ACCREDITED (ACCREDITATION) (Healthcare Insurance Legal Dictionary)
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.
ACCUMULATION PERIOD (Healthcare Insurance Legal Dictionary)
Timeframe within a policy period in which deductible and out-of-pocket amounts are calculated. For most health insurance policies, the accumulation period is a calendar year.
ACTUARY (Healthcare Insurance Legal Dictionary)
An actuary is a health insurance carrier number cruncher responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.
ADMINISTRATIVE SERVICES ONLY (ASO) (Healthcare Insurance Legal Dictionary)
An arrangement in which an employer hires a third party to deliver employee benefit administrative services to the employer. These services typically include health claims processing and billing. The employer bears the risk for health care expenses under an ASO plan.
ADMITTING PHYSICIAN (Healthcare Insurance Legal Dictionary)
The doctor responsible for admitting you to a hospital or other inpatient health facility.
ADMITTING PRIVILEGE (Healthcare Insurance Legal Dictionary)
Admitting privilege is the right granted to a doctor to admit patients to a particular hospital.
ADMITTING PRIVILEGES (Healthcare Insurance Legal Dictionary)
The right granted to a doctor to admit patients to a particular hospital
ADVANCE CARE PLANNING CONSULTATIONS (Healthcare Insurance Legal Dictionary)
A controversial provision of H.R. 3200 would have paid physicians to provide counseling to elderly or terminally ill patients who request the counseling. The provision ? ultimately omitted from the passed health reform legislation ? would have paid for one counseling session at least every five years, during which patients could discuss advance care planning, advance directives, living wills, palliative care and hospice and possible life-sustaining treatments for the terminally ill. Critics said the proposal would create “death panels” and described its intent as “guiding you in how to die.”
ADVANCE DIRECTIVE (Healthcare Insurance Legal Dictionary)
An advance directive indicates the person designated to make medical decisions for you if you are unable physically or mentally to make those decisions yourself.
ADVOCACY (Healthcare Insurance Legal Dictionary)
Any activity done to help a person or group to get something the person or group needs or wants.
AFFORDABLE CARE ACT (ACA) (Healthcare Insurance Legal Dictionary)
The Patient Protection and Affordable Care Act (PPACA) ? also known as the Affordable Care Act or ACA ? is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will “continue to be rolled out over the next four years.” Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures…(more)
AFTER CARE (Healthcare Insurance Legal Dictionary)
The care or follow-up treatment needed by a patient who has recently undergone surgery, been involved in an accident or has experienced an illness requiring hospitalization.
AGENT (Healthcare Insurance Legal Dictionary)
Licensed salespersons who represent one or more health insurance companies and presents their products to consumers.
AGENT OF RECORD (Healthcare Insurance Legal Dictionary)
The insurance agent recognized by a client to represent the client’s interests in doing business with an insurance company.
ALLOWABLE CHARGE (Healthcare Insurance Legal Dictionary)
The amount a benefit plan determines to be a reasonable charge for a service.
AMBULATORY CARE (Healthcare Insurance Legal Dictionary)
All types of health services that do not require an overnight hospital stay
AMBULATORY SURGERY (Healthcare Insurance Legal Dictionary)
Surgery performed on an outpatient basis where the patient is goes home the same day of the surgery.
ANCILLARY SERVICES (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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.
ASSOCIATION (Healthcare Insurance Legal Dictionary)
Associations can offer group health insurance plans specially designed for their members and that give their members purchasing power because of the groups larger pool of enrollees.
ATTACHMENT (Healthcare Insurance Legal Dictionary)
A policy modification which changes, restricts or clarifies coverage
BENEFICIARY (Healthcare Insurance Legal Dictionary)
A person eligible for benefit under a health insurance policy
BENEFIT (Healthcare Insurance Legal Dictionary)
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss
BENEFIT CAP (Healthcare Insurance Legal Dictionary)
Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year
BENEFIT PACKAGE (Healthcare Insurance Legal Dictionary)
The list of covered services a benefit plan offers to a group or individual.
BENEFITS (Healthcare Insurance Legal Dictionary)
The payments or value of services available under the coverage of a plan for treatment of medical costs.
BOARD CERTIFIED (Healthcare Insurance Legal Dictionary)
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
BRAND-NAME DRUG (Healthcare Insurance Legal Dictionary)
Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
BROKER (Healthcare Insurance Legal Dictionary)
A licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company.
CAPITATION (Healthcare Insurance Legal Dictionary)
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.
CARE PLAN (Healthcare Insurance Legal Dictionary)
A written plan for one’s health care
CARRIER (Healthcare Insurance Legal Dictionary)
The insurance company or HMO offering a health plan.
CASE MANAGEMENT (Healthcare Insurance Legal Dictionary)
Comprehensive coordination or supervision of a member’s healthcare when the chronically ill or otherwise impaired person may require long-term care.
CASE MANAGEMENT: (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants
CERTIFICATE OF COVERAGE: (Healthcare Insurance Legal Dictionary)
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company
CERTIFICATE OF INSURANCE (Healthcare Insurance Legal Dictionary)
The certificate of insurance is a printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. It discloses what is covered, what is not, and dollar limits.
CLAIM (Healthcare Insurance Legal Dictionary)
Form submitted to a payer (by a health care provider or patient) to request payment for items or services
CLINICAL PRACTICE GUIDELINES (Healthcare Insurance Legal Dictionary)
Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it
CO-INSURANCE (Healthcare Insurance Legal Dictionary)
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.
CO-PAYMENT (CO-PAY) (Healthcare Insurance Legal Dictionary)
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.
COBRA (Healthcare Insurance Legal Dictionary)
Consolidated Omnibus Budget Reconciliation Act. A federal law passed in 1985 that permits many people who lose eligibility under a group health plan to continue using that coverage.
COINSURANCE (Healthcare Insurance Legal Dictionary)
The percentage of costs a patient pays out-of-pocket for medical care.
COINSURANCE MAXIMUM (Healthcare Insurance Legal Dictionary)
The total amount of coinsurance a member pays each year before the benefit plan pays 100% of allowable charges for covered services.
CONCURRENT REVIEW (Healthcare Insurance Legal Dictionary)
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.”
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) (Healthcare Insurance Legal Dictionary)
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.
CONTINUUM OF CARE (Healthcare Insurance Legal Dictionary)
The range of medical, nursing and social services most appropriate for the level or type of care required. For example, a hospital may offer services ranging from a nursery to hospice.
CONTRACT YEAR (Healthcare Insurance Legal Dictionary)
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.
CONVERSION PLAN (Healthcare Insurance Legal Dictionary)
A member’s group plan is discontinued and the member chooses to continue coverage under an individual plan.
COOPERATIVES (Healthcare Insurance Legal Dictionary)
Cooperatives or insurance cooperatives were proposed in the Senate as an alternative to a proposed government plan or public option. The cooperatives, which would have been structured as non-profits and owned by their members, would offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide “seed money” for the cooperatives, which would then be sustained by customer premiums. Read this Commonwealth Fund history of health cooperatives
COORDINATED CARE (Healthcare Insurance Legal Dictionary)
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.
COORDINATION OF BENEFITS (Healthcare Insurance Legal Dictionary)
A provision that applies when an individual has coverage under more than one plan. It is designed to avoid duplicate payment and to determine the plan that pays before the other.
COORDINATION OF BENEFITS (COB) (Healthcare Insurance Legal Dictionary)
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.
COPAYMENT (Healthcare Insurance Legal Dictionary)
Copayment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 copayment for each office visit, regardless of the type or level of services provided during the visit. Copayments are not usually specified by percentages. Related terms: co-insurance, deductible
COST SHARING (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.
CREDENTIALING (Healthcare Insurance Legal Dictionary)
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
CREDIT FOR PRIOR COVERAGE (Healthcare Insurance Legal Dictionary)
Credit for coverage may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer’s (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.
CREDITABLE COVERAGE (Healthcare Insurance Legal Dictionary)
Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. See “HIPPA”
CRITICAL ACCESS HOSPITAL (Healthcare Insurance Legal Dictionary)
A small facility that gives limited outpatient and inpatient hospital services to people in rural areas
CURRENT PROCEDURAL TERMINOLOGY (CPT) (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
Personal care, such as bathing, cooking, and shopping
CUSTOMARY AND REASONABLE (Healthcare Insurance Legal Dictionary)
Refers to the dollar amount allowed for a particular service and is often set by the insurance company or third-party payer. Companies typically establish this amount based on the average cost of the procedure in your geographical area. Also called Reasonable and Customary.
DEDUCTIBLE (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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
DEDUCTIBLE CARRY-OVER (Healthcare Insurance Legal Dictionary)
In some benefit plans, this arrangement applies to bills received during the last three months of the year toward the deductible for the next year.
DEFENSIVE MEDICINE (Healthcare Insurance Legal Dictionary)
Use of unnecessary treatments, procedures or other medical services by doctors to minimize the threat of a malpractice lawsuit
DENIAL OF CLAIM (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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
DEPENDENT WORKER (Healthcare Insurance Legal Dictionary)
A worker in a family in which someone else has greater personal income.
DEPENDENTS (Healthcare Insurance Legal Dictionary)
Spouse and/or children (usually 18 or under or full-time students) defined as eligible in an employee benefit plan.
DESIGNATED FACILITY (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
Ending a person’s health care coverage with a health plan
DRG (DIAGNOSTIC RELATED GROUP) (Healthcare Insurance Legal Dictionary)
A Medicare-developed healthcare cost schedule in which medical service providers are assigned a uniform payment for specific services.
DRUG FORMULARY (Healthcare Insurance Legal Dictionary)
List of designated prescription drugs eligible for coverage by a managed care plan.
DURABLE MEDICAL EQUIPMENT (Healthcare Insurance Legal Dictionary)
Equipment which meets the following criteria: (a) can withstand repeated use; (b) is primarily and customarily used to serve a medical purpose; (c) generally, is not useful to a person in the absence of illness/injury; and (d) is appropriate for home use.
EAP (Healthcare Insurance Legal Dictionary)
Employee Assistance Program. A program of counseling and other forms of assistance for alcoholism, substance abuse or emotional and family problems.
EFFECTIVE DATE (Healthcare Insurance Legal Dictionary)
The date health insurance coverage begins
ELIGIBLE DEPENDENT (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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
ELIGIBLE PERSON (Healthcare Insurance Legal Dictionary)
A person who meets the qualifications of a health plan contract.
EMERGENCY CARE (Healthcare Insurance Legal Dictionary)
Services provided in connection with an unforeseen acute illness or injury requiring immediate medical attention.
EMPLOYEE ASSISTANCE PROGRAMS (EAPS) (Healthcare Insurance Legal Dictionary)
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.
EMPLOYER MANDATE (Healthcare Insurance Legal Dictionary)
The new health reform legislation requires employers with 50 or more employees to provide health coverage to those employees and sets a minimum baseline of coverage and employer contributions. Employers who do not comply will face annual penalties based on the number of employees in the firm.
EMPLOYER TAX CREDITS (Healthcare Insurance Legal Dictionary)
Employer tax credits ? or Small Business Health Care Tax Credits ? provide a tax credit of up to 35 percent of small business premium costs in 2010 ? with that rate increasing to 50 percent in 2014. Who’s eligible? Employers with fewer than 25 full-time workers and average annual wages less than $50,000. Read more about the credit.
EMPLOYER-SPONSORED HEALTH INSURANCE (Healthcare Insurance Legal Dictionary)
Of Americans who have health coverage, nearly 60 percent secure that coverage through an employer-sponsored plan, often called group health insurance. Millions take advantage of the coverage for reasons as obvious as employer responsibility for a significant portion of the health care expenses. Group health plans are also guaranteed issue, meaning that a carrier must cover all applicants whose employment qualifies them for coverage. In addition, employer-sponsored plans typically are able to include…(more)
EMPLOYER-SPONSORED HEALTH PLANS (Healthcare Insurance Legal Dictionary)
Employer-sponsored health plans currently provide some level of health coverage for approximately 160 million Americans. Employer-sponsored health plans are more likely to be provided by larger companies; in fact, an estimated 99 percent of companies with 200 or more workers offer health benefits, according to recent testimony in Congress. However, the plans face rapidly escalating premiums ? up 119 percent since 1998 ? and even at larger firms, up to 21 percent of workers may not be eligible for…(more)
ENROLLEE (Healthcare Insurance Legal Dictionary)
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.
EOB (Healthcare Insurance Legal Dictionary)
Explanation of Benefits. A statement sent to enrollees explaining services provided, amount to be billed and payments made.
EPISODE OF CARE (Healthcare Insurance Legal Dictionary)
The health care services given during a certain period of time, usually during a hospital stay
ERISA (Healthcare Insurance Legal Dictionary)
Employee Retirement Income and Security Act. An act which places regulations on employee benefit plans, including health insurance.
EVIDENCE OF INSURABILITY (Healthcare Insurance Legal Dictionary)
Proof of physical condition. This may be provided through physician records or by the results of an examination.
EXCHANGE (Healthcare Insurance Legal Dictionary)
A health insurance exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans msut meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
EXCLUSION (Healthcare Insurance Legal Dictionary)
An exclusion is a provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage or locations.
EXCLUSION PERIOD (Healthcare Insurance Legal Dictionary)
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.
EXCLUSIONS (Healthcare Insurance Legal Dictionary)
Specific healthcare services, sicknesses or injuries that aren’t covered by the benefit plan.
EXCLUSIONS AND LIMITATIONS (Healthcare Insurance Legal Dictionary)
Medical services that are either not covered or limited in benefit by a health insurance insurance policy
EXPLANATION OF BENEFITS (Healthcare Insurance Legal Dictionary)
An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the client must pay. The document is sometimes accompanied by a benefits check.
EXPLANATION OF BENEFITS (EOB) (Healthcare Insurance Legal Dictionary)
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.
FEE SCHEDULE (Healthcare Insurance Legal Dictionary)
A complete listing of fees used by health plans to pay doctors or other providers
FEE-FOR SERVICE (Healthcare Insurance Legal Dictionary)
Fee-for-service is a system of health insurance payment in which a doctor or other health care provider is paid a free for each particular service rendered..
FEE-FOR-SERVICE (Healthcare Insurance Legal Dictionary)
A payment system for health care where the provider is paid for each service rendered rather than a pre-negotiated amount for each patient
FIRST DOLLAR COVERAGE (Healthcare Insurance Legal Dictionary)
Refers to not having to meet a calendar year deductible prior to receiving reimbursement or payment for a medical service
FLEXIBLE BENEFIT PLAN (Healthcare Insurance Legal Dictionary)
A benefits package allowing an employee to choose from a range of benefit choices
FLEXIBLE SPENDING ACCOUNT (FSA) (Healthcare Insurance Legal Dictionary)
An employee benefits cash account from which non-taxable withdraws can be made to fund eligible expenses defined by the employer-sponsored plan. The FSA is funded by reductions in salary prior to calculation of federal income and social security taxes.
FORMULARY (Healthcare Insurance Legal Dictionary)
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
FREE-LOOK PERIOD (Healthcare Insurance Legal Dictionary)
Typically a 10-day period during which a newly insured person can cancel a policy and receive a full refund of paid premium.
FULL-TIME STUDENT (Healthcare Insurance Legal Dictionary)
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.) . 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 (Healthcare Insurance Legal Dictionary)
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.
GENERAL AGENT (Healthcare Insurance Legal Dictionary)
This typically refers to a “middle man” agent who facilitates business between “retail” agents and the insurance company.
GENERIC DRUG (Healthcare Insurance Legal Dictionary)
Once a company’s patent on a brand-name prescription drug has expired, other drug companies are allowed to sell the same drug under a generic label. Generic drugs are less expensive, and most prescription and health plans reward clients for choosing generic drugs.
GRIEVANCE (Healthcare Insurance Legal Dictionary)
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 INSURANCE (Healthcare Insurance Legal Dictionary)
Coverage through an employer or other entity that covers all individuals in the group. Read more about group health insurance. Related terms: employer-sponsored health insurance, private health insurance, individual health insurance
GROUP HEALTH PLAN (Healthcare Insurance Legal Dictionary)
A health plan that provides health coverage to employees and their families, and is supported by an employer or employee organization
GUARANTEED ISSUE (Healthcare Insurance Legal Dictionary)
Under guarantee issue, a health insurance company or HMO must issue coverage to an applicant regardless of prior medical history. In Illinois and Indiana, small employers (defined as 2 to 50 employees) cannot be refused coverage for their employees regardless of the medical history of one or more employees.
HCFA (Healthcare Insurance Legal Dictionary)
Health Care Financing Administration. The agency within the Department of Health and Human Services which administers federal health financing and related regulatory programs, principally the Medicare, Medicaid and Peer Review Organization.
HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) (Healthcare Insurance Legal Dictionary)
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 DECISION COUNSELING (Healthcare Insurance Legal Dictionary)
Services, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of medical tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual’s unique set of circumstances.
HEALTH CARE PROVIDER (Healthcare Insurance Legal Dictionary)
A doctor, hospital, laboratory, nurse, or anyone who delivers medical or health-related care
HEALTH CHOICES ADMINISTRATION (Healthcare Insurance Legal Dictionary)
Health reform legislation called for the creation of the Health Choices Administration, a federal agency that would oversee its provisions, including the establishment of health plan benefit standards, establishment and operation of the health insurance exchanges, and administration of individual affordability credits or subsidies. The commission’s additional responsibilities would include prevention of abuses within the Health Insurance Exchange system.
HEALTH CHOICES COMMISSIONER (Healthcare Insurance Legal Dictionary)
Health reform legislation called for the creation of a federal agency called the Health Choices Administration. Overseeing that agency would be the Health Choices Commissioner, an individual appointed by the President to oversee provisions of health reform, including the establishment of health plan benefit standards, establishment and operation of the health insurance exchanges, and administration of individual affordability credits or subsidies. The commissioner’s additional responsibilities would include prevention of abuses within the Health Insurance Exchange system.
HEALTH EMPLOYER DATA AND INFORMATION SET (HEDIS) (Healthcare Insurance Legal Dictionary)
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 EXCHANGE (Healthcare Insurance Legal Dictionary)
A health insurance exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans must meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) (Healthcare Insurance Legal Dictionary)
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 INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) (Healthcare Insurance Legal Dictionary)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers…(more)
HEALTH MAINTENANCE ORGANIZATION (HMO) (Healthcare Insurance Legal Dictionary)
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 MAINTENANCE ORGANIZATIONS (HMOS) (Healthcare Insurance Legal Dictionary)
Health maintenance organizations represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician’s own office (as with IPAs.)
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) (Healthcare Insurance Legal Dictionary)
A tax-advantaged employee health spending account funded and owned by the employer. Funds remaining in the account at year-end revert to the employer. For the employee, HRAs are a “use it or lose it” proposition.
HEALTH SAVINGS ACCOUNT (HSA) (Healthcare Insurance Legal Dictionary)
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) (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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.
HSA (Healthcare Insurance Legal Dictionary)
Health Savings Account. HSAs were created by the Medicare bill in 2003 and are designed to help individuals save for future qualified medical and retiree health expenses on a tax-free basis.
IMPAIRED RISK (Healthcare Insurance Legal Dictionary)
An insurance applicant who has pre-existing poor health or is in substandard physical condition, is engaged in dangerous activities, or has a hazardous occupation.
IN-NETWORK (Healthcare Insurance Legal Dictionary)
In-network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
INCURRAL DATE (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
IPAs are similar to HMOs, except that individuals receive care in a physician’s own office, rather than in an HMO facility.
INDEPENDENT PRACTICE ASSOCIATIONS (IPA) (Healthcare Insurance Legal Dictionary)
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.
INDIVIDUAL AFFORDABILITY CREDITS (Healthcare Insurance Legal Dictionary)
Individual affordability credits are included in the health reform legislation to help ensure the goals of the legislation’s individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the health insurance exchanges.
INDIVIDUAL HEALTH INSURANCE (Healthcare Insurance Legal Dictionary)
Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan. Read more about individual health insurance. Read recent news articles about individual health insurance.
INDIVIDUAL MANDATE (Healthcare Insurance Legal Dictionary)
The individual mandate provision of the recently passed health reform legislation requires citizens to have insurance coverage that meets minimum standards set as part of health insurance exchanges, including guaranteed access to affordable coverage, essential benefits and other consumer protections. The legislation imposes a tax penalty on individuals ? with some exceptions ? who do not purchase coverage.
INDIVIDUAL SUBSIDIES (Healthcare Insurance Legal Dictionary)
Individual subsidies ? or individual affordability credits ? are included in the health reform legislation to help ensure the goals of the legislation’s individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the health insurance exchanges. Related terms: individual affordability credits, subsidies
INPATIENT CARE (Healthcare Insurance Legal Dictionary)
Health care that you get when you stay overnight in a hospital
INSURANCE COOPERATIVES (Healthcare Insurance Legal Dictionary)
Cooperatives or insurance cooperatives were proposed in the Senate as an alternative to a proposed government plan or public option. The cooperatives, which would have been structured as non-profits and owned by their members, would offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide “seed money” for the cooperatives, which would then be sustained by customer premiums. Read this Commonwealth Fund history of health cooperatives
INSURANCE EXCHANGE (Healthcare Insurance Legal Dictionary)
A health insurance exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans msut meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
INSURED (Healthcare Insurance Legal Dictionary)
A person who has obtained health insurance coverage under a health insurance plan
INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION, CLINICAL MODIFICATION (ICD-9-CM) (Healthcare Insurance Legal Dictionary)
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.
LAPSE (Healthcare Insurance Legal Dictionary)
Termination of insurance for non-payment of premium
LENGTH OF STAY (LOS) (Healthcare Insurance Legal Dictionary)
LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
LIFETIME MAXIMUM (Healthcare Insurance Legal Dictionary)
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.
LIFETIME MAXIMUM BENEFIT (OR MAXIMUM LIFETIME BENEFIT) (Healthcare Insurance Legal Dictionary)
the maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.
LIFETIME MAXIMUM BENEFIT: THE TOTAL AMOUNT OF MONEY A BENEFIT PLAN WILL PAY PROVIDERS FOR THE TREATMENT OF A PATIENT. (Healthcare Insurance Legal Dictionary)
LIMITATIONS (Healthcare Insurance Legal Dictionary)
a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
LIMITED POLICY (Healthcare Insurance Legal Dictionary)
A policy that covers only specified accidents or sicknesses (e.g. a cancer policy)
LONG-TERM CARE POLICY (Healthcare Insurance Legal Dictionary)
Insurance policies that cover specified services for a specified period of time. Long-term care policies (and their prices) vary significantly. Covered services often include nursing care, home health care services, and custodial care.
LONG-TERM DISABILITY INSURANCE (Healthcare Insurance Legal Dictionary)
Pays an insured a percentage of their monthly earnings if they become disabled.
MAJOR MEDICAL (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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).
MASTER POLICY (Healthcare Insurance Legal Dictionary)
The group insurance policy that explains coverage to all members of the group.
MAXIMUM DOLLAR LIMIT (Healthcare Insurance Legal Dictionary)
The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
MEDICAID (Healthcare Insurance Legal Dictionary)
Federal and state health insurance program for low-income individuals who meet established eligibility criteria (programs vary from state to state)
MEDICAL NECESSITY (Healthcare Insurance Legal Dictionary)
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
MEDICAL SAVINGS ACCOUNT (MSA) (Healthcare Insurance Legal Dictionary)
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.
MEDICAL UNDERWRITING (Healthcare Insurance Legal Dictionary)
Medical underwriting is a process used by insurance companies to evaluate whether to accept an applicant for health coverage and/or to determine the premium rate for the policy.
MEDICALLY NECESSARY (Healthcare Insurance Legal Dictionary)
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.
MEDICARE (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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.
MEDIGAP (Healthcare Insurance Legal Dictionary)
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.
MEDIGAP INSURANCE POLICIES (Healthcare Insurance Legal Dictionary)
Medigap plans offer supplemental benefits sold by private companies to extend traditional Medicare. Fifteen plans offer varying combinations of benefits, ranging from coverage of copayments and deductibles to coverage of foreign travel emergency expenses, at-home care and preventive care. Learn more about Medicare benefits and eligibility.
MEMBER (Healthcare Insurance Legal Dictionary)
An eligible employee or an eligible dependent of an employee who has enrolled in the plan. Synonymous with enrollee and participant.
MISREPRESENTATION (Healthcare Insurance Legal Dictionary)
Lying or misleading an insurance company about the facts affecting a policy. Misrepresentation is grounds for voiding a policy.
MORBIDITY (Healthcare Insurance Legal Dictionary)
A mathematical representation of the occurrence of illnesses to a specific classification of people.
MULTIPLE EMPLOYER TRUST (MET) (Healthcare Insurance Legal Dictionary)
A trust consisting of multiple small employers in the same industry, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would be available to each of the employers individually.
NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS (NAIC) (Healthcare Insurance Legal Dictionary)
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) (Healthcare Insurance Legal Dictionary)
A national group responsible for devising and monitoring quality measurements and standards for health care entities
NATIONAL DRUG CODE (NDC) (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
Groups of physicians, hospitals and other health care providers working with the health plan to offer care at negotiated rates
NETWORK PROVIDER (Healthcare Insurance Legal Dictionary)
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.”
NON-PROFIT COOPERATIVES (Healthcare Insurance Legal Dictionary)
Non-profit cooperatives or insurance cooperatives have been proposed in the Senate as an alternative to a proposed government plan. The cooperatives, which would be structured as non-profits and owned by their members, could offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide “seed money” for the cooperatives, which would then be sustained by customer premiums. Read more about insurance cooperatives.
NONCANCELLABLE POLICY (Healthcare Insurance Legal Dictionary)
A policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.
NONRENEWABLE (Healthcare Insurance Legal Dictionary)
An insurance policy that cannot be renewed or continued after its expiration date.
OPEN ENROLLMENT (Healthcare Insurance Legal Dictionary)
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.
OPEN-ENDED HMOS (Healthcare Insurance Legal Dictionary)
HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional’s services under a traditional indemnity plan.
OUT-OF-NETWORK (Healthcare Insurance Legal Dictionary)
Health care services received outside the HMO or PPO network
OUT-OF-PLAN (Healthcare Insurance Legal Dictionary)
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-PLAN (OUT-OF-NETWORK) (Healthcare Insurance Legal Dictionary)
This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants 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 only in part by an individual’s insurance company.
OUT-OF-POCKET COSTS (Healthcare Insurance Legal Dictionary)
Insured health care costs for which one is responsible, because of the application of deductibles, coinsurance and co-payments
OUT-OF-POCKET MAXIMUM (Healthcare Insurance Legal Dictionary)
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.
OUTPATIENT (Healthcare Insurance Legal Dictionary)
An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
PARTICIPANT (Healthcare Insurance Legal Dictionary)
An eligible employee or an eligible dependent of an employee who has enrolled in the plan. Synonymous with enrollee and member.
PARTICIPATING PROVIDER (Healthcare Insurance Legal Dictionary)
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.
PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA) (Healthcare Insurance Legal Dictionary)
The Patient Protection and Affordable Care Act (PPACA) ? also known as the Affordable Care Act or ACA ? is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will “continue to be rolled out over the next four years.” Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures…(more)
PERMANENT INSURANCE (Healthcare Insurance Legal Dictionary)
Coverage that can be continued relatively indefinitely (such as to age 65 for most permanent health insurance policies) as long as the policyholder makes scheduled premium payments and refrains from actions that would invalidate the policy (such as misrepresentations on the application)
PLAN ADMINISTRATION (Healthcare Insurance Legal Dictionary)
Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums, and similar duties.
POLICY (Healthcare Insurance Legal Dictionary)
The insurance agreement or contract
POLICY YEAR (Healthcare Insurance Legal Dictionary)
The twelve month period beginning with the effective date or renewal date of the policy.
POLICYHOLDER (Healthcare Insurance Legal Dictionary)
The insured person named on the insurance policy
PORTABILITY (Healthcare Insurance Legal Dictionary)
The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors
PPO (Healthcare Insurance Legal Dictionary)
Preferred Provider Organization. An affiliation of healthcare providers, such as hospitals and physicians, who have agreed through formal agreements to provide healthcare at a discounted fee.
PRE-ADMISSION CERTIFICATION (Healthcare Insurance Legal Dictionary)
Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).
PRE-ADMISSION REVIEW (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility
PRE-AUTHORIZATION (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
A health problem that existed before the date your insurance became effective. Each health insurance company uses its own particular definitions of pre-existing condition. 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.”
PREADMISSION TESTING (Healthcare Insurance Legal Dictionary)
Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.
PREFERRED PROVIDER ORGANIZATION (PPO) (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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.
PREMIUM (Healthcare Insurance Legal Dictionary)
The amount you or your employer pays in exchange for health insurance coverage
PREVENTIVE CARE (Healthcare Insurance Legal Dictionary)
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) (Healthcare Insurance Legal Dictionary)
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.
PRIMARY CARE PROVIDER (PCP) (Healthcare Insurance Legal Dictionary)
A health care professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.
PRIOR AUTHORIZATION (Healthcare Insurance Legal Dictionary)
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.
PRIVATE HEALTH INSURANCE (Healthcare Insurance Legal Dictionary)
Private health insurance ? insurance plans marketed by the private health insurance industry ? currently dominates the U.S. health care landscape, with approximately two-thirds of the non-elderly population covered by private health insurance. Coverage includes policies obtained through employer-sponsored insurance, with approximately 62 percent of non-elderly Americans receiving insurance provided as a benefit of employment. Another 5 percent of the non-elderly group bought coverage outside of…(more)
PROVIDER (Healthcare Insurance Legal Dictionary)
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care
PUBLIC OPTION (Healthcare Insurance Legal Dictionary)
A public option ? also referred to as a public plan ? was a proposal within the recently passed health reform legislation that would have created a qualified health benefit plan to compete with other plans that qualify for health insurance exchanges. The public option, which ultimately was omitted from the final Affordable Care Act, would have been subject to the same requirements ? regarding benefit levels, provider networks, consumer protections and cost sharing ? that would apply to other plans within the exchanges.
PUBLIC PLAN (Healthcare Insurance Legal Dictionary)
A public plan ? also referred to as a public option ? was a proposal within the recently passed health reform legislation that would have created a qualified health benefit plan to compete with other plans that qualify for health insurance exchanges. The public plan, which ultimately was omitted from the passed Affordable Care Act, would have been subject to the same requirements ? regarding benefit levels, provider networks, consumer protections and cost sharing ? that would apply to other plans within the exchanges.
QUALIFYING EVENT (Healthcare Insurance Legal Dictionary)
An occurrence (such as death, termination of employment, divorce, etc.) that changes an employee’s eligibility status under a group health plan. The term is most frequently used in reference to COBRA eligibility.
RATIONING (Healthcare Insurance Legal Dictionary)
Rationing – actually the threat of rationing – is one of the most powerful arguments leveled against proposals for an expanded government control of the U.S. health care system. Critics of such expanded control – which might take the form of a public plan or public option – argue that in order to control costs in a revamped system, the government would have to restrict (or ration) care, by refusing to pay for certain procedures or medication or by putting limits on care for the elderly or…(more)
REASONABLE AND CUSTOMARY (R &C) CHARGE (Healthcare Insurance Legal Dictionary)
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.”
REASONABLE AND CUSTOMARY FEES (Healthcare Insurance Legal Dictionary)
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
REFERRAL (Healthcare Insurance Legal Dictionary)
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.
RENEWAL (Healthcare Insurance Legal Dictionary)
A continuation of an insurance policy on revised terms, such as adjusted health insurance rates
RESCISSION (Healthcare Insurance Legal Dictionary)
Rescission is an insurance industry practice in which an insurer takes action retroactively to cancel a policy holder’s coverage by citing omissions or errors in the customer’s application, even if the policy holder has been diligently keeping their policy current. As of September 2010, rescission is no longer allowed except where fraud is proven. Related term: pre-existing condition
RIDER (Healthcare Insurance Legal Dictionary)
An attachment, amendment or endorsement to an insurance policy
RISK (Healthcare Insurance Legal Dictionary)
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.
SCHEDULE OF BENEFITS AND EXCLUSIONS (Healthcare Insurance Legal Dictionary)
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 OPINION (Healthcare Insurance Legal Dictionary)
It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.
SECOND SURGICAL OPINION (Healthcare Insurance Legal Dictionary)
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-FUNDED (Healthcare Insurance Legal Dictionary)
A health plan for which the employer sets aside funds to cover employee medical claims and assumes the risk, as opposed to paying premiums to an insurance company. A third party usually handles claims administration.
SELF-INSURED (SELF ADMINISTERED) (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
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.
SHORT-TERM DISABILITY (Healthcare Insurance Legal Dictionary)
An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual’s full or partial wages during a time of injury or illness (that is not work-related) that would prohibit the individual from working.
SHORT-TERM HEALTH INSURANCE (Healthcare Insurance Legal Dictionary)
Short-term major medical health insurance policies were designed to provide coverage for individuals who need temporary health insurance coverage for a short period of time, usually from 30 days to six months. The policies ? offered by private health insurance companies ? are intended to provide a safety net in the event of a health crisis that might otherwise cause a serious financial hardship.
SHORT-TERM MEDICAL INSURANCE (Healthcare Insurance Legal Dictionary)
Temporary major medical coverage designed to fill “gaps” in traditional medical coverage. Short-term plans typically last no longer than one year and cannot be renewed.
SINGLE-PAYER SYSTEM (Healthcare Insurance Legal Dictionary)
Single-payer system is a health care system in which one entity ? a single payer ? collects all health care fees and pays for all health care costs. Proponents of a single-payer system argue that because there are fewer entities involved in the health care system, the system can avoid an enormous amount of administrative waste. Instead, all health care providers in a single-payer system would bill one entity for their services. Within a single-payer system, all citizens would receive high-quality,…(more)
SKILLED NURSING FACILITY (Healthcare Insurance Legal Dictionary)
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.
SMALL BUSINESS HEALTH CARE TAX CREDITS (Healthcare Insurance Legal Dictionary)
Employer tax credits ? or Small Business Health Care Tax Credits ? provide a tax credit of up to 35 percent of small business premium costs in 2010 ? with that rate increasing to 50 percent in 2014. Who’s eligible? Employers with fewer than 25 full-time workers and average annual wages less than $50,000. Read more about the credit.
SMALL EMPLOYER GROUP (Healthcare Insurance Legal Dictionary)
Generally means groups with 1-99 employees. The definition may vary between states.
SOCIALIZED MEDICINE (Healthcare Insurance Legal Dictionary)
Socialized medicine is, by definition, a health care system in which the government owns and operates health care facilities and employs the health care professionals, thus also paying for all health care services. Examples abroad include the British National Health Service, and national health systems in countries such as Finland and Spain, but NOT including Canada’s Medicare system (which is publicly funded but which does not own all of the health facilities). Closer to home, the Veterans Health…(more)
SPECIAL BENEFIT NETWORKS (Healthcare Insurance Legal Dictionary)
Provider networks for particular services, such as mental health, substance abuse, or prescription drugs
STAFF MODEL (Healthcare Insurance Legal Dictionary)
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.
STANDARD INDUSTRIAL CLASSIFICATION (SIC) (Healthcare Insurance Legal Dictionary)
Coding of businesses by their product or service. This classification is used in group insurance in determining rates for various industries.
STATE INSURANCE DEPARTMENT (Healthcare Insurance Legal Dictionary)
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 (Healthcare Insurance Legal Dictionary)
When a state passes laws requiring that health insurance plans include specific benefits.
STATE-MANDATED BENEFITS (Healthcare Insurance Legal Dictionary)
Benefits for a variety of medical conditions that a given state requires of health insurance policies sold in that state
STOP-LOSS (Healthcare Insurance Legal Dictionary)
The dollar amount of claims filed for eligible expenses at which point you’ve paid 100 percent of your out-of-pocket and the insurance begins to pay at 100 percent. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
STOP-LOSS PROVISIONS (Healthcare Insurance Legal Dictionary)
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
STUDENT HEALTH INSURANCE (Healthcare Insurance Legal Dictionary)
In recent years, many colleges have begun requiring proof of health insurance for students. Coverage options include insurance through family policies and coverage through school-sponsored student health plans, now offered by more than 80 percent of public four-year colleges. Students may also seek coverage through an employer’s plan if they’re employed full time, or they can purchase their own individual health insurance plan from a licensed health insurance provider. And, depending on the state…(more)
SUBSIDIES (Healthcare Insurance Legal Dictionary)
Individual subsidies ? or individual affordability credits ? are included in the health reform legislation to help ensure the goals of the legislation’s individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the health insurance exchanges. Related terms: individual affordability credits, individual subsidies
TERTIARY CARE (Healthcare Insurance Legal Dictionary)
Specialized healthcare requiring sophisticated technology, multiple specialists and support facilities. Cancer care, brain surgery and burn care are examples of tertiary care services.
THIRD-PARTY PAYER (Healthcare Insurance Legal Dictionary)
Any payer of health care services other than the insured person. This can be an insurance company, HMO, PPO, or the federal government.
TPA (Healthcare Insurance Legal Dictionary)
Third Party Administrator. An organization that administers healthcare benefits, mostly for self-funded employers.
UNDERWRITER (Healthcare Insurance Legal Dictionary)
The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
UNDERWRITING (Healthcare Insurance Legal Dictionary)
The act of reviewing and evaluating prospective insured persons for risk assessment and appropriate premium
URGENT CARE (Healthcare Insurance Legal Dictionary)
Health care provided in situations of medical duress that have not reached the level of emergency. Claim costs for urgent care services are typically much less than for services delivered in emergency rooms.
USUAL AND CUSTOMARY (U&C) CHARGE (Healthcare Insurance Legal Dictionary)
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.”
USUAL, CUSTOMARY AND REASONABLE (UCR) OR COVERED EXPENSES (Healthcare Insurance Legal Dictionary)
An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
UTILIZATION REVIEW (Healthcare Insurance Legal Dictionary)
A mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers
WAITING PERIOD (Healthcare Insurance Legal Dictionary)
A period of time when the health plan does not cover a person for a particular health problem
WELL-BABY CARE (Healthcare Insurance Legal Dictionary)
Preventative health services, including immunizations, for young children within an age range specified by the health plan
WELLNESS OFFICE VISIT (Healthcare Insurance Legal Dictionary)
A physician’s office visit which is not prompted by sickness or injury
WORKERS COMPENSATION (Healthcare Insurance Legal Dictionary)
Insurance that employers are required to have to cover employees who get sick or injured on the job
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