- 24-Hour Approval
- "24-Hour Approval" is a special feature offered on some health insurance plans. When you apply for coverage under plans offering "24-Hour Approval," you can be advised via email of the insurance company's coverage decision within 24 hours.
- A network plan may be right for you if
- Your favorite doctor already participates in the network (use our Doctor Finder tool to find out).
- You want some freedom to direct your own health care but don't mind working within a network of preferred providers.
- A POS plan may be right for you if
- You're willing to play by the rules and possibly coordinate your care through a primary care physician.
- Your favorite doctor already participates in the network (use our Doctor Finder tool to find out).
- A PPO may be right for you if
- Your favorite doctor already participates in the PPO (use our Doctor Finder tool to find out).
- You want some freedom to direct your own health care but don't mind working within a list of preferred providers.
- The availability of medical care. The quality of one's access to medical care may be determined by location, transportation options, the type of medical care facilities available in the area, etc.
- For health insurance purposes, an accident is an unforeseen, unexpected, and unintended event resulting in bodily injury.
- Accumulation Period
- The period of time during which an insured person incurs eligible medical expenses toward the satisfaction of 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 returns to work.
- Actual Charge
- The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
- A person professionally trained in the mathematical and statistical aspects of the insurance industry. Actuaries frequently calculate premium rates, reserves, and dividends and assist in estimating the costs and savings of benefit changes.
- An alternative method of relieving pain by placing needles into a person's skin at particular points on the body. Typically, acupuncture services are performed by a licensed acupuncturist, and like many alternative medicine methods, this may not be covered by health insurance plans.
- Acute Care
- Medical care administered for the treatment of a serious injury or illness or during recovery from surgery, frequently in a hospital or by nursing professionals. Medical conditions requiring acute care are typically periodic or temporary in nature, rather than chronic.
- Administrative Services Only (ASO) Agreement
- A business contract under which an insurance company agrees to perform specific administrative duties for the maintenance of a self-funded health insurance plan.
- A statistic used by health insurance companies describing the number of hospital admissions for each 1,000 persons covered under a health insurance plan within a given time period.
- Hospital admissions. A term used to describe the number of persons admitted to a hospital within a given period.
- Adverse Selection
- The tendency of those who experience greater health risks to apply for and continue their coverage under any given health insurance plan. When adverse selection increases, health insurance companies experience greater expenses and may raise rates.
- Age Change
- For insurance purposes, this is the date on which a person's age changes. Note that this may not correspond with the individual's actual birthday, but may fall midway between birthdays. An age change may result in an increase in rates.
- Age Limits
- Ages below and above which an insurance company will not accept applications or renew policies.
- Age/Sex Factor
- A factor employed by insurance companies in the underwriting process, used to determine a group's risk of incurring medical costs, based on the ages and genders of the persons in that group.
- A state-licensed individual or entity representing one or more insurance companies. An agent solicits and facilitates the sale of insurance contracts or policies and provides services to the policyholder on behalf of the insurer.
See also Broker.
- Allied Health Personnel
- Also referred to as paramedical personnel, these are health workers (often licensed) who perform duties that would otherwise be performed by physicians, optometrists, dentists, podiatrists, nurses, and chiropractors.
- Allowable Charge
- The dollar amount typically considered payment-in-full by an insurance company and an associated network of health care providers. The Allowable Charge is typically a discounted rate rather than the actual charge. For example: You visit your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company's network of providers, he or she may be required to accept $80 as payment-in-full for the visit -- this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any copayment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. However, if the doctor is not a network provider, then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100. This term may also be used within a Medicare context to refer to the amount that Medicare considers payment-in-full for a particular, approved medical service or supply. Also referred to as the Allowed Amount, Approved Charge, or Maximum Allowable. See also, Usual, Customary, and Reasonable Charge.
- Allowable Costs
- Charges for health care services and supplies for which benefits are available under your health insurance plan.
- Alternate Delivery System
- Health care services or facilities which "deliver" care that is more cost-effective than what is provided in a hospital. Alternate Delivery Systems may include skilled nursing facilities, hospice programs, and home health care services.
- Alternative Medicine
- Any medical practice of form of treatment not generally recognized as effective by the medical community at large. Alternative medicine may encompass a broad range of services and practices including acupuncture, homeopathy, aromatherapy, naturopathy, etc. Many insurance companies do not provide coverage for these services.
- Ambulatory Care
- Medical care rendered on an outpatient basis and that may include diagnosis, certain forms of treatment, surgery, and rehabilitation. See also Ambulatory Setting.
- Ambulatory Setting
- Medical facilities such as surgery centers, clinics, and offices where health care is provided on an outpatient basis.
- An HMO may be right for you if
- You're willing to play by the rules and coordinate your care through a primary care physician.
- You're looking for comprehensive benefits at a reasonable monthly premium.
- You value preventive care services coverage for check-ups, immunizations, and similar services, which are often emphasized by HMOs.
- An indemnity plan may be right for you if
- You want the greatest level of freedom possible in choosing which doctors or hospitals to visit.
- You don't mind coordinating the billing and reimbursement of your claims yourself.
- Ancillary Fee
- An extra fee sometimes associated with obtaining prescription drugs which are not listed on a health insurance plan's formulary of covered medications.
- Ancillary Products
- Additional health insurance products (such as vision or dental insurance) that may be added to a medical insurance plan for additional fees.
- Ancillary Services
- Supplemental health care services such as laboratory work, X-rays, or physical therapy that are provided in conjunction with medical or hospital care.
- Annual Limit
- Many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. Beginning September 23, 2010, PPACA phased out annual dollar limits over the next 3 years until 2014, when they will not be permitted for most plans. There is an exception to this phase-out for Grandfathered Plans.
Beginning September 23, 2012, annual limits can be no lower than $2 million, except for Grandfathered Plans. Beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited, except for Grandfathered Plans.
- Application Fee
- The health insurance company may require a one-time application fee. Some insurance companies may refund this fee if the application is not approved.
- Approved Health Care Facility or Program
- A medical facility or health care program (often organized through a hospital or clinic) that has been approved by a health insurance plan to provide specific services for specific conditions.
- Assignment of Benefits
- The payment of health insurance benefits to a health care provider rather than directly to the member of a health insurance plan.
- Attending Physician Statement (APS)
- A physician's assessment of a patient's state of health as outlined in office notes and test results compiled by the physician. An APS may be requested by an insurance company in lieu of a medical examination to determine the state of a health insurance applicant's health for underwriting purposes.
- Balance Billing
- The amount you could be responsible for (in addition to any copayments, deductibles, or coinsurance) if you use an out-of-network provider and the fee for a particular service exceeds the allowable charge for that service.
- Bed Days/1,000
- A statistic used by health insurance companies describing the number of inpatient hospital days for each 1,000 persons covered under a health insurance plan within a given time period.
- A general term referring to any service (such as an office visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by a health insurance plan in the normal course of a patient's health care.
- Benefit Level
- The maximum amount a health insurance company agrees to pay for a specific covered benefit.
- Benefit Package
- A description of the health care services and supplies that a health insurance company covers for members of a specific health insurance plan.
- Benefit Riders
- This term may be used to describe ancillary products purchased in conjunction with a medical insurance plan.
- Benefit Year
- The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.
- Binding Receipt
- When you submit an application for health insurance and include an initial payment, the health insurance company may provide you with a binding receipt. A binding receipt indicates that, if coverage is approved, the health insurance company is required to initiate coverage from the date on which payment was received.
- Birthday Rule
- One method used by health insurance companies to determine which parent's health insurance coverage will be primary for a dependent child if each parents have separate coverage. Typically, the health insurance plan of the parent whose birthday falls earliest in the year will be considered primary. For more information, see also, COB.
- A board-certified physician is one that has successfully completed an educational program and evaluation process approved by the American Board of Medical Specialties, including an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in a certain specialty.
- Though sometimes used as synonymous with the term agent, a broker typically works to match applicants with a health insurance company or plan best matched to their needs. The broker is paid a commission by the insurance company, but represents the applicant rather than the insurance company itself.
- Business License
- A license from a governmental agency authorizing an individual or an employer to conduct business.
- Business Structure
- A state-designated legal structure that governs business taxes, liability, and operational requirements. Examples include sole proprietorship, partnership, corporation, or LLC.
- A method of compensation sometimes employed by health insurance companies, in which payment is made to a health care provider on a per-patient rather than a per-service basis. For example, under capitation an HMO doctor may be paid a fixed amount each month to serve as the primary care physician for a specific number of HMO members assigned to his or her care, regardless of how little or how much care each member needs.
- Any insurer, managed-care organization, or group hospital plan, as defined by applicable state law.
- Carry-Over Provision
- A provision of some health insurance plans allowing medical expenses paid for by the member in the last three months of the year to be carried over and applied toward the next year's deductible.
- Case Management
- When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient's health care providers to assist in the management of the patient's long-term needs, with appropriate recommendations for care, monitoring, and follow-up. A case manager will also help ensure that the member's health insurance benefits are being properly and fully used and that non-covered services are avoided when possible.
- Centers for Medicare and Medicaid Services
- Formerly known as the Health Care Financing Administration, the Centers for Medicare and Medicaid Services (CMS) is part of the federal government's Department of Health and Human Services and is responsible for the administration of the Medicare and Medicaid programs. The CMS establishes standards for health care providers that must be complied with in order for providers to meet certain certification requirements.
- Certificate of Coverage
- A document given to an insured person that describes the benefits, limitations, and exclusions of coverage provided by an insurance company.
- Chemical Dependency Inpatient
- Typically, services relating to the treatment of a chemical dependency that requires a stay at a hospital or other medical facility.
- A type of therapy employing manipulation and adjustment of body structures, typically provided by a licensed chiropractor. Some health insurance plans may cover limited chiropractic therapy.
- In health care and insurance terminology, a chronic condition is one that is permanent, recurring, or long lasting, as opposed to an acute condition.
- A bill for medical services rendered, typically submitted to the insurance company by a health care provider.
- COB (Coordination of Benefits)
- This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy.
- COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
- Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan, at the individual's expense, for up to 18 months in certain circumstances. COBRA coverage may be extended beyond 18 months in certain circumstances.
COBRA rules typically apply when an employee loses coverage through loss of employment (except in cases of gross misconduct) or due to a reduction in work hours. COBRA benefits also extend to spouses or other dependents in case of divorce or the death of the employee. Children who are born to, adopted, or placed for adoption with the covered employee while he or she is on COBRA coverage are also entitled to coverage. All companies that have averaged at least 20 full-time employees over the past calendar year must comply with COBRA regulations.
- The amount that you are obliged to pay for covered medical services after you've satisfied any copayment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a health care provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.
- The insurance company that is offering this health insurance plan.
- A specific charge that your health insurance plan may require that you pay for a specific medical service or supply, also referred to as a "copay." For example, your health insurance plan may require a $15 copayment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.
- Health care provider charges for which a patient is responsible under the terms of a health plan.
Common forms of cost-sharing include deductibles, coinsurance, and copayments. Balance-billed charges from out-of-pocket physicians are not considered cost-sharing.
Beginning in 2014, PPACA limits total out-of-pocket maximum spending to $5,950 for an individual and $11,900 for a family. These amounts will be adjusted annually to reflect the growth of premiums.
- A specific dollar amount that your health insurance company may require you to pay out-of-pocket each year before your health insurance plan begins to make payments for claims.
Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most indemnity and PPO plans do.
- Date of Service
- The date on which a health care service was provided.
- Department of Health and Human Services
- A department of the federal government responsible for certain social service functions, such as the administration and supervision of the Medicare program.
- Dependent Coverage
- Health insurance coverage extended to the spouse and unmarried children of the primary insured member. Certain age restrictions on the coverage of children may apply.
- Designated Mental Health Provider
- An organization hired by a health insurance plan to provide mental health and/or substance abuse treatment services.
- Drug Formulary
- A list of prescription medications selected for coverage under a health insurance plan.
Drugs may be included on a drug formulary based upon their efficacy, safety, and cost-effectiveness.
Some health insurance plans may require that patients obtain preauthorization before non-formulary drugs are covered. Other health insurance plans may require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription.
- Drug Maintenance List
- A list of commonly prescribed drugs intended for patients' ongoing or long-term use.
- Drug Utilization Review (DUR)
- The process by which health insurance companies evaluate or review the use of prescription drugs for appropriateness in the treatment of a patient.
- Durable Medical Equipment (DME)
- Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc. Coverage levels for DME often differ from coverage levels for office visits and other medical services.
- Effective Date
- The date on which health insurance coverage comes into effect.
- Eligibility Date
- The date on which a person becomes eligible for insurance benefits.
- Eligibility Requirements
- Conditions that must be met for an individual or group to be considered eligible for insurance coverage.
- Eligible Dependent
- A dependent (usually spouse or child) of an insured person who is eligible for insurance coverage.
- Eligible Employee
- An employee who is eligible for insurance coverage based upon the stipulations of the group health insurance plan.
- Eligible Expenses
- Expenses defined by the health insurance plan as eligible for coverage.
- Eligible Person
- 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.
- Emergency Room
- 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.
- Employee Contribution
- The portion of the health insurance premium paid by the employee, usually deducted from wages by the employer.
- Employer Contribution
- The portion of an employee's health insurance premium paid 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.
- Enrollment Period
- 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 Exclusive Provider Organization has a specific network of doctors and hospitals that members can use. There are no out-of-network benefits, and members cannot go outside the EPO network for care.
- 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.
- Essential 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.
- Estimated Cost
- 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.
- Evidence of Insurability
- 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 may only be required in specific cases (for example, 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 health care 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 health care provider, how those charges were processed, and the total amount of patient responsibility for the claim.
- Extended Coverage
- A provision of some health insurance plans allowing for coverage of certain health care 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.
- Fictitious Business Name Statement
- A certificate provided by a local or state governmental office that clarifies the true owner of a business or company. When a company or individual conducts business under an assumed name, this is referred to as a "fictitious name." It may also be referred to as a "trade name" or "doing-business-as" (DBA) name.
For the purposes of group health insurance, this statement confirms the identity of the business applying for coverage with a health insurance company.
- A term used to describe the role of the primary care physician in an HMO plan. In an HMO plan, a primary care physician serves as the patient's main point of contact for health care services and refers a patient to specialists for specific needs.
- Generic Drug
- A drug that is exactly the same as a brand name prescription drug, but can be produced by other manufacturers after the brand name drug's patent has expired. Generic drugs are usually less expensive than brand name drugs.
- Grace Period
- A time period after the payment due date during which insurance coverage remains in force and the policyholder may make a payment without penalty.
- Grandfathered Plan
- Health insurance coverage that existed as of March 23, 2010, that is subject only to certain provisions of the PPACA.
Any policy sold in the individual health insurance market after March 23, 2010, will not be grandfathered even if the product sold was offered before that date.
New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans.
If you're not sure whether you have a grandfathered plan, contact the plan directly.
- Grievance Procedure
- The procedure by which a member or health care provider is allowed to file a complaint with a health insurance company and seek a remedy.
- A number of individuals covered under a single health insurance contract, usually a group of employees.
- Group Health Insurance
- A health insurance plan that provides benefits for employees of a business or members of an organization, as opposed to individual and family health insurance.
- Guaranteed Issue
- A term used to describe insurance coverage that must be issued regardless of health status. In most states, group health insurance plans are often described as guaranteed issue plans, because a health insurance company generally cannot refuse coverage to a qualifying business or organization based on the health status of their employees or members. In some states, all health insurance plans may be guaranteed issue.
- Guaranteed Renewable Contract
- A contract under which the insured person has the right (usually up to a certain age) to renew and continue his or her health insurance policy by the timely payment of premiums.
- HIPAA (Health Insurance Portability and Accountability Act of 1996)
- Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies to streamline the health care and insurance industries and to protect the privacy and identity of health care consumers.
HIPAA also provides additional protections for consumers to help them obtain or retain health insurance coverage in certain circumstances.
For more information on HIPAA rules and regulations, visit the Centers for Medicare and Medicaid Services website at http://www.cms.gov.
- HMO means "Health Maintenance Organization." HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO or agree to provide services to members at a pre-negotiated rate.
As a member of an HMO, you will need to choose a primary care physician (PCP) who will provide most of your health care and refer you to HMO specialists as needed.
Some HMO plans require you to fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.
- Hospitalization Insurance
- Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.
- How It Works:
- Apply online for a health insurance plan.
- Complete and submit the application online through our website.
- The insurance company will then review your application and you can receive an update within 24 hours on whether you are approved. In some cases, you may receive a status update or request for further information instead, depending on whether the insurance company needs more information, when you submit your application, or other conditions, some exceptions may apply.
- HSA (Health Savings Account)
- A tax advantaged savings account used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made to the account on a tax-free basis. Funds remain in the account from year to year and may be invested at the discretion of the individual owning the account. Interest or investment returns accrue tax-free. Penalties may apply when funds are withdrawn to pay for anything other than qualifying medical expenses.
- In-Area Services
- Health care services rendered within a health insurance plan's coverage area.
- Incontestable Clause
- A provision in an insurance policy that states that the validity of the insurance contract cannot be contested after two (or sometimes three) years.
- Indemnity Plan
- Also called "fee-for-service" plans, indemnity plans typically let you direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically require you to fulfill an annual deductible. Because of the freedom they allow members, indemnity plans are sometimes more expensive than other types of plans.
- Individual and Family Health Insurance
- A type of health insurance purchased by an individual or family, independent of any employer group or organization.
- Typically, any medical services, both inpatient and outpatient, that assist with the conception of child.
- A person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.
- Integrated Delivery System
- A group of doctors, hospitals, and other providers who work together to deliver a broad range of health care services.
- Intermediate Care
- A level of nursing care considered less intensive than skilled nursing care, but that may be rendered in a skilled nursing or intermediate care facility.
- IPA (Individual Practice Association)
- An organization of physicians who may maintain separate offices but who negotiate contracts with insurance companies and medical facilities as a group. Some health insurance applications will ask you to provide your primary care physician's IPA number. It can usually be found in the health insurance plan's online directory.
- A term referring to any maximums that a health insurance plan imposes on specific benefits.
- Typically, any diagnostic lab test or diagnostic/therapeutic X-ray performed in support of basic health services.
Lab services typically include services such as blood panels and urinalysis.
X-ray services typically include basic outpatient skeletal or other plain film X-rays, outpatient ultrasound, GI series, MRI, and CT scan.
Prostate cancer screening, mammograms, and Pap smears may be covered by lab/X-ray benefit, or they may be covered by periodic OB-GYN benefit or preventative care benefits. Typically, dental X-rays are not included in lab/X-ray benefits.
- The termination of insurance coverage due to lack of payment after a specific period of time.
- Length of Stay (LOS)
- The total number of days that a patient stays in a facility such as a hospital.
- Lifetime Limit
- Many health insurance plans place dollar limits upon the claims that the plan will pay over the course of an individual's life.
PPACA prohibits lifetime limits on the dollar value of benefits deemed essential by the Department of Health and Human Services for plan or policy years beginning on September 23, 2010.
- Lifetime Maximum
- Lifetime maximum or lifetime limits refers to the maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime.
For plan or policy years beginning on or after September 23, 2010, plans may not establish any lifetime limit on the dollar amount of benefits for any individual. All plans are required by PPACA to remove the lifetime maximum restrictions.
- Long-Term Care
- Care provided on a continuing basis for the chronically ill or disabled. Long-term care may be provided on an inpatient basis (at a long-term care facility) or in the home setting.
- Major Medical Insurance
- A type of medical insurance plan that provides benefits for a broad range of health care services, both inpatient and outpatient. Major medical insurance plans often carry a high deductible.
- Managed Care
- A general term used to describe a variety of health care and health insurance systems that attempt to guide a member's use of benefits, typically by requiring that a member coordinate his or her health care through a primary care physician or by encouraging the use of a specific network of health care providers.
The management of health care is intended to keep costs and monthly premiums as low as possible. There are several different types of managed-care health insurance plans, including HMO, PPO, and POS plans
- Maternity (Inpatient)
- Typically, inpatient maternity services include hospitalization and physician fees associated with the birth of a child.
- Maternity (Outpatient)
- Typically, outpatient maternity services include OB-GYN office visits during pregnancy and immediately after giving birth.
- Maternity Coverage
- Maternity coverage means the insurance covers part or all of the medical cost during a woman's pregnancy.
Coverage is broken down into inpatient and outpatient services. Typically, inpatient coverage includes hospitalization and physician fees associated with child birth. Outpatient coverage pays for prenatal and postnatal OB-GYN office visits.
- Max Duration
- Maximum duration is the longest coverage period offered by the plan. You should choose a short-term insurance plan with a coverage period that will safely cover your insurance needs.
- Maximum Out-of-Pocket Costs
- An annual limitation on all cost-sharing that patients are responsible under a health insurance plan. This limit does not apply to premiums, balance-billed charges from out-of-network health care providers, or services that are not covered by the plan.
- A state-funded health care program for low-income and disabled persons.
- Medical Necessity
- A basic criterion used by health insurance companies to determine if health care services should be covered.
A medical service is generally considered to meet the criteria of medical necessity when it is considered appropriate, consistent with general standards of medical care, consistent with a patient's diagnosis, and the least expensive option available to provide a desired health outcome. Of course, preventive care services that may be covered under a health insurance plan are not always subject to the criteria of medical necessity.
- A national, federally administered health insurance program authorized in 1965 to cover the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals.
- Medicare Beneficiary
- Anyone entitled to Medicare benefits based on the rules for eligibility outlined by the Social Security Administration.
- Medicare Supplement Insurance
- Private health insurance available to individuals that is intended to help fill in the gaps in the coverage provided by Medicare.
- Anyone covered under a health insurance plan, whether an an enrollee or eligible dependent.
- Mental Health Inpatient
- Typically, this refers to services rendered when a patient stays at a hospital or other medical facility for treatment of a mental health condition.
- Mental Health Office Visits
- Typically, these are visits to a licensed medical provider for treatment of a mental health condition.
- MSA (Medical Savings Account)
- A tax-advantaged personal savings account used in conjunction with a high-deductible health insurance plan. MSAs are currently being phased out and replaced with HSAs. See HSA.
- National Association of Insurance Commissioners (NAIC)
- The NAIC is a national association of state officials charged with regulating insurance. The NAIC was formed to help provide some measure of national uniformity in insurance regulation.
- National Drug Code (NDC)
- A system employed by health care providers and insurance companies for classifying and identifying drugs. Each prescription drug in common use is assigned an NDC number.
- A plan with a "network" is a variation on a PPO plan.
With a network plan, you'll need to get your medical care from doctors or hospitals in the insurance company's network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the network. Services rendered by out-of-network providers may not be covered or may be paid at a lower level.
- Network Provider
- A health care provider who has a contractual relationship with a health insurance company. Among other things, this contractual relationship may establish standards of care, clinical protocols, and allowable charges for specific services.
In return for entering into this kind of relationship with an insurance company, a health care provider typically gains in numbers of patients, and a primary care physician may receive a capitation fee for each patient assigned to his or her care.
- Non-Duplication of Benefits
- Applicable when a person has insurance coverage from multiple sources, this provision in some policies specifies that benefits will not be paid for amounts reimbursed by others. See also COB.
- Nursing Home
- A licensed facility which provides general nursing care to those who are chronically ill or who require constant supervision and assistance with the needs of daily living.
- Office Visit
- An office visit is the amount you pay when you see the doctor or dentist for routine care. Examples for an doctor's allowable charge of $100:
- If the plan's office visit is $25, then you pay $25.
- If the plan's office visit is 30% before deductible, then you pay $30.
- If the plan's office visit is 35% after deductible, then if you have not yet reached your deductible, you pay $100; if you have reached your deductible, you pay $35.
- Office Visit (IFP)
- Typically, an office visit is an outpatient visit to a physician's office for illness or injury.
- Open Enrollment Period
- A time period under the Affordable Care act or group coverage during which eligible persons or eligible employees may opt to sign up for coverage under a group health insurance plan. During an open enrollment period, applicants typically will not be required to provide evidence of insurability.
- Out-of-Network Care
- Health care rendered to a patient outside of the health insurance company's network of preferred providers. In many cases, the health insurance company will not pay for these services.
- A patient who receives care at a medical facility but who is not admitted to the facility overnight or is admitted for 24 hours or less. The term may also refer to the health care services that such a patient receives.
- Outpatient Surgery
- Typically, outpatient surgery is defined as any surgical procedure that does not require an overnight stay in a hospital.
- Over-the-Counter (OTC) Drugs
- Drugs that may be obtained without a prescription.
- Part-Time Employee
- For the purposes of qualifying for group health insurance, a part-time employee is one working between 20-29 hours per week.
- Partial Disability
- A condition in which, as the result of an illness or injury, a group health insurance member cannot perform all the duties of his or her occupation, but can perform some. Exact definitions differ between health insurance plans.
- Partial Hospitalization Services
- Also referred to as "partial hospital days," this is a health care term used to refer to outpatient services performed in a hospital setting as an alternative or follow-up to inpatient mental health or substance abuse treatment.
- Participating Provider
- Generally, this term is used like "network provider."
However, not all health care providers contract with health insurance companies at the same level. Some providers contracting with insurers at lower levels may sometimes be referred to as "participating providers" as opposed to "preferred providers."
- Peer Review
- This term refers to the process by which a physician or team of health care specialists review the services, course of medical treatment, or the conclusions of a scientific medical study conducted by another physician or group of medical experts.
Peer review must be provided by a physician or team of medical experts with training and expertise equal to the physician or team conducting the treatment or research in question.
- Periodic Health Exam
- Typically, an exam that occurs on a regular basis for preventative purposes, such as a routine physical or annual check-up.
- Periodic OB-GYN Exam
- Typically, an OB-GYN exam that occurs on a regular basis for preventative purposes, often including a Pap smear.
- Physical Therapy
- Typically, rehabilitative services provided by a licensed physical therapist to help restore bodily functions such as walking, speech, the use of limbs, etc.
- Place of Service
- The type of facility in which health care services were provided, whether it be the home, hospital, clinic, office, etc.
- Plan Name
- The name of the health plan offered by the insurance company.
- Plan Type: PPO
- PPO means "Preferred Provider Organization."
Like the name implies, with a PPO plan, you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO.
Services rendered by out-of-network providers may not be covered or may be paid at a lower level.
A broad variety of PPO plans are available, many with low monthly premiums.
- Policy Form Number
- A unique number that identifies each health insurance policy filed with a state's department of insurance.
- Policy Term
- The period of time for which a health insurance policy provides coverage.
- POS stands for "Point of Service." POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket and may not be covered at all.
- On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law.
This legislation (Public Law 111-148) is commonly referred to as the health reform law. Among other things, the new law requires that all Americans maintain minimum essential coverage starting in 2014. At that time, health insurance companies will not be able to deny insurance coverage to individuals based on a pre-existing condition.
- Practical Nurse
- A licensed nurse who provides "custodial" care services, such as assistance in walking, bathing, feeding, etc. Practical nurses do not administer medications or perform other strictly medical services.
- Pre-Existing Condition
- A health problem that existed or was treated before the effective date of your health insurance coverage. Most health insurance contracts have a pre-existing condition clause that describes how and when the health insurance company will cover medical expenses related to a pre-existing condition.
For more information, see also Pre-Existing Condition Exclusion.
- Pre-Existing Condition Exclusion
- In some cases, a health insurance company may exclude a patient's pre-existing condition from coverage under a new health insurance plan. This is more typical with individual and family health insurance plans and less common with group health insurance plans.
HIPAA legislation imposes certain limitations on when a health insurance company can exclude coverage for a pre-existing condition. PPACA prohibits pre-existing condition exclusions for all plans beginning January 2014, and prohibits pre-existing condition exclusions for all children under the age of 19 in new policies sold on or after September 23, 2010.
- The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Within the context of group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee or the employee's dependents.
- Prescription Drug Coverage
- Prescription drug coverage varies by carrier and plan type. Typically, prescription drugs are covered in one of two ways:
- Insurance covers a percentage after plan deductible is met.
- Insurance covers cost of the drug, but a copayment is required when the prescription is filled.
- Prescription Medication
- A drug that may be obtained only with a doctor's prescription and which has been approved by the Food and Drug Administration.
- Preventive Benefits
- Covered services that are intended to prevent disease or to identify disease while it is more easily treatable.
PPACA requires insurers to provide coverage for certain preventive benefits without deductibles, copayments, or coinsurance. This rule does not apply to Grandfathered Plans. HHS is continuing to update what it defines as preventative benefits.
- Preventive Care
- Medical care rendered not for a specific complaint but focused on prevention and early detection of disease. This type of care is best exemplified by routine examinations and immunizations.
Some health insurance plans limit coverage for preventive care services, while others encourage such services.
Note that well-baby care, immunizations, periodic prostate exams, pap smears, and mammograms, though considered preventive care, may be covered even if your health insurance plan limits coverage for other preventive care services.
- Primary Care
- Basic health care services, generally rendered by those who practice family medicine, pediatrics, or internal medicine.
See also Secondary Care and Tertiary Care.
- Primary Care Physician (PCP)
- A patient may be required to choose a primary care physician (PCP). A primary care physician usually serves as a patient's main health care provider. The PCP serves as a first point of contact for health care and may refer a patient to specialists for additional services.
- Primary Coverage
- If a person is covered by more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first.
See also Secondary Coverage and COB.
- Probationary Period
- A waiting period determined by the health insurance company during which coverage for certain pre-existing conditions may be excluded.
- A term commonly used by health insurance companies to designate any health care provider, whether a doctor, nurse, hospital, or clinic.
- Provider Write-Off
- The difference between the actual charge and the allowable charge. A network provider cannot charge this write-off to a patient who belongs to a health insurance plan that uses the provider network. See also Allowable Charge.
- The process through which a patient under a managed-care health insurance plan is authorized by his or her primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.
- Registered Nurse (RN)
- A licensed professional nurse with a four-year nursing degree, trained to provide all levels of nursing care including the administration of medication.
- Renewal occurs when a member continues coverage under a health insurance plan beyond the original time frame of the contract. At the end of each benefit year, a plan member is generally invited to renew his or her coverage.
- Renewal Date
- The date on which a member's health insurance plan benefit year renews.
- Respite Care
- Normally associated with hospice care, respite care is a benefit often made available for family members of a patient, providing the patient's primary caretaker with a break or respite from caring for the patient. Respite care may be provided for the patient in either the home or a nursing home setting.
- Schedule C
- The federal tax form used to report business income or business losses. A copy of this form may be required when applying for a group health insurance plan.
- Schedule K-1
- The federal tax form used to report a business partner's share or the income, credits, and deductions from a business organized as a partnership. This is submitted to the federal government with the partner's federal tax return. A copy of this form may be required when applying for a group health insurance plan.
- Second Surgical Opinion
- Some health insurance companies may require a second opinion from a qualified physician or specialist before extending coverage for certain surgical procedures.
- Secondary Care
- Medical care rendered by a specialist (e.g., urologist, cardiologist) rather than a primary care physician.
See also Primary Care and Tertiary Care.
- Secondary Coverage
- When a person is covered under more than one health insurance plan, this term describes the health insurance plan that provides payment on claims second, after the primary coverage.
See also Primary Coverage and COB.
- Self-Funded Health Insurance Plan
- A health insurance plan that is funded by an employer rather than through a health insurance company. A health insurance company will typically handle the administration of such a plan, but the cost of claims will be paid for by the employer through a fund set up for this purpose. See also Administrative Services Only (ASO) Agreement.
- Service Area
- The geographic area in which a health insurance plan's benefits are made available. Some health insurance plans will not provide coverage outside of a plan's service area.
- Short-Term Plans
- Short-term health insurance plans provide coverage for a limited period of time.
Typically, short-term plans offer coverage up to six months and some plans may offer coverage up to 12 months. It is important to note that short-term health insurance is not considered minimum essential coverage under the Affordable Care Act.
- Skilled Nursing Care
- Intensive care usually required around the clock and rendered by, or under the supervision of, a registered nurse or licensed practical nurse. It is provided only when prescribed by a doctor and usually on an inpatient basis at a hospital or skilled nursing facility.
Skilled nursing care may include the administration of medications, tube feeding, the changing of wound dressings, and some types of minor surgery.
- Small Group Market
- The market for health insurance coverage offered to small businesses -- those with between 2 and 50 employees in most states.
PPACA will broaden the market to those with between 1 and 100 employees, though until 2016 states may continue to limit small group to 50 employees or less.
- Special Enrollment Period
- Under PPACA, this is a 60-day period triggered by a qualifying event such as job loss, marriage, birth or adoption of a child, permanently moving to a new area, and other changes in status.
- A doctor who does not serve as a primary care physician, but who provides secondary care, specializing in a specific medical field. See also Secondary Care.
- Standard Industrial Classification (SIC) Codes
- These are codes used to describe or classify businesses based upon the products or services they provide. When you apply for group health insurance coverage, you may be asked to provide the SIC code for your business. This code provides the insurance company with information about the kind of work your employees are likely to perform, and it may be used to help determine a monthly premium.
- The process by which a health insurance company determines whether medical bills should be paid for by the health insurance company itself or by another insurer or third party.
For example, claims are frequently subject to subrogation when medical care is rendered as the result of an automobile accident. In most cases, the automobile insurer is considered the primary payer. When a health insurance company has determined through the subrogation process that the automobile insurer will no longer pay on medical claims, then the health insurance company will typically become the primary payer.
- This term may be used in two senses. First, it may refer to the person or organization that pays for health insurance premiums. Second, it may refer to the person whose employment makes him or her eligible for group health insurance benefits.
- Temporary Partial Disability
- This describes a the condition of a person who is unable to work at full capacity due to injury, but is able to work at reduced efficiency and is expected to fully recover.
- Temporary Total Disability
- This describes the condition of a person is who unable to work due to injury, but who is expected to fully recover.
- Terminally Ill
- In health care and insurance usage, this describes a person who is not expected to live beyond six months due to a specific illness.
- Tertiary Care
- Services rendered by specialized providers such as intensive care units, neurologists, neurosurgeons, and thoracic surgeons. Such services frequently require highly sophisticated equipment and facilities. See also Primary Care and Secondary Care.
- Treatment Facility
- May refer to any facility, either residential or non-residential, that is authorized to provide treatment for mental illness or substance abuse.
- A method of classifying sick or injured patients according to the severity of their conditions to ensure that medical facilities and staff are used most effectively.
- The process by which an insurer determines whether it will accept an application for insurance based upon risks and projections and through which a determination of a monthly premium is made.
- Uniform Billing Code of 1992 (UB-92)
- The Uniform Billing Code of 1992 set industry-wide standards for medical billing practices.
- Usual, Customary, and Reasonable (UCR) Charge
- The standard or most common charge for a particular medical service when rendered in a particular geographic area. It is often employed in determining Medicare payment amounts.
- This term refers to how frequently a group uses the benefits associated with a particular health insurance plan or health care program.
- Utilization Management/Review
- This term is often used to describe a group (or the work performed by a group) of nurses and doctors who work with health insurance plans to determine if a patient's use of health care services was medically necessary, appropriate, and within the guidelines of standard medical practice.
Utilization Management/Review may also be referred to as Medical Review.
- Vision Care Coverage
- An insurance plan typically offered only on a group basis that covers routine eye examinations and may also cover all or part of the costs associated with contact lenses or eyeglasses.