| Accredited (Accreditation): |
| A "seal of approval" for health care facilities. Being
accredited means that a facility has met certain quality standards. These
standards are set by private, nationally recognized groups that check on the
quality of care at health care facilities. |
| |
| Admitting Physician: |
| The doctor responsible for admitting you to a hospital or
other inpatient health facility. |
| |
| Admitting Privileges: |
| The right granted to a doctor to admit patients to a
particular hospital. |
| |
| Ambulatory Care: |
| All types of health services that do not require an overnight
hospital stay. |
| |
| Ancillary Services: |
| Services, other than those provided by a physician or
hospital, which are related to a patient’s care, such as laboratory work,
x-rays and anesthesia. |
| |
| Any Willing Provider Laws: |
| Legislation that requires health care plans to accept into
their PPO and HMO networks any provider willing to agree to the network's terms
and conditions. |
| |
| Appeal: |
| Request made to a payer to reconsider a decision, such as a
claim denial or denied prior authorization request. Most appeals must be
submitted in writing within a specified period. |
| |
| Assignment of Benefits: |
| When an insured person assign benefits, they sign a document
allowing the hospital or doctor to collect health insurance benefits directly
from the health insurance company. Otherwise, the insured person pays for the
treatment and is later reimbursed by the health insurance company.
|
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| Beneficiary: |
| A person eligible for benefit under a health insurance policy |
| |
| Benefit: |
| Amount payable by the insurance company to a claimant,
assignee, or beneficiary when the insured suffers a loss. |
| |
| Benefit Cap: |
| Total dollar amount that a payer will reimburse for covered
health care services during a specified period, such as one year. |
| |
| Board Certified: |
| A physician who has passed examinations given by a medical
specialty group and who has, as a result, been certified as a specialist in
this area of practice. |
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| Capitation: |
| Capitation represents a fixed monthly dollar amount that a
Health Maintenance Organization (HMO) pays to a group of health care providers
who have contracted with the HMO. The amount of this fixed dollar amount
depends upon the number of HMO enrollees who have chosen this group of health
care providers for "primary care" services under the HMO plan. This fixed
dollar amount does not vary with how much HMO enrollees use (or don't use)
services offered by this group of HMO providers. Not all HMO utilize capitation
payments. |
| |
| Case Management: |
| A process whereby an insured person with specific health care
needs is identified and a plan which efficiently utilizes health care resources
is designed and implemented to achieve the optimum patient outcome in the most
cost-effective manner. |
| |
| Case Manager: |
| A nurse, doctor, or social worker who arranges all services
that are needed to give proper health care to a patient or group of patients. |
| |
| Catastrophic Illness: |
| A very serious and costly health problem that could be life
threatening or cause life-long disability. The cost of medical services alone
for this type of serious condition could cause financial hardship. |
| |
| Centers of Excellence: |
| Hospitals that specialize in treating particular illnesses,
or performing particular treatments, such as cancer or organ transplants. |
| |
| Certificate of Coverage: |
| A document given to an insured that describes the benefits,
limitations and exclusions of coverage provided by an insurance company. |
| |
| Claim: |
| Form submitted to a payer (by a health care provider or
patient) to request payment for items or services. |
| |
| Co-insurance: |
| Cost-sharing arrangement between an insured person and the
health insurance company in which the insured person is required to pay a
percentage of the cost for the health care services received. Coinsurance
typically applies after satisfaction of a deductible. For example, 80%
coinsurance may apply after a $500 deductible has been satisfied. |
| |
| Consolidated Omnibus Budget Reconciliation Act (COBRA): |
| The Consolidated Omnibus Budget Reconciliation Act of 1985,
commonly known as COBRA, requires group health plans with 20 or more employees
to offer continued health coverage for employees and their dependents for 18
months after the employee leaves the job. Longer durations of continuance are
available under certain circumstances. If a former employee opts to continue
coverage under COBRA, the former employee must pay the entire premium, plus a
2% administration charge. |
| |
| Concurrent Review: |
| Concurrent review involves monitoring the medical treatment
and progress toward recovery, once a patient is admitted to a hospital, to
assure timely delivery of services and to confirm the necessity of continued
inpatient care. This monitoring is under the direction of medical
professionals. Concurrent review is a component of "Utilization Review". |
| |
| Contract Year: |
| The period of time from the effective date of the contract to
the expiration date of the contract. A contract year is typically 12 months
long, but not necessarily from January 1 through December 31. |
| |
| Coordination of Benefits (COB): |
| A provision in the contract that applies when a person is
covered under more than one health insurance plan. It requires that payment of
benefits be coordinated by all plans to eliminate over-insurance or duplication
of benefits. |
| |
| Coordinated Care: |
| Links the treatments or services necessary to obtain an
optimum level of medical care required by a patient and provided by appropriate
providers. It is also another term for "managed care" used by federal
government officials. |
| |
| Co-payment: |
| Co-payment is a predetermined fee, in addition to what health
insurance covers, that an individual pays for health care services. For
example, a PPO may require a $20 "co-payment" for normal services delivered
during a physician office visit. |
| |
| Cost Sharing: |
| This occurs when the users of a health care plan share in the
cost of medical care. Deductibles, coinsurance, and co-payments are examples of
cost sharing. |
| |
| Covered Benefit: |
| A health service or item that is included in a health plan,
and that is partially or fully paid by the health plan. |
| |
| Covered Charges/Expenses: |
| Most insurance plans, whether they are PPOs or HMOs, do not
pay for all services. Some may not pay for prescription drugs. Others may not
pay for mental health care. Covered services are those medical procedures for
which the insurer agrees to pay. They are listed in the policy. |
| |
| Covered Person: |
| An individual who meets eligibility requirements and for whom
premium payments are paid for specified benefits of the contractual agreement. |
| |
| Credentialing: |
| The process used by health insurance companies to examine and
verify the medical qualifications of health care providers who want to
participate in the PPO or HMO network. |
| |
| Creditable Coverage: |
| Any previous health insurance coverage that can be used to
shorten the pre-existing condition waiting period. See "HIPPA" |
| |
| Critical Access Hospital: |
| A small facility that gives limited outpatient and inpatient
hospital services to people in rural areas. |
| |
| Current Procedural Terminology (CPT): |
| A system of terminology and coding developed by the American
Medical Association (AMA) that is used for describing, coding, and reporting
medical services and procedures. |
| |
| Custodial Care: |
| Personal care, such as bathing, cooking, and shopping. |
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| Deductible: |
| Cost-sharing arrangement between an insured person and health
insurance company in which the insured person will be required to pay a fixed
dollar amount of covered expenses each year before the health insurance company
will reimburse for covered health care expenses. Generally, an insured person
is responsible for a deductible each calendar year. |
| |
| Deductible Carry Over Credit: |
| Charges applied to the deductible for services during the
last 3 months of a calendar year which may be used to satisfy the following
year’s deductible. |
| |
| Defensive Medicine: |
| Use of unnecessary treatments, procedures or other medical
services by doctors to minimize the threat of a malpractice lawsuit. |
| |
| Denial Of Claim: |
| Refusal by a health insurance company to honor a request by
an individual (or his or her provider) to pay for health care services obtained
from a health care professional. |
| |
| Dependent: |
| A covered person who relies on another person for support or
obtains health coverage through a spouse or parent who is the covered person
under a health plan. |
| |
| Designated Facility: |
| A facility which has an agreement with a health insurance
plan to render approved services (Organ transplants are the most common
example.). The facility may be outside a covered person’s geographic area. |
| |
| Discharge Planning: |
| Medical personnel of a health plan working with the attending
physician and hospital staff to assess alternatives to hospitalization,
evaluate appropriate settings for care, and arrange for the discharge of a
patient, including planning for subsequent care at home or in a skilled nursing
facility. The goal is to determine when patients are ready to go home, and to
provide a more comfortable, cost-efficient setting for continued treatment. |
| |
| Disenroll: |
| Ending a person's health care coverage with a health plan. |
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| Effective Date: |
| The date health insurance coverage begins. |
| |
| Eligible Dependent: |
| A dependent of a covered person (spouse, child, or other
dependent) who meets all requirements specified in the contract to qualify for
coverage and for who premium payment is made. |
| |
| Eligible Expenses: |
| The lower of the reasonable and customary charges or the
agreed upon health services fee for health services and supplies covered under
a health plan. |
| |
| Employee Assistance Programs (EAPs): |
| Mental health counseling services that are sometimes offered
by insurance companies or employers. Typically, individuals or employers do not
have to directly pay for services provided through an employee assistance
program. |
| |
| Enrollee: |
| The person who is the primary insured. Under an individual or
family policy, this person is the applicant. Under an employer-sponsored group
health policy, this person is the employee. |
| |
| Episode of Care: |
| The health care services given during a certain period of
time, usually during a hospital stay. |
| |
| Exclusions and Limitations: |
| Medical services that are either not covered or limited in
benefit by a health insurance insurance policy. |
| |
| Exclusion Period: |
| A period of time when an insurance company can delay coverage
of a pre-existing condition. Sometimes this is called a pre-existing condition
waiting period. |
| |
| Explanation of Benefits (EOB): |
| Statement sent by health plans to persons who have
experienced a claim under the health plan. The explanation of benefits (EOB)
details the charges for the services received, the amount the health insurance
company will pay for those services, and the amount the insured person will be
responsible for paying. |
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| Fee-for-Service: |
| A payment system for health care where the provider is paid
for each service rendered rather than a pre-negotiated amount for each patient. |
| |
| Fee Schedule: |
| A complete listing of fees used by health plans to pay
doctors or other providers. |
| |
| First Dollar Coverage: |
| Refers to not having to meet a calendar year deductible prior
to receiving reimbursement or payment for a medical service. |
| |
| Formulary: |
| A list of certain drugs and their proper dosages. Under most
health plans, better benefits are provided for formulary drugs than are
provided for non-formulary drugs. |
| |
| Full-Time Student: |
| Under a health plan, an eligible dependant child student
(typically age 19 or older) who meets the health plan's criteria of
"full-time." Such criteria normally typically includes minimum credit hour
requirements (such as 12 credit hours in a semester) and a maximum age (age 23
is typical.). |
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| Gag Rule Laws: |
| Special laws that make sure that health plans let doctors
tell their patients complete health care information. This includes information
about treatments not covered by the health plan.
|
| |
| Gatekeeper: |
| A primary care physician in a managed care environment who is
responsible for managing the patient's overall care and who must authorize all
specialist referrals. In most health maintenance organizations (HMOs), the
secondary care is not covered by insurance if the primary care physician does
not approve it. |
| |
| Grievance: |
| Request made to a health plan to reconsider coverage of a
health care service that the health plan has not interpreted to be a covered
benefit. |
| |
| Group Health Plan: |
| A health plan that provides health coverage to employees and
their families, and is supported by an employer or employee organization. |
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| HCFA Common Procedure Coding System (HCPCS): |
| Name given to CPT codes (Level I), alphanumeric codes (Level
II), and local codes (Level III) used by payers and providers for billing
purposes. Within the industry, most refer to Level II national codes as HCPCS
codes. |
| |
| Health Care Provider: |
| A doctor, hospital, laboratory, nurse, or anyone who delivers
medical or health-related care. |
| |
| Health Employer Data and Information Set (HEDIS): |
| A set of standard performance measures that provides
information about the quality of a health plan. These measures are used to
compare managed care plans. |
| |
| Health Insurance Portability & Accountability Act (HIPAA): |
| A law passed in 1996, which is also called the
"Kassebaum-Kennedy" law. This law expanded health care coverage for persons who
have lost their job, or move from one job to another. HIPAA protects persons
who have pre-existing medical conditions, and/or problems, based on past or
present health, in getting health insurance coverage.
|
| |
| Health Maintenance Organization (HMO): |
| Prepaid health plans which cover doctors' visits, hospital
stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays,
and therapy. In a HMO, one must choose a primary care physician who coordinates
all care and makes referrals to any specialists that may be required. In a HMO,
one must use the doctors, hospitals and clinics that participate in your plan's
network. No benefits are paid for non-emergency benefits provided outside the
HMO network. |
| |
| Health Savings Account (HSA): |
| Operating similarly to IRAs, HSAs are tax-advantaged savings
accounts for health care services. A person must enroll in a qualified
High-Deductible Health Plan (HDHP) before they can establish an HSA. |
| |
| High Deductible Health Plan (HDHP): |
| A person must be enrolled in a qualified High-Deductible
Health Plan (HDHP) before they can establish a Health Savings Account (HSA).
Not all high-deductible health plans qualify for purposes of establishing HSA
eligibility. A qualified HDHP benefit design must conform to various
federally-mandated requirements, such as a minimum $1000 deductible and a lack
of first-dollar benefit provisions. |
| |
| Home Health Care: |
| Services given at home to aged, disabled, sick, or
convalescent individuals not needing institutional care. The most common types
of home care are visiting nurse services and speech, physical, occupational,
and rehabilitation therapy. These services are provided by home health
agencies, hospitals, or other community organizations. |
| |
| Hospice Care: |
| Care for the terminally ill and their families, in the home
or a non-hospital setting, that emphasizes alleviating pain rather than a
medical cure |
| |
| Hospital Care: |
| Reimbursement for both inpatient and outpatient medical care
expenses incurred in a hospital. Inpatient Benefits include; Charges for room
and board, charges for necessary services and supplies sometimes referred to as
'hospital extras,' 'other hospital extras,' 'miscellaneous charges,' and
'ancillary charges. Outpatient Benefits include; surgical procedures,
rehabilitation therapy, and physical therapy. |
| |
| Hospital-Surgical Coverage: |
| A form of health insurance that offers coverage of certain
costs related to hospitalization and surgical procedures. A hospital-surgical
plan does not cover other types of medical services, such as physician office
visits and outpatient prescription drugs. |
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| Incurral Date: |
| The date on which health care services are provided to a
covered person. The incurral date, not the date on which the insurance company
pays a health care claim, is the critical date in determining health insurance
benefits. For example, a health insurance company will not pay a claim for
health care services incurred prior to the effective date of the health
insurance coverage. |
| |
| Indemnity Health Plan: |
| Indemnity health insurance plans are also called
"fee-for-service." These are the types of plans that primarily existed before
the rise of HMOs and PPOs. With indemnity plans, the individual pays a
pre-determined percentage of the cost of health care services, and the health
plan pays the other percentage. For example, an individual might pay 20% for
services and the insurance company pays 80%. The fees for services are defined
by the health care providers and vary from physician to physician and hospital
to hospital.
|
| |
| Independent Practice Associations (IPA): |
| An IPA is a type of HMO in which care is provided by
independent physicians who contract with the HMO. This contrasts with the
"staff model" HMO, in physicians are employees of the HMO. |
| |
| Inpatient Care: |
| Health care that you get when you stay overnight in a
hospital. |
| |
| Insured: |
| A person who has obtained health insurance coverage under a
health insurance plan. |
| |
| International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM): |
| Coding system maintained by the National Center for Health
Statistics and the Center for Medicare and Medicaid Services (CMS). This coding
system differentiates diagnostic conditions and is used by hospitals,
governments, health insurance plans, and health care providers around the
world. |
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| Lifetime Maximum: |
| A cap on the benefits paid for the duration of a health
insurance policy. Many policies have a lifetime limit of $5 million, which
means that the insurer agrees to cover up to $5 million in covered services
over the life of the policy. Once the $5 million maximum is reached, no
additional benefits are payable. |
| |
| Limited Policy: |
| A policy that covers only specified accidents or sicknesses
(e.g. a cancer policy). |
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| Major Medical: |
| Health insurance coverage for expenses associated with
hospital confinements, surgeries and/or medical conditions requiring a broad
range of medical services and supplies. |
| |
| Managed Care: |
| An organized way to manage costs, use, and quality of the
health care system. The major types of managed care plans are health
maintenance organizations (HMOs) and preferred provider organizations (PPOs). |
| |
| Medicaid: |
| Federal and state health insurance program for low-income
individuals who meet established eligibility criteria (programs vary from state
to state). |
| |
| Medical Necessity: |
| Medical information justifying that the service rendered or
item provided is reasonable and appropriate for the diagnosis or treatment of a
medical condition or illness. |
| |
| Medicare: |
| Federal health insurance program for the elderly (age 65 and
older), certain disabled individuals, and those with end-stage renal disease.
Medicare is administered by the Center for Medicare and Medicaid Services
(CMS), formerly the Health Care Financing Administration (HCFA). |
| |
| Medicare Supplement: |
| A supplemental insurance policy to help cover the difference
between approved medical charges and benefits paid by Medicare. These plans are
also known as "Medi-gap" plans. |
| |
| Medical Savings Account (MSA): |
| A tax-advantaged personal savings account used in conjunction
with a high deductible health policy. Individuals can contribute money to this
account on a pre-tax basis to set aside money for qualified medical care and
expenses, including annual deductibles and co-payments. |
| |
| Medically Necessary: |
| Many insurance policies will pay only for treatment that is
deemed "medically necessary" to restore a person's health. For instance, many
health insurance policies will not cover routine physical exams or plastic
surgery for cosmetic purposes. |
| |
| Medigap: |
| A supplemental insurance policy to help cover the difference
between approved medical charges and benefits paid by Medicare. These plans are
also known as "Medicare Supplement" plans. |
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| National Association of Insurance Commissioners
(NAIC): |
| A national organization of state officials charged with
regulating insurance. NAIC was formed to promote national uniformity in
insurance regulations. |
| |
| National Committee for Quality Assurance (NCQA): |
| A national group responsible for devising and monitoring
quality measurements and standards for health care entities. |
| |
| National Drug Code (NDC): |
| Numerical coding system for drug identification. NDC numbers
are assigned by the Food and Drug Administration (FDA) and are typically used
to bill payers for the drugs provided to health care beneficiaries. |
| |
| Network: |
| Groups of physicians, hospitals and other health care
providers working with the health plan to offer care at negotiated rates. |
| |
| Network Provider: |
| Physicians, hospitals or other providers of medical services
that have agreed to participate in a network, to offer their services at
negotiated rates, and to meet other negotiated contractual provisions. Also
called "participating provider." |
| |
| Noncancellable Policy: |
| A policy that guarantees you can receive insurance, as long
as you pay the premium. It is also called a guaranteed renewable policy. |
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| Open Enrollment: |
| A period each year during which employees have an opportunity
to change their employer-provided health care coverage. They usually can choose
among various plans from different health insurance providers. |
| |
| Out-Of-Network: |
| Health care services received outside the HMO or PPO network. |
| |
| Out-Of-Plan: |
| This phrase usually refers to physicians, hospitals or other
health care providers who are considered non-participants in an insurance plan
(usually an HMO or PPO). Depending on an individual's health insurance plan,
expenses incurred by services provided by out-of-plan health professionals may
not be covered, or covered at a reduced benefit level. |
| |
| Out-of-Pocket Costs: |
| Insured health care costs for which one is responsible,
because of the application of deductibles, coinsurance and co-payments. |
| |
| Out-of-pocket maximum: |
| Total dollar amount an insured will be required to pay for
covered medical services during a specified period, such as one year. The
out-of-pocket maximum may also be called the stop-loss limit or catastrophic
expense limit. |
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| Participating Provider: |
| A health care provider who has been contracted to render
medical services or supplies to insured persons at a pre-negotiated fee.
Providers include hospitals, physicians, and other medical facilities that are
part of a PPO or HMO network. |
| |
| Policy: |
| The insurance agreement or contract. |
| |
| Pre-Admission Review: |
| A review of an individual's health care status or condition,
prior to an individual being admitted to a hospital or inpatient health care
facility. Pre-admission reviews are often conducted by case managers or
insurance company representatives (usually nurses) in cooperation with the
individual, his or her physician or health care provider, and hospitals. |
| |
| Pre-Admission Testing: |
| Medical tests that are completed for an individual prior to
being admitted to a hospital or inpatient health care facility. |
| |
| Pre-Authorization: |
| Under a pre-authorization provision of a health insurance
policy, the insured must contact the health insurance company prior to a
hospitalization or surgery, and receive authorization for the service. |
| |
| Pre-Certification: |
| This is a requirement that a insured person call their health
insurance company and advise them a doctor has stated certain medical treatment
is required. This is done before receiving treatment from the doctor or
hospital. A health insurance policy will normally list the medical conditions
that require pre-certification before receiving treatment. When
pre-certification is not received, benefits will be reduced or possibly not
covered. |
| |
| Pre-existing Condition: |
| A health problem that existed before the date your insurance
became effective. Each health insurance company uses its own particular
definitions of pre-existing condtiion. However, the following statement is in
line with most insurance company provisions: "A pre-existing condition is a
medical condition that would cause a normally prudent person to seek treatment
during the twelve months prior to the beginning of coverage." |
| |
| Preferred Provider Organization (PPO): |
| A network of health care providers with which a health
insurer has negotiated contracts for its insured population to receive health
services at discounted costs. Health care decisions generally remain with the
patient as he or she selects providers and determines his or her own need for
services. Patients have financial incentives to select providers within the PPO
network. |
| |
| Pregnancy Care: |
| Federal maternity legislation, enacted in 1978, requires that
employers engaged in interstate commerce who have 15 or more employees provide
the same benefits for pregnancy, childbirth, and related medical conditions as
for any other sickness or injury. This includes all employers who are, or
become, subject to Title VII of the Civil Rights Act of 1964.
|
| |
| Premium: |
| The amount you or your employer pays in exchange for health
insurance coverage. |
| |
| Preventive Care: |
| An approach to health care which emphasizes preventive
measures and health screenings such as routine physicals, well-baby care,
immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other
early detection testing. The purpose of offering coverage for preventive care
is to diagnose a problem early, when it is less costly to treat, rather than
late in the stage of a disease when it is much more expensive, or too late to
treat. |
| |
| Primary Care Physician (PCP): |
| Under a health maintenance organization (HMO) plan, the
primary care physician is usually an insured person's first contact for health
care. This is often a family physician, internist, or pediatrician. A primary
care physician monitors patient health, treats most patient health problems,
and refers patients, if necessary, to specialists. |
| |
| Prior authorization: |
| Review of need for health care items or services before
services are rendered or products are provided. This refers to a decision made
by the health plan to cover or not cover the charges before the services are
provided. |
| |
| Provider: |
| Any person (doctor or nurse) or institution (hospital,
clinic, or laboratory) that provides medical care. |
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| Reasonable and Customary (R &C) Charge: |
| A term used to refer to the commonly charged or prevailing
fees for health services within a geographic area. A fee is generally
considered to be reasonable if it falls within the parameters of the average or
commonly charged fee for the particular service within that specific community.
"Reasonable and Customary (R&C) Charge" essentially means the same thing as
"Usual and Customary (U&C) Charge." |
| |
| Referral: |
| An OK from the primary care physician for the patient to see
a specialist or get certain services. In many HMO plans, the insured person
needs to get a referral before they get care from anyone except the primary
care physician. If the referral is not received, the HMO may cover resulting
expenses. |
| |
| Risk: |
| For a health insurance company, risk is the chance of loss,
the degree of probability of loss or the amount of possible loss. For an
individual, risk represents such probabilities as the likelihood of surgical
complications, medications' side effects, exposure to infection, or the chance
of suffering a medical problem because of a lifestyle or other choice. For
example, an individual increases his or her risk of getting cancer if he or she
chooses to smoke cigarettes. |
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| Schedule of Benefits and Exclusions: |
| A health insurance listing of the benefits which are covered
under the policy guidelines as well as services which are not provided under
the policy. |
| |
| Second Surgical Opinion: |
| This is an opinion provided by a second physician, when one
physician recommends surgery to an individual. Most health insurance policies
cover second surgical opinions. |
| |
| Self-insured: |
| The self-insured employer assumes risk for health care
expenses in a plan that is self-administered or administered through a contract
with a third-party organization. This form of coverage is regulated by the
Employee Retirement Income Security Act of 1974. Hence, self-insured health
plans fall under federal, rather than state, regulation. |
| |
| Service Area: |
| The area where a health plan accepts members. For HMOs, it is
also the area where services are provided. A health plan may terminate coverage
for persons who move out of the plan's service area. |
| |
| Skilled Nursing Facility: |
| A licensed institution that provides regular medical care and
treatment to sick and injured persons. Daily medical records are kept and
patients are under the care of a licensed physician. |
| |
| Special Benefit Networks: |
| Provider networks for particular services, such as mental
health, substance abuse, or prescription drugs. |
| |
| Staff Model: |
| Staff model is a type of HMO in which care is provided by
physicians who are employees of the HMO. This contrasts with the "independent
practice association (IPA)" HMO, in which independent physicians contract with
the HMO. |
| |
| State Insurance Department: |
| An administrative agency that implements state insurance laws
and supervises (within the scope of these laws) the activities of insurance
companies operating within the state. |
| |
| State-Mandated Benefits: |
| Benefits for a variety of medical conditions that a given
state requires of health insurance policies sold in that state. |
| |
| Stop-loss Provisions: |
| A limit in a health insurance policy that provides for 100%
payment of expenses after total patient out-of-pocket expenses exceed a certain
contractual dollar amount. |
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| Third-Party Payer: |
| Any payer of health care services other than the insured
person. This can be an insurance company, HMO, PPO, or the federal government. |
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| Underwriting: |
| The act of reviewing and evaluating prospective insured
persons for risk assessment and appropriate premium. |
| |
| Usual and Customary (U&C) Charge: |
| A term used to refer to the commonly charged or prevailing
fees for health services within a geographic area. A fee is generally
considered to be reasonable if it falls within the parameters of the average or
commonly charged fee for the particular service within that specific community.
"Usual and Customary (R&C)" essentially means the same thing as "Reasonable
and Customary (R&C) Charge." |
| |
| Utilization Review: |
| A mechanism by which the appropriateness, necessity, and
quality of health care services are monitored by both insurers and employers. |
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| Waiting Period: |
| A period of time when the health plan does not cover a person
for a particular health problem. |
| |
| Well-Baby Care: |
| Preventative health services, including immunizations, for
young children within an age range specified by the health plan. |
| |
| Wellness Office Visit: |
| A physician’s office visit which is not prompted by sickness
or injury. |
| |
| Workers Compensation: |
| Insurance that employers are required to have to cover
employees who get sick or injured on the job. |
| |