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The availability of medical care to a patient. This can be determined by location, transportation, type of medical services in the area, etc.
An event that is unforeseen, unexpected, and unintended.
Accidental Bodily Injury
Physical injury sustained as the result of an accident.
Period during which the insured incurs eligible medical expenses to satisfy a deductible.
Most group health insurance policies state that if an employee is not actively at work on the day the policy goes into effect, the coverage will not begin until the employee does return to work.
The actual amount charged by a physician for medical services rendered.
Accredited insurance mathematician who calculates premium rates, reserves, and dividends and who prepares statistical studies and reports.
Skilled, medically necessary care provided by medical and nursing personnel in order to restore a person to good health.
Additional Drug Benefit
Prescription drugs listed as commonly prescribed by physicians for patients' long-term use. Subject to review and change by the health plan involved. Also called drug maintenance list.
Only (ASO) Agreement
Contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, in which the insurer provides certain administrative services. These services may include actuarial support, plan design, claims processing, data recovery and analysis, benefits communication, financial advice, medical care conversions, data preparation for governmental reports, and stop-loss coverage.
Community rating adjusted by factors specific to a particular group. Also known as factored rating.
The number of hospital admissions for each 1,000 members of the health plan.
The number of admissions to a hospital (including outpatient and inpatient facilities).
Tendency of those who are poorer-than-average health risks to apply for, or maintain, insurance coverage.
The date on which a person's age, for insurance purposes, changes. In most Life Insurance contracts this is the date midway between the insured's natural birth dates. Health insurers frequently use the age of the previous birth date for rate determinations. On the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date, depending upon the way in which the rating structure has been established by that particular insurer.
Ages below and above which an insurance company will not accept applications or renew policies.
Compares the age and sex risk of medical costs of one group relative to another. An age/sex factor above 1.00 indicates higher than average risk of medical costs due to that factor. Conversely, a factor below 1.00 indicates a lower than average risk. This measurement is used in underwriting.
Age/Sex Rates (ASR)
Separate rates are established for each grouping of age and sex categories. Preferred over single and family rating because the rates and premiums automatically reflect changes in the age and sex content of the group. Also sometimes called table rates.
Insurance company representative licensed by the state who solicits, negotiates, or effects insurance contracts and who provides services to the policyholder for the insurer.
Allied Health Personnel
Health personnel who perform duties, which would otherwise have to be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors. Also called paramedical personnel.
Payments authorized for specific purposes with a maximum specified for each. In hospital policies, for instance, there may be scheduled benefits for X-rays, drugs, dressings, and other specified expenses.
The lesser of the actual charge, the customary charge and the prevailing charge. It is the amount on which Medicare will base its Part B payment.
Charges that qualify as covered expenses.
Health services that are more cost-effective than inpatient, acute care hospitals, such as skilled and intermediary nursing facilities, hospice programs, and in-home services.
Medical services provided on an outpatient (non-hospitalized) basis' Services may include diagnosis, treatment, surgery, and rehabilitation.
Institutions such as surgery centers, clinics, or other outpatient facilities that provide health care on an outpatient basis.
Health care services that patients receive from providers other than primary care physicians.
Benefits for miscellaneous hospital charges.
Amounts paid under Medicare as the maximum fee for a covered service.
Approved Health Care
Facility or Program
A facility or program that has been approved by a health care plan as described in the contract.
Assignment of Benefits
A method where the person receiving the medical benefits assigns the payment of those benefits to a physician or hospital.
A form of evidence of insurability where the insurance company's underwriting organization relies on physician's office notes, laboratory and x-ray examination results and operative notes to determine an applicant's state of health in lieu of requiring a medical examination. APS's are normally supplied by doctors at the request of the underwriter, subject to applicable state laws and regulations relating to the patient's right to privacy.
Average Cost Per Claim
The total cost of administrative and/or medical services divided by the number of units of exposure such as costs divided by number of admissions, or cost divided by number of outpatient claims, etc.
Average Length of Stay
The total number of patient days divided by the number of admissions and discharges during a specified period of time. This gives the average number of days in the hospital for each person admitted.
Average Wholesale Price
Under the Medicare catastrophic coverage act, payment for prescription drugs is limited to the lowest of the pharmacy's actual charge, the sum of the AWP for the drug plus an administrative allowance, or effective 1992, the 90th percentile of pharmacy charges.
The total amount which covers the cost of health care per person, minus any mental health or substance abuse services, pharmacy, and administrative charges.
Basic Hospital Expense
Hospital coverage providing benefits for room, board and miscellaneous expenses for a specified number of days.
The number of inpatient hospital days per 1,000 members of the health plan.
The maximum amount a person is entitled to receive for a particular service or services as spelled out in the contract with a health plan or insurer.
A description of what services the insurer or health plan offers to those covered under the terms of a health insurance contract.
Defines the period during which a Medicare beneficiary is eligible for Part A benefits. A benefit period is 90 days, which begins the day the patient is admitted to a hospital and ends when the individual has not been hospitalized for a period of 60 consecutive days.
The amounts submitted by a health care provider for services provided to a covered individual.
A receipt given for the payment that accompanies an application for insurance. If the policy is approved, the payment "binds" the company to make the policy effective from the date of receipt.
One method of determining which parent's medical coverage will be primary for dependent children. The parent whose birthday falls earliest in the year will be considered as having the primary plan.
A designation that a physician has successfully completed an approved educational program and evaluation process by the American Board of Medical Specialties (ABMS) which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in a given specialty.
A professional person or physician who is eligible to take a specialty examination.
Person licensed by the state that places business with several insurers; the broker, although paid a commission by the insurer, represents the buyer rather than the insurance company.
Coordination of Benefits. See Nonduplication of Benefits.
See Consolidated Omnibus Budget Reconciliation Act of 1986.
A method of paying for medical services on a per-person rather than a per-procedure basis. Under capitation, an HMO pays a doctor a fixed amount each month to take care of HMO members, regardless of how much or how little care each member needs.
Usually a commercial insurer contracted by the Department of Health and Human Services to process Part B claims payments.
Carry Over Provision
In major medical policies, allowing an insured who has submitted no claims during the year to apply any medical expenses incurred in the last three months of the year toward the new calendar year's deductible.
The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided.
A person, usually an experienced professional, who coordinates the services necessary under the case management approach.
This is an older name for Major Medical. See Major Medical.
Certificate of Authority
Issued by the state, it licenses the operation of an HMO.
Certificate of Insurance
Document that summarizes the provisions and benefits of an insurance contract. May be distributed in booklet form.
The services required in the treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.
Drugs that contain identical amounts of the same ingredients.
A situation where covered insureds must select one primary care physician. That physician is the only one allowed to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper model.
The amount you are required to pay for medical care in a fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. It is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
In Health Insurance, this term originally applied to policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability.
Under this rating system, the charge for insurance to all insureds depends on the medical and hospital costs in the community or area to be covered. Individual characteristics of the insureds are not considered at all.
One rate for all members of the group regardless of their status as single or members of a family.
A plan of insurance which has a low deductible, high maximum benefits, and a coinsurance feature. It is a combination of basic coverage and major medical coverage which has virtually replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.
A case management technique which allows insurers to monitor an insured's hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date.
It provides that if a premium accompanies an application, the coverage will be in force from the date of application or medical examination, if any, whichever is later, provided the insurer would have issued the coverage on the basis of the facts revealed on the application, medical examination and other usual sources of underwriting information. A Life and Health Insurance policy without a conditional binding receipt is not effective until it is delivered to the insured and the premium is paid.
A contract that provides that the insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions stated in the contract.
Budget Reconciliation Act (COBRA) of 1986
Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.
Allows terminated employees to continue their group health insurance coverage under certain conditions.
Consumer Price Index
A measure of the average change in prices over time in a fixed group of goods and services. In this report, all references to the CPI relate to the CPI for Urban Wage Earners and Clerical Workers (CPI-W).
This period runs from the effective date to the expiration date of the contract.
Right given to an insured person under a group insurance contract to change coverage, without evidence of medical insurability, to an individual policy upon termination of the group coverage. The conditions under which conversion can be made are defined in the master policy.
Coordination of Benefits
Method of integrating benefits payable under more than one health insurance plan so that the insured's benefits from all sources do not exceed 100 percent of allowable medical expenses or eliminate incentives to contain costs.
A specific charge you pay for a specific medical service. For example, you may pay $10 for an office visit or $5 for a prescription and the health plan covers the rest of the medical charges.
A Major Medical deductible that provides for a deductible, or "corridor," after the full payment of basic hospital and medical expenses up to a stated amount. In the event of further expenses, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and the deductible is that portion paid by the insured.
An agreement between a provider and the Health Care Financing Administration to provide health services to covered persons based on reasonable costs for service.
A situation where covered persons pay a portion of the health costs such as deductibles, coinsurance, or copayment amounts.
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.
A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements.
The purpose of creditable coverage is to give you credit for prior health care coverage. You will generally be deemed to have creditable coverage if your prior health care coverage was under one of the following:
In general, you should receive a certificate from your current plan or issuer when your coverage ceases, such as when you leave or change your job. The certificate should contain information demonstrating that you have creditable coverage.
If you do not receive a certificate and your new plan or issuer wants to apply a preexisting condition exclusion, ask your new plan or issuer to help you get a certificate from your old plan or issuer. If you still cannot get a certificate, you can use a variety of evidence to prove creditable coverage. Acceptable documentation includes: pay stubs that reflect a premium deduction, explanation of benefit forms (EOBs), a benefit termination notice from Medicare or Medicaid, and verification by a doctor or your former health care benefits provider that you had prior health coverage.
You may request a certificate from your plan or issuer at any time, free of charge. In fact, you can request a certificate ahead of time if you know you will be changing jobs.
Generally, a significant break in coverage is 63 days or more without any creditable coverage. Any coverage occurring prior to a break in coverage of 63 days would not have to be credited against a preexisting condition exclusion period. For example, John Doe had coverage for two years followed by a break in coverage for 70 days, and then resumed coverage for eight months. He would receive credit against any preexisting condition exclusion only for eight months of coverage; no credit would have to be given for the two years of coverage prior to the break of 63 days or more.