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Role description of the primary care physician in HMOs who serves to control utilization and referral of enrollees.
A drug which is exactly the same as a brand name drug and which is allowed to be produced after the brand name drug's patent has expired. It is also called a "generic equivalent."
Specified time (usually 30 days) following the premium due date during which insurance remains in force and a policyholder may pay the premium without penalty.
A procedure which allows a member of a health plan or a provider of benefits to express complaints and seek remedies.
Coverage of a number of individuals under one contract. The most common "group" is employees of the same employer.
The document provided to each member of a group plan. It shows the benefits provided under the group contract issued to the employer or other insured.
Group Model HMO
A health plan where a group of physicians is reimbursed for services they provide at a negotiated rate. The HMO also contracts with hospitals for the care of the patients of the physicians who belong to the group.
Contract under which an insured has the right, commonly up to a certain age, to continue the policy by the timely payment of premiums. Under renewable contracts, the insurer reserves the right to change premium rates by policy class.
An underwriting term used to describe the fact that a group insurance contract was issued without reference to any medical underwriting. All group participants are covered regardless of health history.
Home Health Agency
A certified facility approved by a health plan to provide services under contract.
Home Health Care
Care received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or choreworkers.
Health Care Financing Administration (HCFA)
The Health Care Financing Administration is now known as the Centers for Medicare and Medicaid Services. This is the federal government agency responsible for administering Medicare and federal participation in Medicaid.
A form used by underwriters to assist in evaluating groups or individuals to determine whether they are acceptable risks.
This refers to any kind of plan that covers health care services such as HMOs, insured plans, preferred provider organizations, etc.
Health Insurance (HI)
Insurance against loss by sickness or bodily injury. The generic form for those forms of insurance that provide lump sum or periodic payments in the event of loss occasioned by bodily injury, sickness or disease, and medical expense. The term Health Insurance is now used to replace such terms as Accident Insurance, Sickness Insurance, Medical Expense Insurance, Accidental Death Insurance, and Dismemberment Insurance. The form is sometimes called Accident and Health, Accident and Sickness, Accident, or Disability Income Insurance.
Health Insurance Association
of America (HIAA)
An association supported by Life and Health insurers to provide the research, public relations, education, and legislative base for the promotion of voluntary private Health Insurance.
Health Insurance Institute
The public relations arm of the Health Insurance Association of America. It provides for a flow of information from Health insurers to the public and from the public to the insurers.
Health Insurance Portability
and Accountability Act (HIPAA)
A federal law passed in 1996 that provided numerous protections for persons who were losing their insurance coverage due to changes in employment status. HIPAA provided for accessibility to coverage for a person who moved from one employer sponsored plan to another employer sponsored plan, by providing for guaranteed acceptance and waiver of pre-existing condition exclusions based upon the time covered under the prior employer plan.
HIPAA also addressed the issue of accessibility to coverage for a person who chose to leave an employer sponsored plan and obtain coverage in the individual market. If such person meets the qualifications under HIPAA as a Federally Eligible Individual ("FEI") he or she is entitled to coverage on a guaranteed issue basis in the individual market with a complete waiver of pre-existing condition exclusions. This coverage must be provided by an insurance company that is currently marketing insurance products in the individual market unless the state where the FEI resides has elected to provide coverage to FEI's under an alternative mechanism. The most prevalent alternative mechanism is a state risk pool.
Federally Eligible Individual, "FEI", is defined under HIPAA as a person who: 1. Has had at least 18 months of continuous coverage with no break in coverage greater than 63 days (may be longer in some states); 2. Most recent coverage was under a group health plan (defined as an employee welfare plan), a governmental plan or a church plan; 3. Is not eligible for coverage under a group health plan, Part A or B of Medicare, Medicaid or similar state plan; 4. Does not have other health insurance; and, 5. Has exhausted coverage under any federal or state continuation of coverage provisions (COBRA) if eligible.
(Health Maintenance Organization)
Prepaid health plans in which you pay a monthly premium and the HMO covers your cost of care to see doctors within their network at pre-negotiated rates. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. If you are an HMO member and you do not use the doctors, hospitals and clinics that participate in your plan's network, you will usually bear the cost of those medical services.
Health Service Agreement
The agreement between employer and the health plan which outlines a description of benefits, enrollment procedures, eligibility standards, etc.
The benefits covered under a health contract.
Plan Employer Data and Information Set)
HEDIS is NCQA's tool used by health plans to collect data about the quality of care and service they provide. HEDIS consists of a set of performance measures that tell how well health plans perform in key areas: quality of care, access to care and member satisfaction with the health plan and doctors. HEDIS requires health plans to collect data in a standardized way so that comparisons are fair and valid. Health plans can arrange to have their HEDIS results verified by an independent auditor.
An organization which is primarily designed to provide pain relief, symptom management and supportive services for the terminally ill and their families. Hospice care is covered under Part A of Medicare.
A contract whereby one or more hospitals agrees to provide benefits to members of a specific health plan.
Benefits payable for hospital room and board, plus miscellaneous charges resulting from hospitalization.
A form of insurance that provides reimbursement within contractual limits for hospital and specific related expenses arising from hospitalization caused by injury or sickness.
(Independent Practice Association)
An independent group of physicians who contract with an HMO to provide services for the HMO members. Some health insurance applications will ask for a physician's IPA number. It can usually be found in an online provider directory for the health plan or by calling the physician's office.
Services which are provided within the "authorized" service area as designated in the plan.
A provision in a policy that the insurer may not contest the validity of an insurance contract after it has been in force for two (sometimes three) years.
Traditional health insurance that usually covers a percentage of the cost of care (often 80%) after the consumer pays an annual deductible. Patients with indemnity coverage can choose any doctor or hospital for their care.
A policy that provides protection to a policyholder and/or his or her family; sometimes called personal insurance, as distinct from group and blanket insurance.
The time period during which prospective members can apply for coverage without providing evidence of insurability.
Risk management plan that, for a price, offers the insured an opportunity to share the costs of possible financial loss through an insurer.
Stipulation in an insurance policy that states the type of loss the policy covers and lists the parties to the contract.
A group of doctors, hospitals and other providers who work together to deliver a broad range of health care services.
A level of care associated with a skilled nursing facility which provides nursing care under the supervision of physicians or a registered nurse. The care provided is a step down from the degree of care described as skilled nursing care.
Intermediate Care Facility
A facility licensed by the state, which provides nursing care to persons who do not require the degree of care which a hospital or skilled nursing facility provides.