
|
Broker
Sometimes used as a synonym for
agent, a health insurance broker typically works to
match applicants with a health insurance company or
plan best matched to their needs. The broker is paid a
commission by the health insurance company, but
represents the applicant rather than the insurance
company itself.
top
|
|
C |
|
Catastrophic Health
Insurance
Health Insurance Policy
with a very high deductible, covering an injury or
illness with medical expenses that are above the normal
parameters of basic health insurance. This is typically
purchased by individuals of very good health, who aren't
concerned with becoming ill, and are purchasing the
coverage to protect themselves against having a
catastrophic health situation.
top |
|
Claim
A health-related bill submitted for
payment to a health insurance company by the policy
holder or health care provider.
top |
COB ( or
Coordination of Benefits)
This is the process by which a health
insurance company determines if it should be the
primary or secondary payer of medical claims for a
patient who has coverage from more than one health
insurance policy.
top
|
COBRA
(Consolidated
Omnibus Budget Reconciliation Act of 1985)
Federal legislation allowing an
employee or an employee's dependents to maintain
group
health insurance coverage through an employer's
health insurance plan, at the individual's expense,
for up to 18 months in certain circumstances.
All companies that have averaged at least 20 full-time
employees over the past calendar year must comply with
COBRA regulations.
top
|
Coinsurance
The amount that you are obliged to pay
for covered medical services after you've satisfied
any co-payment or deductible required by your health
insurance plan. Coinsurance is typically expressed as
a percentage of the charge or allowable charge for a
service rendered by a healthcare provider. For
example, if your insurance company covers 80% of the
allowable charge for a specific service, you may be
required to cover the remaining 20% as coinsurance.
top
|
|
Consumer-driven
health plan
top |
Co-payment
A specific charge that your health
insurance plan may require that you pay for a
specific medical service or supply, also referred to
as a "co-pay." For example, your health insurance plan
may require a $15 co-payment for an office visit or
brand-name prescription drug, after which the health
insurance company often pays the remainder of the
charges.top
|
|
D |
Deductible
A specific dollar amount that your
health insurance company may require that you pay
out-of-pocket each year before your health insurance
plan begins to make payments for claims. Not all
health insurance plans require a deductible. As a
general rule (though there are many exceptions),
HMO plans typically do not
require a deductible, while most
Indemnity plans and
PPO plans do.
top
|
Dependent
Coverage
Health insurance coverage
extended to the spouse and unmarried children of the
primary insured member. Certain age restrictions on
the coverage of children may apply.
top
|
Drug
Formulary
A list of prescription medications
selected for coverage under a health insurance plan.
Drugs may be included on a drug formulary based upon
their efficacy, safety and cost-effectiveness. Some
health insurance plans may require that patients
obtain preauthorization before non-formulary drugs are
covered. Other health insurance plans may require that
a patient pay a greater share or all of the cost
involved in obtaining a non-formulary prescription.
top
|
Durable
Medical Equipment (DME)
Medical equipment used in the course of
treatment or home care, including such items as
crutches, knee braces, wheelchairs, hospital beds,
prostheses, etc.. Health Coverage levels for DME often
differ from coverage levels for office visits and
other medical services.
top
|
Discount Dental Plan
Discount dental plans are not technically
"insurance", but rather they provide a discount on
dental services rendered, typically 40-65%.top |
|
E |
|
Effective
Date
|
|
Eligible
Employee
|
Employee
Contribution
The portion of the health insurance
premium paid for by the employee, usually deducted
from wages by the employer.
top
|
Evidence
of Insurability
When applying for an
individual
health insurance plan, an applicant may be asked
to confirm his or her health condition in writing,
through a questionnaire or through a medical
examination. When applying for group health insurance,
evidence of insurability is only required in specific
cases (for instance, when a person fails to enroll in
the group plan during the enrollment period.
top
|
Exclusions
Specific conditions, services or
treatments for which a health insurance plan will not
provide coverage.
top
|
EOB (or
Explanation of Benefits)
A statement sent from the health
insurance company to a member listing services that
were billed by a healthcare provider, how those
charges were processed, and the total amount of
patient responsibility for the claim.
top
|
|
F |
|
Fee-for-service Plan
top |
|
Formulary
(see Drug Formulary)
top |
|
G |
Gatekeeper
A term used to describe the role of the
primary care physician in an HMO plan. In an HMO plan,
primary care physicians serves as the patient's main
point of contact for healthcare services and refer
patients to specialists for specific needs.
top
|
Generic
Drug
A drug which is exactly the same as a
brand name prescription drug, but which can be
produced by other manufacturers after the brand name
drug's patent has expired. Generic drugs are usually
less expensive than brand name drugs.
top
|
Group Health Insurance
A health insurance plan that provides
benefits for employees of a business or members of an
organization, as opposed to individual and family
health insurance.
top
|
Guaranteed Issue
A term used to describe insurance
coverage that must be issued regardless of health
status. In most states, group health insurance plans
are often described as guaranteed issue plans, because
a health insurance company generally cannot refuse
coverage to a qualifying business or organization
based on the health status of their employees or
members. In some states, all health insurance plans
are guaranteed issue.
top
|
|
Guaranteed Renewable
A contract under which the insured
person has the right (usually up to a certain age) to
renew and continue his or her health insurance policy
by the timely payment of premiums.
top |
|
H |
High
Deductible Health Plan
A High Deductible
Health Plan (HDHP) is a health
insurance plan with lower premiums
and higher deductibles than a
traditional health plan. It is
sometimes referred to as a
catastrophic health insurance plan.
A qualifying HDHP is required with a
Health Savings
Accounttop
|
HIPAA
Legislation mandating specific privacy
rules and practices for medical care providers and
health insurance companies, designed to streamline the
healthcare and insurance industries and to protect the
privacy and identity of healthcare consumers. HIPAA
also provides additional protections for consumers,
designed to help them obtain or retain health
insurance coverage in certain circumstances.
top
|
HMO (or
Health Maintenance Organization)
A health insurance plan or organization
that provides a wide range of comprehensive healthcare
services through a network of doctors, hospitals,
labs, etc. who agree to provide services to HMO
members at a pre-negotiated rate. As a member of an
HMO, you will need to see your primary care physician
for care or a referral to a specialist, except in case
of emergency. Your choice of doctors is often
restricted to those in the network. As an HMO member,
if you don't use the healthcare providers that
participate in your plan's network, you will usually
bear the full cost of these services.
top
|
|
HSA (or Health Savings Account)
top |
Home
Health Care
Part-time care that is provided by
medical professionals in the home setting rather than
in a hospital or skilled nursing facility.
top
|
Hospice
Care
Care rendered either on an inpatient
basis or in the home setting for a terminally ill
patient. Often referred to as "palliative" or
"supportive" care, hospice care emphasizes the
management of pain and discomfort and the emotional
support of the patient and family.
top
|
|
I |
Indemnity Plan
A health insurance plan that reimburses
the member or healthcare provider at a certain
percentage of charges for services rendered, often
after a deductible has been satisfied. Indemnity plans
typically place no restrictions on which providers a
member may visit for healthcare services. Indemnity
plans are also referred to as "fee-for-service"
plans. They offer great freedom in choosing your
healthcare provider, but may involve more paperwork
and out-of-pocket expenses for the member.
top
|
Individual Health Insurance
(or Family Health Insurance)
A type of health insurance policy
purchased by an individual or family, independent of
any employer group or organization. In most states, a
health insurance company may decline coverage for an
individual or
family health insurance plan based on the medical
conditions or health histories of the applicants or
dependents.top
|
Inpatient
A term used to describe a person
admitted to a hospital for at least 24 hours. It may
also be used to describe the care rendered in a
hospital when the duration of the stay is at least 24
hours.top
|
|
J |
|
K |
|
L |
Lifetime
Maximum
The maximum dollar amount that a health
insurance company agrees to pay on behalf of a member
for covered services during the course of his or her
lifetime.
top
|
Long Term Care
Care provided on a continuing basis for
the chronically ill or disabled. Long-term care may be
provided on an inpatient basis (at a long-term care
facility) or in the home setting.
top
|
|
M |
MSA
A tax-advantaged personal savings
account used in conjunction with a high-deductible
health insurance plan. MSAs are currently being
phrased out and replaced with HSAs.
top
|
Major Medical
Insurance
A type of medical insurance plan that
provides benefits for a broad range of healthcare
services, both inpatient and outpatient. Major medical
insurance plans often carry a high deductible.
top
|
Managed Care
A general term used to describe a
variety of healthcare and health insurance systems
that attempt to guide a member's use of benefits,
typically by requiring that a member coordinate his or
her healthcare through a primary care physician, or by
encouraging the use of a specific network of
healthcare providers. The management of healthcare is
intended to keep costs -and monthly premiums- as low
as possible. There are several different types of
managed care health insurance plans, including HMO,
PPO, and POS plans.
top |
Medicaid
A state-funded healthcare program for
low income and disabled personstop.
|
Medicare
A national, federally-administered
senior health
insurance program authorized in 1965 to cover the
cost of hospitalization, medical care, and some
related health services for seniors over age 65 and
certain other eligible individuals.top
|
Medicare Advantage
With the passage of the
Balanced Budget Act of 1997, Medicare
beneficiaries were given the option to
receive their Medicare benefits through
private health insurance plans,
instead of through the Original Medicare
plan (Parts A and B). These programs
were known as "Medicare+Choice" or "Part
C" plans. Later became known as
"Medicare Advantage" plans.
top |
Medicare Part D
Medicare Part D went into
effect on January 1, 2006. Anyone with
Part A or B is eligible for Part D. It
was made possible by the passage of the
Medicare Prescription Drug, Improvement,
and Modernization Act. In order to
receive this benefit, a person with
Medicare must enroll in a stand-alone
Prescription Drug Plan (PDP) or
Medicare Advantage plan with
prescription drug coverage (MA-PD).
These plans are approved and regulated
by the Medicare program, but are
actually designed and administered by
private health insurance companies.
top |
Medicare Supplemental
Insurance
Health insurance provided to an
individual or group that is intended to help fill in
the gaps in the coverage provided by Medicare.
top
|
|
Medigap coverage
(see Medicare Supplemental Insurance) top |
|
MedicareRx
(also see Medicare Part D) top |
|
Maternity Coverage top |
|
N |
NAIC (or
National Association of Insurance Commissioners)
The NAIC is a national association of
state officials charged with regulating insurance. The
NAIC was formed to help provide some measure of
national uniformity in insurance regulation.
top
|
Network
Provider
A healthcare provider who has a
contractual relationship with a health insurance
company. Among other things, this contractual
relationship may establish standards of care, clinical
protocols, and allowable charges for specific
services. In return for entering into this kind of
relationship with an insurance company, a healthcare
provider typically gains in numbers of patients and a
primary care physician may receive a capitation fee
for each patient assigned to his or her care.top
|
|
O |
Open
Enrollment Period
A time period during which eligible
persons or eligible employees may opt to sign up for
coverage under a group health insurance plan. During
an open enrollment period, applicants typically will
not be required to provide evidence of insurability.top
|
Out of
network care
Healthcare rendered to a patient
outside of the health insurance company's network of
preferred providers. In many cases, the health
insurance company will not pay for these services.top
|
Outpatient
A term referring to a patient who
receives care at a medical facility but who is not
admitted to the facility overnight, or for 24 hours or
less. The term may also refer to the healthcare
services that such a patient receives.top
|
|
P |
POS (or
Point of Service Plan)
A type of managed care health insurance
plan. Benefit levels vary depending on whether you
receive your care in or out of the health insurance
company's network of providers. POS plans combine
elements of both HMO and PPO plans. As a member of a
POS plan, you will likely be required to designate a
primary care physician who will then make referrals to
network specialists when needed. You may receive care
from non-network providers but with greater
out-of-pocket costs. With a POS plan, you may be
responsible for co-payments, coinsurance and an annual
deductible.top
|
PPO (or
Preferred Provider Organization)
A type of managed care health insurance
plan that allows you, as a member, to visit whatever
in-network physician or healthcare provider you wish
without first requiring a referral from a primary care
physician. Services will typically be covered at a
higher benefit level when rendered by a network
provider. As a member of a PPO plan, you will not be
required to choose a primary care physician, but may
self-refer to specialists of your choice. PPO plans
may require co-payments or coinsurance and almost
always require that you pay an annual deductible
before coverage begins.top
|
PCP ( or Primary Care
Physician)
Under an HMO or POS plan, a patient may
be required to choose a primary care physician. A
primary care physician usually serves as a patient's
main healthcare provider. The PCP serves as a first
point of contact for healthcare and may refer a
patient to specialists for additional services.
top
|
Pre-existing Condition
A health problem that existed or was
treated before the effective date of your health
insurance coverage. Most health insurance contracts
have a pre-existing condition clause that describes
conditions under which the health insurance company
will cover medical expenses related to a
pre-existing condition. For more information,
top
|
Private
Health insurance
is coverage by a health insurance
plan that provided through an employer, or union,
association or purchased by an individual from a
private health insurance company.top
|
|
Preventive Care top |
|
Q |
Qualifying Event
An event (such as
termination or employment, divorce or the death of
the employee) that triggers a group health insurance
member's protection under
COBRA benefits.
top
|
|
R |
Referral
The process through which a patient
under a managed care health insurance plan is
authorized by his or her primary care physician to a
see a specialist for the diagnosis or treatment of a
specific condition.top
|
|
S |
Self-funded health insurance plan
A health insurance plan that is
funded by an employer rather than through a health
insurance company. A health insurance company will
typically handle the administration of such a plan,
but the cost of claims will be paid for by the
employer through a fund set up for this purpose.
top
|
Service Area
The geographic area in which a health
insurance plan's benefits are made available. Some
health insurance plans will not provide
health
coverage outside of a plan's service area.
top
|
Short Term
plans
Short-term health insurance plans are
similar to
individual and family health insurance plans.
However, coverage typically extends for no more than
6 months and benefits are often less comprehensive
than those provided by a long-term health insurance
plan.top
|
Skilled
Nursing Care
Intensive care usually required
around the clock and rendered by, or under the
supervision of, a Registered Nurse or licensed
Practical Nurse. It is provided only when prescribed
by a doctor and usually on an inpatient basis at a
hospital or skilled nursing facility. Skilled
nursing care may include the administration of
medications, tube feeding, the changing of wound
dressings, and some types of minor surgery.
top
|
|
Subrogation
top |
Subscriber
This term may be used in two senses:
First, it may refer to the person or organization
that pays for health insurance premiums; Secondly,
it may refer to the person whose employment makes
him or her eligible for group health insurance
benefits.
top
|
|
T |
Terminally Ill
In healthcare and insurance usage,
this term is used to describe a person who is not
expected to live beyond six months due to a specific
illness.
top
|
Triage
A method of classifying sick or
injured patients according to the severity of their
conditions in order to ensure that medical
facilities and staff are most effectively utilized.
top
|
|
Temporary
health plan
(see Short Term Plans)
|
|
|
|
U |
Underwriting
The process by which a
health insurer determines whether it will
accept an application for insurance based upon risks
and projections, and through which a determination
on monthly premium is made.
top
|
UCR
charges (Usual, Customary, and Reasonable)
This refers to the standard or most
common charge for a particular medical service when
rendered in a particular geographic area. It is
often employed in determining Medicare payment
amounts.
top
|
Universal Healthcare
universal healthcare is health
coverage that is provided to all citizens of a
governed region, and is publicly funded via taxation
etc.
top
|
|
V |
Vision Coverage
An insurance plan typically offered
only on a group basis which covers routine eye
examinations and which may also cover all or part of
the costs associated with contact lenses or
eyeglasses.
top
|
|
W |
Well
Baby/ Well Child Care
Regularly scheduled,
preventive care
services, including immunizations, provided to
children up to an age specified by a health
insurance company or mandated by a government
agency. HMO and POS plans typically provide coverage
for well-baby care, though coverage for these
services may be limited under a PPO or
fee-for-service plan.
top |
|
|