Accident and health insurance
-- Coverage that pays benefits in case of sickness, accidental
injury or accidental death. It sometimes provides for loss of
income or debt payment if taken out in connection with a loan.
Actuary -- A person who calculates statistically
risks, premiums, life expectancies and other factors for insurance
firms.
Additional monthly benefit -- Addendum to a
disability income policy that provides an extra monthly stipend
in the first year of injury, before Social Security benefits start.
Adult day care -- Out-of-home care for disabled
adults providing for physical and social needs.
Aftercare -- Services provided after hospitalization
and rehabilitation.
Allowable costs -- Covered costs of a medical
insurance plan.
Ambulatory benefits -- Coverage for health
care services provided while the insured is not confined to a
hospital or institution. Could include home health care, physical
therapy, emergency room care and pre-admission testing.
Ancillary services -- All the extras that make
that hospital stay special, excluding room, meals and nursing
care. Ancillary services can include just about everything else:
lab services, drugs, dressings, radiology, operating room services
and anesthesiology. Could also cover these same services in a
nonhospital setting.
Assignment of benefits -- When an insured arranges
for the plan to pay someone else directly, usually the physician
or hospital.
Basic hospital expense insurance
-- Covers room, board and some miscellaneous expenses for a certain
number of days.
Benefit levels -- The maximum that a person
can receive for a service or procedure under a policy.
Benefit package -- What the insurer covers
under a particular policy.
Billed claims -- The amount a hospital or doctor
bills the plan.
Blanket medical expense policy -- A plan that
pays all medical expenses on a claim without limiting any services
or procedures up to a certain ceiling amount.
Board certified -- A doctor who has passed
an exam that qualifies him or her as a specialist in a certain
field.
Board eligible -- A doctor who is eligible
to take the board exam that will make him or her board certified.
Broker -- A person who represents the insurance
buyer, not the insurance company or agent, and helps a buyer obtain
the proper insurance coverage.
Capitation -- A method of paying
for health care services. A fixed amount per person guarantees
access to specified medical services, whether plan members take
advantage of them or not.
Carrier -- The insurer.
Carry-over provision -- Clause in medical policy
that allows a person who has submitted no medical expenses in
a year to apply, or carry over, expenses occurring in the last
three months of the year toward the next year's deductible.
Claim -- Request for payment under the terms
of the policy. May be submitted by the insured or the health care
or service provider.
Closed access -- Also known as a gatekeeper
model or closed panel. A plan that stipulates the insured will
be reimbursed for initial visits to only one doctor, and that
doctor must be the one to recommend more specialized care.
COBRA (Consolidated Omnibus Budget Reconciliation
Act) -- Federal legislation that requires businesses of a
certain size to keep former employees and their dependents on
the group health plan for a limited period, provided the
ex-employee pays the premiums.
Co-insurance -- In health insurance, the
percentage of the claims that an individual must pay, less the
deductible. In property and casualty insurance, a provision that
requires the insured to maintain a specified amount of insurance
based on the value of the property insured.
Comprehensive major medical -- A policy with
a low deductible and high maximum coverage limits, as well as
a coinsurance provision, which combines basic coverage with major
medical coverage.
Conditionally renewable -- Gives the individual
the right to renew coverage up to a certain age or specified date.
If the company decides not to renew, it must be for specific reasons
or conditions stated in the contract.
Continuation -- Allows employees to continue
their group health coverage under certain conditions. (See COBRA.)
Co-pay -- The portion of a bill that the insured
pays, usually at the time of service. Often expressed as a set
fee for a specific service.
Credit health insurance -- A policy that protects
a creditor should the debtor become disabled.
Custodial care -- Personal care administered
with a doctor's recommendation but possibly carried out by nonmedical
staff.
Deductible -- The amount
a policyholder agrees to pay toward the insurance loss. The deductible
may apply to all claims made during a specified period, as with
health insurance, or to each claim for a loss occurrence, such
as an automobile accident.
Dependents -- Usually includes a lawful spouse
and unmarried children, adopted, step, foster or biological, up
to a certain age.
Diagnosis Related Groups (DRGs) -- A system
used for classification and reimbursement of inpatient hospital
services.
Disability income insurance -- Health insurance
that provides some payment to replace lost income if the insured
becomes sick or disabled.
Dread disease policy -- A policy with a high
maximum limit to cover all the medical expenses associated with
a particular disease.
Drug formulary -- A list of drugs covered by
the plan and supplied by participating pharmacies.
Duplicate Coverage Inquiry (DCI) -- An inquiry
by the insuring organization to determine whether an individual
carries duplicate coverage.
Elective benefits -- A lump
sum that the insured can elect to take for some conditions, rather
than collecting periodic reimbursements.
Emergency -- A disease or injury that occurs
suddenly and requires immediate (usually defined as within 24
hours) treatment.
Encounter -- Each time a person receives medical
services.
Enrollment period -- The time period during
which a person can join a health plan.
Entire contract clause -- An addendum stipulating
that everything in the insurer/insured relationship is spelled
out in the contract. In other words, if it's not in writing, it
doesn't exist.
Experimental or unproven procedures -- Treatment
that the plan deems medically unacceptable or scientifically unproven.
Explanation of benefits (EOB) -- Paperwork
sent by the insurer to the insured listing the cost of treatment,
the charges paid by the plan and the remainder to be paid by the
individual.
Extended coverage -- An addendum specifying
that if the insured has an ongoing condition, like a pregnancy,
that began when the policy was in force, expenses associated with
the condition will be covered even after the policy has expired.
Extension of benefits -- A provision of some
plans that extends coverage past the plan expiration date in certain
situations, such as hospitalization and disability.
Flat maternity benefit -- In
some plans, the amount that will be paid for hospital maternity
care, regardless of the actual cost.
Group insurance -- Insurance
coverage usually issued to an employer under a master policy for
the benefit of employees.
Health Care Financing Administration
(HCFA) -- The federal agency that oversees Medicare and Medicaid,
and sets certification standards for health care providers.
Health maintenance organization (HMO) --
Prepaid medical plan in which members agree to use a specific
network of providers.
Hospital indemnity insurance -- Pays a set
amount for a hospital stay based on daily, weekly or monthly limits,
regardless of expenses.
Indemnity health plan -- A
traditional fee-for-service plan.
Inflation protection -- Increases in benefits
built into a policy to compensate for inflation.
Inside limits -- Within a policy, ceilings
on reimbursed benefits for certain services.
Invalidity -- Illness.
Lapse -- The termination
or discontinuance of a policy, usually resulting from the insured's
failure to pay the premium due.
Legend drug -- Drug which federal law stipulates
can only be obtained with a prescription.
Living benefits rider -- Provision on a life
insurance policy that allows the insured to tap into the benefits
to cover long term care or expenses associated with a terminal
illness.
Long-term care insurance -- Health insurance
coverage designed to cover the cost of custodial care in nursing
homes or extended care facilities.
Major hospitalization policy
-- A policy that typically has high deductibles and high coverage
limits. Similar to major medical coverage, except that it applies
only to hospitalization.
Major medical policy -- A policy that typically
has high deductibles and high coverage limits. Sometimes called
a catastrophic policy.
Mandated benefits -- Benefits required by federal
or state law.
Maximum allowable costs (MAC) list -- Slate
of drugs for which the reimbursement is based on the cost of the
generic equivalent.
Maximum out-of-pocket costs -- Limit the insured
will have to pay out of pocket. Includes things like deductibles,
coinsurance and co-payments.
Medicaid -- A state and federal program providing
some health care benefits for people who meet minimum income limits.
Medical Information Bureau (MIB) -- Sort of
like the credit bureau for medical information. This organization
keeps health histories of people who have applied for life and
health insurance and shares the information with subscribing insurers.
Medically necessary -- Treatment that, if it
were omitted, would negatively affect the patient's life.
Medicare -- Federal program that provides health
benefits for people who qualify -- usually those over 65 and the
disabled. Medicare Part A covers hospitalization, and is funded
by the government. Part B, also called Supplemental Medical Insurance,
covers basic medical expenses, and is paid jointly by the government
and the insured.
Modified fee-for-service -- Reimbursement is
based on the actual cost of services, taking into account plan
limits.
Nursing home -- Licensed facility
that cares for those who are chronically ill or unable to care
for themselves. Sometimes called a long-term care facility.
Open access -- Also called
an open panel. A plan that allows individuals to see another medical
professional in the network without a gatekeeper referral.
Optionally renewable -- The insurer reserves
the right to cancel the policy at specific times, such as when
the premium is due or at any policy anniversary, but can't cancel
at any other time.
Outpatient -- Individual receiving services
in a facility but not staying overnight.
Point-of-service plan -- Allows
an individual to choose between service from a provider in the
plan network or outside of the network, with varying levels of
reimbursement.
Portability -- The ability to switch insurers
seamlessly without pre-existing condition exclusions.
Pre-admission authorization -- Also called
pre-admission certification. In many plans, the insured must contact
the company for permission to enter a hospital.
Pre-existing condition -- A health-related
situation that pre-dates the person's coverage under the policy
or plan.
PPO (Preferred Provider Organization) -- A
plan that offers discounted rates on services to members who use
providers in the network. Often, if the individual seeks care
outside the network, a smaller portion of the charges is reimbursed.
Premium -- The payment, or one of the periodic
payments, for insurance coverage.
Primary care network -- The slate of primary
care doctors who serve health plan members.
Qualified Medicare beneficiary
-- Someone living below the federal poverty guidelines for whom
the government is required to pick up premiums, deductibles and
co-pay costs for Medicare Part B (basic medical) coverage.
Reasonable and customary charges
-- Fees for medical treatment or services that fall within the
average for a specific geographic location.
Respite care -- Designed to give family a short
break from the duties of constant care.
Second surgical opinion --
Many plans pay for a second opinion before surgery. Some require
it.
Sickness -- Conditions requiring care, including
illness, disease and pregnancy. Often, mental illness is not included.
Supplemental Medical Insurance (SMI) -- Also
called Part B of Medicare. It covers basic medical expenses, and
is paid jointly by the government and the insured.
Therapeutic alternatives
-- Drugs that may differ in chemical make up but are purported
to have the same effect.
Third-Party Administrator (TPA) -- Company
that acts as a go-between for the members of a group plan and
the insuring organization.
Third-party payer -- Any company or entity
that pays medical expenses for the insured. Typically an insurance
company, HMO, etc.
Wellness program -- Coverage
for services aimed at maintaining good health. Could include such
things as preventative care, health screenings or fitness programs.
