It always helps to understand the definition of the terms related the health insurance.
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.
Administrative Services Only (ASO):
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.
The doctor responsible for admitting you to a hospital or other inpatient health facility.
The right granted to a doctor to admit patients to a particular hospital
All types of health services that do not require an overnight hospital stay
Services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, x-rays and anesthesia
Any Willing Provider Laws:
Legislation that requires health care plans to accept into their PPO and HMO networks any provider willing to agree to the network’s terms and conditions
Request made to a payer to reconsider a decision, such as a claim denial or denied prior authorization request. Most appeals must be submitted in writing within a specified period.
Assignment of Benefits:
When an insured person assign benefits, they sign a document allowing the hospital or doctor to collect health insurance benefits directly from the health insurance company. Otherwise, the insured person pays for the treatment and is later reimbursed by the health insurance company.
A person eligible for benefit under a health insurance policy
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss
Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year
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
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.
A written plan for one’s health care
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
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
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
Centers of Excellence:
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants
Certificate of Coverage:
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company
Form submitted to a payer (by a health care provider or patient) to request payment for items or services
Clinical Practice Guidelines:
Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it
Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may apply after a $500 deductible has been satisfied.
Consolidated Omnibus Budget Reconciliation Act (COBRA):
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer durations of continuance are available under certain circumstances. If a former employee opts to continue coverage under COBRA, the former employee must pay the entire premium, plus a 2% administration charge.
Concurrent review 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”.
The period of time from the effective date of the contract to the expiration date of the contract. A contract year is typically 12 months long, but not necessarily from January 1 through December 31.
Coordination of Benefits (COB):
A provision in the contract that applies when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits.
Links the treatments or services necessary to obtain an optimum level of medical care required by a patient and provided by appropriate providers. It is also another term for “managed care” used by federal government officials.
Co-payment 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.
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.
A health service or item that is included in a health plan, and that is partially or fully paid by the health plan
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.
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement
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
Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. See “HIPPA”
Critical Access Hospital:
A small facility that gives limited outpatient and inpatient hospital services to people in rural areas
Personal care, such as bathing, cooking, and shopping
Current Procedural Terminology (CPT):
A system of terminology and coding developed by the American Medical Association (AMA) that is used for describing, coding, and reporting medical services and procedures
Personal care, such as bathing, cooking, and shopping
Cost-sharing arrangement between an insured person and health insurance company in which the insured person will be required to pay a fixed dollar amount of covered expenses each year before the health insurance company will reimburse for covered health care expenses. Generally, an insured person is responsible for a deductible each calendar year.
Deductible Carry Over Credit:
Charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following yearýs deductible
Use of unnecessary treatments, procedures or other medical services by doctors to minimize the threat of a malpractice lawsuit
Denial Of Claim:
Refusal by a health insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional
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
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 persons geographic area.
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.
Ending a person’s health care coverage with a health plan
The date health insurance coverage begins
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
The lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan
Employee Assistance Programs (EAPs):
Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to directly pay for services provided through an employee assistance program.
The person who is the primary insured. Under an individual or family policy, this person is the applicant. Under an employer-sponsored group health policy, this person is the employee.
Episode of Care:
The health care services given during a certain period of time, usually during a hospital stay
Exclusions and Limitations:
Medical services that are either not covered or limited in benefit by a health insurance insurance policy
A period of time when an insurance company can delay coverage of a pre-existing condition. Sometimes this is called a pre-existing condition waiting period.
Explanation of Benefits (EOB):
Statement sent by health plans to persons who have experienced a claim under the health plan. The explanation of benefits (EOB) details the charges for the services received, the amount the health insurance company will pay for those services, and the amount the insured person will be responsible for paying.
A payment system for health care where the provider is paid for each service rendered rather than a pre-negotiated amount for each patient
A complete listing of fees used by health plans to pay doctors or other providers
First Dollar Coverage:
Refers to not having to meet a calendar year deductible prior to receiving reimbursement or payment for a medical service
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
Under a health plan, an eligible dependent 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.
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.
Request made to a health plan to reconsider coverage of a health care service that the health plan has not interpreted to be a covered benefit
Group Health Plan:
A health plan that provides health coverage to employees and their families, and is supported by an employer or employee organization
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 Common Procedure Coding System (HCPCS):
Name given to CPT codes (Level I), alphanumeric codes (Level II), and local codes (Level III) used by payers and providers for billing purposes. Within the industry, most refer to Level II national codes as HCPCS codes.
Health Care Provider:
A doctor, hospital, laboratory, nurse, or anyone who delivers medical or health-related care
Health Employer Data and Information Set (HEDIS):
A set of standard performance measures that provides information about the quality of a health plan. These measures are used to compare managed care plans.
Health Insurance Portability & Accountability Act (HIPAA):
A law passed in 1996, which is also called the “Kassebaum-Kennedy” law. This law expanded health care coverage for persons who have lost their job, or move from one job to another. HIPAA protects persons who have pre-existing medical conditions, and/or problems, based on past or present health, in getting health insurance coverage.
Health Maintenance Organization (HMO):
Prepaid health plans which cover doctors’ visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. In a HMO, one must choose a primary care physician who coordinates all care and makes referrals to any specialists that may be required. In a HMO, one must use the doctors, hospitals and clinics that participate in your plan’s network. No benefits are paid for non-emergency benefits provided outside the HMO network.
Health Savings Account (HSA):
Operating similarly to IRAs, HSAs are tax-advantaged savings accounts for health care services. A person must enroll in a qualified High-Deductible Health Plan (HDHP) before they can establish an HSA.
High Deductible Health Plan (HDHP):
A person must be enrolled in a qualified High-Deductible Health Plan (HDHP) before they can establish a Health Savings Account (HSA). Not all high-deductible health plans qualify for purposes of establishing HSA eligibility. A qualified HDHP benefit design must conform to various federally-mandated requirements, such as a minimum $1000 deductible and a lack of first-dollar benefit provisions.
Home Health Care:
Services given at home to aged, disabled, sick, or convalescent individuals not needing institutional care. The most common types of home care are visiting nurse services and speech, physical, occupational, and rehabilitation therapy. These services are provided by home health agencies, hospitals, or other community organizations.
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
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.
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..
The date on which health care services are provided to a covered person. The incurral date, not the date on which the insurance company pays a health care claim, is the critical date in determining health insurance benefits. For example, a health insurance company will not pay a claim for health care services incurred prior to the effective date of the health insurance coverage.
Indemnity Health Plan:
Indemnity health insurance plans are also called “fee-for-service.” These are the types of plans that primarily existed before the rise of HMOs and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the health plan pays the other percentage. For example, an individual might pay 20% for services and the insurance company pays 80%. The fees for services are defined by the health care providers and vary from physician to physician and hospital to hospital.
Independent Practice Associations (IPA):
An IPA is a type of HMO in which care is provided by independent physicians who contract with the HMO. This contrasts with the “staff model” HMO, in physicians are employees of the HMO.
Health care that you get when you stay overnight in a hospital
Insurance leads are consumers looking on the internet for health insurance information and want to speak with an insurance agent or broker. As a health insurance lead, you will get to speak with multiple insurance agents and decide which agent and plan best fits your needs.
A person who has obtained health insurance coverage under a health insurance plan
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM):
Coding system maintained by the National Center for Health Statistics and the Center for Medicare and Medicaid Services (CMS). This coding system differentiates diagnostic conditions and is used by hospitals, governments, health insurance plans, and health care providers around the world.
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.
A policy that covers only specified accidents or sicknesses (e.g. a cancer policy)
Health insurance coverage for expenses associated with hospital confinements, surgeries and/or medical conditions requiring a broad range of medical services and supplies
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).
Federal and state health insurance program for low-income individuals who meet established eligibility criteria (programs vary from state to state)
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
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).
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.
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.
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..
National Association of Insurance Commissioners (NAIC):
A national organization of state officials charged with regulating insurance. NAIC was formed to promote national uniformity in insurance regulations.
National Committee for Quality Assurance (NCQA):
A national group responsible for devising and monitoring quality measurements and standards for health care entities
National Drug Code (NDC):
Numerical coding system for drug identification. NDC numbers are assigned by the Food and Drug Administration (FDA) and are typically used to bill payers for the drugs provided to health care beneficiaries.
Groups of physicians, hospitals and other health care providers working with the health plan to offer care at negotiated rates
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.”
A policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.
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.
Health care services received outside the HMO or PPO network
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.
Insured health care costs for which one is responsible, because of the application of deductibles, coinsurance and co-payments
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.
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.
The insurance agreement or contract
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
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.
Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility
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.
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.
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.”
Preferred Provider Organization (PPO):
A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he or she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
Federal maternity legislation, enacted in 1978, requires that employers engaged in interstate commerce who have 15 or more employees provide the same benefits for pregnancy, childbirth, and related medical conditions as for any other sickness or injury. This includes all employers who are, or become, subject to Title VII of the Civil Rights Act of 1964.
The amount you or your employer pays in exchange for health insurance coverage
An approach to health care which emphasizes preventive measures and health screenings such as routine physicals, well-baby care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other early detection testing. The purpose of offering coverage for preventive care is to diagnose a problem early, when it is less costly to treat, rather than late in the stage of a disease when it is much more expensive, or too late to treat.
Primary Care Physician (PCP):
Under a health maintenance organization (HMO) plan, the primary care physician is usually an insured person’s first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician monitors patient health, treats most patient health problems, and refers patients, if necessary, to specialists.
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.
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care
Reasonable and Customary (R &C) Charge:
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. “Reasonable and Customary (R&C) Charge” essentially means the same thing as “Usual and Customary (U&C) Charge.”
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.
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:
A health insurance listing of the benefits which are covered under the policy guidelines as well as services which are not provided under the policy
Second Surgical Opinion:
This is an opinion provided by a second physician, when one physician recommends surgery to an individual. Most health insurance policies cover second surgical opinions.
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.
The area where a health plan accepts members. For HMOs, it is also the area where services are provided. A health plan may terminate coverage for persons who move out of the plan’s service area.
Skilled Nursing Facility:
A licensed institution that provides regular medical care and treatment to sick and injured persons. Daily medical records are kept and patients are under the care of a licensed physician.
Special Benefit Networks:
Provider networks for particular services, such as mental health, substance abuse, or prescription drugs
Staff model is a type of HMO in which care is provided by physicians who are employees of the HMO. This contrasts with the “independent practice association (IPA)” HMO, in which independent physicians contract with the HMO.
State Insurance Department:
An administrative agency that implements state insurance laws and supervises (within the scope of these laws) the activities of insurance companies operating within the state
Benefits for a variety of medical conditions that a given state requires of health insurance policies sold in that state
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
Any payer of health care services other than the insured person. This can be an insurance company, HMO, PPO, or the federal government.
The act of reviewing and evaluating prospective insured persons for risk assessment and appropriate premium
Usual and Customary (U&C) Charge:
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. “Usual and Customary (R&C)” essentially means the same thing as “Reasonable and Customary (R&C) Charge.”
A mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers
A period of time when the health plan does not cover a person for a particular health problem
Preventative health services, including immunizations, for young children within an age range specified by the health plan
Wellness Office Visit:
A physician’s office visit which is not prompted by sickness or injury
Insurance that employers are required to have to cover employees who get sick or injured on the job