ERISA (Employment Retiree Income Security Act of 1974):
Federal legislation designed to protect the rights of retirees and beneficiaries of benefit plans offered by employers.
The date on which health insurance coverage comes into effect.
The date on which a person becomes eligible for insurance benefits.
Conditions that must be met in order for an individual or group to be considered eligible for insurance coverage.
A dependent (usually spouse or child) of an insured person who is eligible for insurance coverage.
An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan.
Expenses defined by the health insurance plan as eligible for coverage.
This term is used to designate a person who is eligible for insurance coverage even though he or she may not be an employee, but rather a member of an organization or union.
Typically, emergency room services include all services provided when a patient visits an emergency room for an emergency condition. An emergency condition is any medical condition of recent onset and severity, including but not limited to severe pain, that would lead to a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organ or part.
The portion of the health insurance premium paid for by the employee, usually deducted from wages by the employer.
The portion of an employee's health insurance premium paid for by the employer.
Employer Wage and Tax Statement:
An employer tax reporting statement submitted to the applicable governmental agency to establish and report the employer's tax responsibilities.
An eligible person or eligible employee who is enrolled in a health insurance plan. Dependents are not referred to as enrollees.
The process through which an approved applicant is signed up with the health insurance company and coverage is made effective. This term may also be used to describe the total number of enrollees in a health insurance plan.
The period of time during which an eligible employee or eligible person may sign up for a group health insurance plan.
EPO(Exclusive Provider Organization):
An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.
PPACA requires all health insurance plans sold after 2014 to include a basic package of benefits including hospitalization, outpatient services, maternity care, prescription drugs, emergency care, and preventive services among other benefits. It also places restrictions on the amount of cost-sharing that patients must pay for these services.
The amount quoted is an estimated cost of the health plan, which is subject to change during the enrollment process of the health plan, the optional benefits you selected, if any, and other relevant factors. It may be the sum of estimated premiums and other recurring charges, if the insurance company has such charges.
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).
In health insurance usage, this generally refers to a medical examination performed as part of an application for a life or health insurance plan. See, Evidence of Insurability.
Specific conditions, services or treatments for which a health insurance plan will not provide coverage.
Experimental or Investigational Procedures:
Any healthcare services, supplies, procedures, therapies or devices the effectiveness of which a health insurance company considers unproven. These services are generally excluded from coverage.
Explanation of Benefits (EOB):
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.
A provision of some health insurance plans allowing for coverage of certain healthcare services after the member is no longer covered on the plan. For example, a member's maternity benefits may be extended beyond the expected end of coverage if the woman was already receiving covered maternity services.
Extension of Benefits:
A provision of some health insurance plans allowing for coverage to be extended beyond a scheduled termination date. The extended coverage is made available only when the member is disabled or hospitalized as of the intended termination date, and continues only until the patient leaves the hospital or returns to work.
please note, however, that definitions of certain terms may vary across insurance companies.