Health insurance terms and definitions

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.


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