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Access
The availability of medical care to a patient. This can be determined by location,
transportation, type of medical services in the area, etc.
Accident
An event that is unforeseen, unexpected, and unintended.
Accidental Bodily Injury
Physical injury sustained as the result of an accident.
Accumulation Period
Period during which the insured incurs eligible medical expenses to satisfy
a deductible.
Actively-at-work
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.
Actual Charge
The actual amount charged by a physician for medical services rendered.
Actuary
Accredited insurance mathematician who calculates premium rates, reserves,
and dividends and who prepares statistical studies and reports.
Acute Care
Skilled, medically necessary care provided by medical and nursing personnel
in order to restore a person to good health.
Additional Drug Benefit
List
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.
Administrative Services
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.
Adjusted Community
Rating (ACR)
Community rating adjusted by factors specific to a particular group. Also
known as factored rating.
Admissions/1,000
The number of hospital admissions for each 1,000 members of the health plan.
Admits
The number of admissions to a hospital (including outpatient and inpatient
facilities).
Adverse Selection
Tendency of those who are poorer-than-average health risks to apply for, or
maintain, insurance coverage.
Age Change
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.
Age Limits
Ages below and above which an insurance company will not accept applications
or renew policies.
Age/Sex Factor
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.
Agent
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.
Allocated Benefits
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.
Allowable Charge
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.
Allowable Costs
Charges that qualify as covered expenses.
Alternate Delivery
System
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.
Ambulatory Care
Medical services provided on an outpatient (non-hospitalized) basis' Services
may include diagnosis, treatment, surgery, and rehabilitation.
Ambulatory Setting
Institutions such as surgery centers, clinics, or other outpatient facilities
that provide health care on an outpatient basis.
Ancillary Services
Health care services that patients receive from providers other than primary
care physicians.
Ancillary Benefits
Benefits for miscellaneous hospital charges.
Approved Charge
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.
Attending Physician
Statement (APS)
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
(ALOS)
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
(AWP)
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.
Base Capitation
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
Insurance
Hospital coverage providing benefits for room, board and miscellaneous expenses
for a specified number of days.
Bed Days/1,000
The number of inpatient hospital days per 1,000 members of the health plan.
Benefit Levels
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.
Benefit Package
A description of what services the insurer or health plan offers to those
covered under the terms of a health insurance contract.
Benefit Period
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.
Billed Claims
The amounts submitted by a health care provider for services provided to a
covered individual.
Binding Receipt
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.
Birthday Rule
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.
Board-certified
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.
Board Eligible
A professional person or physician who is eligible to take a specialty examination.
Broker
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.
COB
Coordination of Benefits. See Nonduplication of Benefits.
COBRA
See Consolidated Omnibus Budget Reconciliation Act of 1986.
Capitation
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.
Carrier
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.
Case Management
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.
Case Manager
A person, usually an experienced professional, who coordinates the services
necessary under the case management approach.
Catastrophe Policy
This is an older name for Major Medical. See Major Medical.
Certificate of Authority
(COA)
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.
Chemical Dependency
Services
The services required in the treatment and diagnosis of chemical dependency,
alcoholism, and drug dependency.
Chemical Equivalents
Drugs that contain identical amounts of the same ingredients.
Closed Panel
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.
Coinsurance
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.
Commercial Policy
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.
Community Rating
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.
Composite Rate
One rate for all members of the group regardless of their status as single
or members of a family.
Comprehensive Major
Medical
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.
Concurrent Review
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.
Conditional Binding
Receipt
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.
Conditionally Renewable
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.
Consolidated Omnibus
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.
Continuation
Allows terminated employees to continue their group health insurance coverage
under certain conditions.
Consumer Price Index
(CPI)
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).
Contract Year
This period runs from the effective date to the expiration date of the contract.
Conversion Privilege
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
(COB)
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.
Copayment
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.
Corridor Deductible
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.
Cost Contract
An agreement between a provider and the Health Care Financing Administration
to provide health services to covered persons based on reasonable costs for
service.
Cost Sharing
A situation where covered persons pay a portion of the health costs such as
deductibles, coinsurance, or copayment amounts.
Covered Expenses
Health care expenses incurred by an insured or covered person that qualify
for reimbursement under the terms of a policy contract.
Covered Person
A person who pays premiums into the contract for the benefits provided and
who also meets eligibility requirements.
Creditable Coverage
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:
Creditable coverage does not include:
How do I show that I have creditable coverage?
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.