[ Close Window ]
[ A B C ] [ D E F ] [ G H I ] [ J K L ] [ M N O ] [ P Q R ] [ S T U ] [ V W X Y Z ]
Schedule (Surgical)
A list of specified amounts payable for surgical procedures, dismemberments,
ancillary expenses, and the like in hospital and medical reimbursement policies.
Second Surgical Opinion
A cost containment technique to help patients and insurance companies determine
whether a recommended procedure is necessary, or whether an alternative method
of treatment could accomplish the same result. Some health policies require
a second surgical opinion before specified procedures will be covered, and
many policies pay for the second opinion.
Secondary Care
Medical services provided by physicians who do not have first contact with
patients. Examples would be specialists such as urologists, cardiologists,
etc. See also Primary Care and Tertiary Care.
Secondary Coverage
Coverage which provides payment for charges not covered by the primary policy
or plan. See also Coordination of Benefits.
Section 125 Plan
A plan which provides flexible benefits. This plan qualifies under the IRS
code which allows employee contributions to meet with pre-tax dollars.
Self-Funded Plan
Plan of insurance where an employer, which has fairly predictable claim costs,
pays the claims rather than an insurance company. See also Administrative
Services Only.
Self-Inflicted Injury
An injury to the body of the insured inflicted by himself.
Service Area
The area, allowed by state agencies or by the certification of authority,
in which a health plan can provide services.
Service Plans
Plans of insurance where benefits are the actual services rendered rather
than a monetary benefit.
Short-term plans
Short-term plans are similar to standard, individual and family health plans,
except they are designed to provide coverage for only 1 to 6 months.
Skilled Nursing Care
Daily nursing and rehabilitative care that is performed only by or under the
supervision of skilled professional or technical personnel. Skilled care includes
administering medication, medical diagnosis and minor surgery.
Social Health Maintenance
Organization (SHMO)
A demonstration project funded by the Health and Human Services Department
that combines the delivery of acute and long term care with adult day care
services and transportation.
Social Security Tax
A tax paid by workers and employers on wages earned. The taxes support the
benefit programs under the Social Security System.
Staff Model HMO
This is an HMO where physicians are employed and all premiums are paid to
the HMO, which then compensates the physicians on a salary and bonus arrangement.
Stop-Loss Insurance
This is a type of reinsurance which can be taken out by a health plan or self-funded
employer plan. The plan can be written to cover excess losses over a specified
amount either on a specific or individual basis, or on a total basis for the
plan over a period of time such as one year.
Subscriber
This term has two meanings _ first, it refers to a person or organization
who pays the premiums, and second, the person whose employment makes him or
her eligible for membership in the plan.
Subscriber Contract
An agreement which describes the individual's benefits under a health care
policy.
Summary Plan Description
This is a recap or summary of the benefits provided under the plan. It is
used most often with employees covered by self-funded plans.
Supplementary Medical Insurance (SMI)
The Medicare program which pays for a portion of the costs of physician's
services, outpatient hospital services, and other related medical and health
services for voluntarily insured aged and disabled individuals. Also known
as Part B.
Surgical Schedule
Usually part of a basic medical expense plan which itemizes various surgical
procedures and the monetary benefit allocated to each procedure.
Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA)
This act defines the primary and secondary coverage responsibilities of the
Medicare program and also the provisions to be used by health plans in their
contracts with the Centers for Medicare and Medicaid Services (CMS).
Temporary
Partial Disability
A condition where an injured party's capacity is impaired for a time, but
he is able to continue working at reduced efficiency and is expected to fully
recover.
Temporary Total Disability
A condition where an injured party is unable to work at all while he is recovering
from injury, but he is expected to recover.
Tertiary Care
Services provided by such providers as thoracic surgeons, intensive care units,
neurosurgeons, etc.
Terminally Ill
A term which refers to the status of a person who will normally die within
6 months of a specific illness or sickness. Often refers to the terminally
ill requirement for hospice care.
Therapeutic Alternatives
Alternate drug products which may be different in chemical content, but provide
the same effect when administered to patients.
Therapeutic Equivalence
Different drugs which will control a symptom or illness exactly the same as
other drugs used to control that illness.
Third Party Administrator
(TPA)
A firm which provides administrative services for employers and other associations
having group insurance policies.
Time Limit on Certain
Defenses
One of the uniform individual accident and sickness provisions required by
state law to be included in every Individual Health Policy. It sets a limit
on the number of years after a policy has been in force that an insurer can
use as a defense against a claim the fact that a physical condition of the
insured existed before the policy was issued, but was not declared at that
time.
Treatment Facility
Any facility, either residential or nonresidential, which is authorized to
provide treatment for mental illness or substance abuse.
Trend Factor
The factor applied to rates which allows for such changes as increased cost
of medical providers, the cost of new and expensive medical technology, etc.
Triage
A method of ranking sick or injured people according to the severity of their
sickness or injury in order to ensure that medical and nursing staff facilities
are used most efficiently.
Triple Option
A plan where employees have their choice, among different types of provides
such as HMO, PPO, or basic indemnity plan. Usually, their choice depends on
how much they want to pay for the coverage.
Underwriting
Process by which an insurer determines whether or not, and on what basis,
it will accept an application for insurance.
Uniform Billing Code
of 1992 (UB-92)
This code is scheduled to be implemented on October 1, 1993. It's a federal
directive which states how a hospital must provide their patients with bills,
itemizing all services included and billed on each invoice.
Uniform Premium
A rating system that is used to calculate premiums for all insureds with no
distinctions as to age, sex or occupation.
Uniform Provisions
A set of provisions regarding the operating conditions of individual Health
policies developed in a model law recommended by the National Association
of Insurance Commissioners and required, with minor variations by almost all
jurisdictions, and permitted in all jurisdictions.
Uninsurables
High-risk persons who do not have health care coverage through private insurance
and who fall outside the parameters of risks of standard health underwriting
practices.
Usual, Customary, and
Reasonable (UCR)
See Reasonable and Customary.
Utilization
This refers to how much a covered group uses a particular health plan or program.
Utilization and Review
Committee
A committee composed of medical personnel whose purpose it is to monitor the
health care services and supplies provided to Medicare patients.
Utilization Management
This procedure or process utilizes a review coordinator to evaluate the necessity
and appropriateness of various health care services.
Utilization Review
A cost control mechanism by which the appropriateness, necessity, and quality
of health care is monitored by both insurers and employers.