Health insurance terms and definitions

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.

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