Actual Charge
The actual dollar amount charged by a physician or other health provider for medical services rendered, as distinguished from the allowable charge.
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.
ASO (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.
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.
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.
Allowable Charge
The lesser of the actual charge, the customary charge and the prevailing charge.
Allowed Amount (see Allowable Charge above)
Alternative Medicine
Any medical practice or 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.
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.
Board Certified
A board-certified physician is one who 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.
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.
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.
Claim
A health-related bill submitted for payment to a health insurance company by the policy holder or health care provider.
COB (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.
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.
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.
Consumer-driven health plan Health insurance plans that allow members to use personal Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs), or similar medical payment products to pay routine health care expenses directly, while a high-deductible health insurance policy protects them from catastrophic medical expenses.
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.
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.
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.
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 pre-authorization 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.
DME (Durable Medical Equipment)
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.
Discount Dental Plan
Discount dental plans are not technically "insurance", but rather they provide a discount on dental services rendered, typically 40-65%.
E
Effective Date
The date on which your health insurance coverage comes into effect.
Eligible Employee
An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan.
Employee Contribution
The portion of the health insurance premium paid for by the employee, usually deducted from wages by the employer.
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).
Exclusions
Specific conditions, services or treatments for which a health insurance plan will not provide coverage.
EOB (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.
F
Fee-for-service Plan
A fee for service plan (also called indemnity insurance) is a type of health care insurance in which payment to health care providers are paid at the time of service.
Formulary (see Drug Formulary)
G
Gatekeeper
A term used to describe the role of the primary care physician in an HMO plan. In an HMO plan, the primary care physician serves as the patient's main point of contact for healthcare services and refers patients to specialists for specific needs.
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.
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.
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.
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.
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 Account 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.
HMO (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.
HSA (or Health Savings Account)
Is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier.
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.
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.
I
Indemnify
to make compensation to for incurred hurt, loss, or damage
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.
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.
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.
Insurance Policy
An Insurance contract (or policy) determines the legal framework under which the features of an insurance policy are enforced. Insurance contracts are designed to meet very specific needs and thus have many features not found in many other types of contracts. Many features are similar across a wide variety of different types of insurance policies.
Insured
The person, group, or property for which an insurance policy is issued.
Insurer
The party to an insurance arrangement who undertakes to indemnify for losses.
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.
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.
M
MSA
A tax-advantaged personal savings account used in conjunction with a highdeductible health insurance plan. MSAs are currently being phrased out and replaced with HSAs.
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.
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.
Medicaid
A state-funded healthcare program for low income and disabled persons
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.
Medicare Advantage
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries weregiven 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. 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 (MAPD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies.
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. Medigap coverage (see Medicare Supplemental Insurance)
MedicareRx (also see Medicare Part D)
Maternity Coverage
This coverage usually includes prenatal care from the first obstetric (OB) visit, labor and delivery, postpartum care for up to six weeks after the birth of the child, and treatment of complications. These benefits can vary from company to company.
N
NAIC (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.
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.
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. 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.
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.
P
POS (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.
PPO (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.
PCP (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.
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.
Private Health insurance
Coverage by a health insurance plan that is provided through an employer, or union, association or purchased by an individual from a private health insurance company.
Preventive Care
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.
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.
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.
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.
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.
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.
Subrogation
Typically, subrogation occurs whenan insurance company which pays its insured client for injuries and losses then sues the party which the injured person contends caused the damages to him/her.
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.
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.
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.
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. 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.
Universal Healthcare
Health coverage that is provided to all citizens of a governed region, and is publicly funded via taxation etc.
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.
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.
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