Glossary

A

Accident Insurance

Insurance plan which gives cash benefits to someone who has a covered accident.

Actuary

An insurance professional who analyzes insurance rates, statistics and reserves.

Admitting privilege

Admitting a patient to a specific health facility for inpatient care.

Advance care planning consultations

A meeting between a medical practitioner and a senior discussing advance care planning including, living wills, powers of attorney and functions of health care proxies.

Advance directive

Documents which lay out decisions for end-of-life care to family, friends and doctors. The patient can also provide a living will and durable power of attorney.

Advocacy

Public support for a certain insurance proposal or insurance cause.

Affordable Care Act (ACA)

A law signed in March 2010 which aims to reduce health care costs, create more health care alternatives, increase accountability of insurance companies and increase overall health care quality.

Agent

A licensed representative who is permitted to sell insurance.

Assignment

Insurance policy holder who receives a loan by transferring benefits from the policy to a lender.

Association

Organization which purchases insurance for a group of people.

B

Balance Billing

A common illegal process of medical institutions billing patients for services rendered even though the insurance company has reimbursed them already.

Beneficiary

Chosen recipient of an insurance policy, property, trust or anything documented within a written will.

Benefit

The monetary value policyholders receive from insurance companies after they induce a loss.

Brand-Name Drug

A drug that is sold and produced by a company, which holds a patent and trade name over the drug.

Broker

A designated insurance salesperson that generates quotes and policy options for clients.

C

Capitation

Participants in a health plan that pay an annual fee to medical providers.

Carrier

An insurance company that offers health insurance plans.

Case Management

An efficient practice of supplying medical services to patients, to decrease costs and improve overall patient care.

Certificate of Insurance -

A document an individual receives from an insurance company that specifies the active coverage the individual receives.

Claim

Made by a policyholder to an insurance company to pay for services rendered.

Claim Form

The form used when a person files an insurance claim.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

Piece of legislation that allows employees to keep their health coverage for a period of time after they have left the company.

Coinsurance

Part of a health plan which the policyholder splits the cost of healthcare with the carrier.

Commercial Insurers

Insurance which covers a range of property, liability and workers’ compensation policies.

Complaint

A claim made by a party in which there’s evidence of violation in policies, contract provisions or certain rules/statutes.

Cooperatives

Health payment arrangements that can reduce the cost of health insurance.

Copayment

The monetary amount that the injured party must pay on a medical bill.

Credit for Prior Coverage

Discount offered to a client who has valuable assets already insured, made by an insurance company.

D

Deductible

Annual fee a policyholder pays in order for their insurance coverage to start.

Denial of Claim

A policy of health insurance companies to refuse a claim made by the insured party.

Dental Insurance

Insurance that covers a portion of costs integrated with dental care.

Dependent

Person associated with the insured party who is financially intrusted.

Dependent Worker

Person in a family who generates income but relies financially on someone else within the family.

Discount Medical Program

A program that grants discounts to people who visit certain providers, to save on health care costs.

Drug Card

Specific plans that offer varying discounts on medicine.

E

Effective Date

The date that an insurance policy begins.

Electronic Medical Records

An electronic system where health information is stored and retrieved.

Employee Assistance Programs

Therapy services available for workers that have personal dilemmas which affect their day-to-day work.

Employee Benefits Consultant

Professionals who provide steps for health care programs to reduce costs and increase profits.

Employer Mandate

Programs that aim to decrease uninsured individuals by adding to the employer’s group health insurance system.

Employer Tax Credits

Program that grants tax credit to help employers purchase health insurance for employees.

Employer-Sponsored Health Insurance

Coinciding with employee benefit packages, health insurance is paid for by the employer.

Employer-Sponsored Health Plans

Certain health plans and benefits which are provided by the company.

Exchange

Offers of other health insurance providers which offer other qualified plans.

Exclusions

Certain health care or medical services which can’t be covered by an insurance policy.

Explanation of Benefits

Hardcopy explanation concerning a claim from the insurance company which states the amount paid by the company and the amount the client must pay.

External Appeal/External Review

Process to review a case if coverage is denied due to the determination it’s not medically necessary.

F

Fee for Service (FFS)

Payments to doctors or health care providers after certain services are performed.

First-level Internal Appeal Process

The first step process to receive a decision on the utilization review appeal.

Flexible Spending Account

Pre-tax income can be used for any health care expenses with this savings account.

Formulary

Comprehensive list of covered prescription drugs.

G

Generic Drug

A drug that was once under patent by one company, can then be sold generically by any other drug company.

Grievance

The right of consumers to receive reviews on certain decisions by their health plans.

Group Health Insurance

All individuals within a group are covered by either an employer or other authority.

Guaranteed Issue

Coverage that is guaranteed to applicants no matter what, and will continue if the insured continues to pay the premium.

Guaranteed Renewal

Insurance policy that will automatically be renewed if the policy holder pays the policy premium.

H

Health Care Decision Counseling

A service which helps people make improved choices in relation to health and medical care needs.

Health Choices Administration

Federal agency established to overlook health plan benefit standards, operations of health insurance exchanges and supervision of individual affordability credits/subsidies.

Health Choices Commissioner

A person who is responsible for overseeing health reform provisions. This person is appointed by the President.

Health Insurance Exchange

Providing a variety of competing providers that offer different qualified plans.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Upon new employment, a person is able to receive comparable health insurance coverage.

Health Maintenance Organization (HMO) Plan

Instead of paying for a service on an individual basis, people can choose to pay a monthly fee for services rendered.

Health Reimbursement Arrangement

Employer’s certain amount of money to spend on health care expenses for employees.

Health Savings Account (HSA)

A savings account that uses tax-free income to help pay for health care expenses.

High Risk Pool

Health insurance coverage for people who have pre-existing medical conditions.

High-Deductible Health Plan (HDHP)

A plan with a specific deductible to an individual or family: $1,100 and $2,200 respectively.

I

Indemnity Health Plan

Same health plan as a Fee For Service plan.

Independent Practice Associations (IPA)

This policy is similar to an HMO, but IPA Policy holders can receive care in the own office of a physician.

Individual Affordability Credits

Provision that helps individuals and families purchase health insurance coverage. Income can be upwards of four times the poverty level to apply.

Individual Health Insurance

Coverage that is solely for an individual.

Individual Mandate

A certain provision in which people are required to receive coverage up to certain standards, which were set coinciding with health insurance exchanges.

Individual Subsidies

See Individual Affordability Credits.

In-Network

Agreement between a health care professional and a health plan to provide medical services discounts and in return receive patient referrals.

Inpatient

Procedure where patients stay overnight in a hospital or medical facility.

Insurability

The procedure to determine if an applicant is eligible for a health plan.

Insurance Exchange

A provision that provides a variety of competing providers, with each providing different qualified plans, all up to standards set by the Health Choices Administration.

L

Length of Stay (LOS)

The length of time a person stays in a hospital or inpatient facility.

Lifetime Maximum Benefit

During a person’s lifetime, it’s the max. amount a health plan pays in benefits to the policy holder.

Limitations

Certain amount of benefits paid for a covered expense.

Long-Term Care Policy

Certain services on a policy are only covered for a certain amount of time.

Long-Term Disability Insurance

If a person becomes disabled, it pays a certain percentage of their monthly earnings.

M

Major Medical Insurance

Any major or disastrous medical care is covered by major medical.

Managed Care Plan

Plans that aim to provide care at reduced costs by partnering with providers and medical facilities.

Maximum Dollar Limit

The highest amount an insurance company pays for claims in a certain time period.

Maximum Lifetime Benefit

The highest amount an insurance company pays for claims and benefits during the insured’s life span.

Medicaid

Health insurance program that is sponsored by the government, providing low-income Americans with coverage.

Medical Underwriting

Whether or not to accept an applicant for health coverage, insurance companies will sometimes use this process.

Medicare

Health care coverage for Americans over 65 or with end-stage renal disease.

Medicare Advantage

Medicare benefits that include prescription drug coverage, as well as Part A, and Part B coverage.

Medigap Medicare Supplement

Insurance which cover certain costs that a Medicare plan does not cover.

Multiple Employer Trust

When many employers in the same industry come together to purchase group health insurance at a lower cost to provide to their employees.

Mutual Insurance Company

Policyholders are the sole owners of these insurance companies.

N

Network

A collection of health care providers who provide insurance policy holders services at a lower rate.

Non-Profit Cooperative

Alternative cooperatives that offer networks of health care providers for medical services.

Non-profit Indemnity Insurers

Insurers that approach policyholders by reimbursing them as well as physicians and hospitals, by using a managed care strategy.

O

Open-Ended HMO

Under a regular indemnity plan, these individuals can use out-of-plan providers and continue to have coverage for the services rendered.

Out-of-Network

Health care providers who don’t participate in a HMO or PPO. Some expenses may not be covered by out-of-network health professionals.

Out-of-Pocket Maximum

Highest amount of cost for health care a policy holder pays on their own annually.

Outpatient

Procedure in which a patient is not required to stay overnight in a hospital.

P

Participating Provider

Health care providers that are under health plans to provide services and care to policy holders.

Patient Protection and Affordable Care Act (PPACA)

Health care reform legislation signed in March 2010 by the President, with the aim to provide coverage to uninsured Americans, lower health care costs and cut out pre-existing conditions as a prerequisite for denial of coverage.

Physician-Hospital Organization (PHO)

A company which represents certain physicians and hospitals as agents.

Plan Administration

Administration that oversees the daily activities of running and installing a health plan.

Point of Service (POS) Plan

A plan that takes aspects of HMO and PPO plans, including choosing a Primary Care Physician and coverage either in or out-of-network providers.

Pre-Admission Certification

Individual can enter a medical facility after being approved by a health care professional.

Pre-Admission Review

See Pre-Admission Certification.

Preadmission Testing

Certain medical tests performed before admission to a hospital or health care facility.

Precertification

Prior to admission for a surgery or hospital, approval must be met.

Pre-Existing Condition

Conditions that occur before health care coverage begins.

Preferred Provider Organization (PPO)

A plan which includes coverage for in and out-of-network doctors as well as hospitals and other providers.

Premiums

Monthly fee paid to the insurance company to have continued coverage.

Prescription Drug Plan

Prescription drug coverage which can be added to original Medicare coverage.

Preventive Care

Routine doctor’s visits that help prevent serious illness.

Primary Care Physician (PCP)

Physicians which are categorized as primary doctors for an individual or family.

Primary Care Provider (PCP)

Physicians who offer primary care to patients either by choice or assignment.

Private Health Insurance

Health insurance plans that are sponsored by the private health insurance industry.

Prompt Pay Complaint

Formal complaint made against an insurance company, producer or insurance agency.

Provider

Health care professionals ranging from doctors to hospitals to specialists.

Public Option

A public plan which would be a health benefit plan that competes with other plans that qualify as part of health insurance exchanges.

Public plan

See Public Option.

Q

Quote

Options for an insurance plan which can be run by an insurance company, agent or an automated system.

R

Rate-Up

The amount of annual increase in premiums.

Rationing

Argument that the government has to restrict care if health care were to be a public option.

Reasonable and Customary Fees

In a geographic area, these standard fees are charged by health care practitioners.

Referral

When care of a patient is transferred to another clinic.

Rescission

If an application has errors in their application, an insurer has the option to cancel that policy holder’s coverage.

Rider

Option of adding or excluding coverage on an insurance policy.

Risk

The probability of loss an insurance company takes on with the insured.

S

Schedule of Allowances

The amount a dental patient pays between the cost of service and allowance.

Screening Programs

Programs used to identify a disease in its early stages.

Second Opinion

Attaining another opinion from a second health professional after an initial opinion was given from the first professional.

Second Surgical Opinion

Attaining another opinion from a second health professional after an initial opinion was given from the first professional on a possible surgical procedure.

Self-Insured Health Plan

A group health plan in which the organization provides the group health care directly to the employees, and not from an insurance provider.

Short-Term Disability

An employee is out of work for a short period due to and injury or illness.

Short-Term Health Insurance

Insurance coverage that lasts anywhere from one month, to one year.

Single-Payer System

System where one person pays all fees and costs associated with their health care plan.

Small Business Health Care Tax Credits

See Employer Tax Credits.

Small Employer Group

Groups that range from 1-99 employees.

Specialist

A physician or health care professional that is trained in one branch of medicine.

State Children’s Health Insurance Program (SCHIP)

Families with children who receive health insurance from the state, receive these matched funds benefits from the United States Department of Health and Human Services.

State Mandated Benefits

Certain state laws that are passed and must include specific benefits in health insurance plans.

Stop-Loss

Once the insured has paid all out-of-pocket expenses, insurance pay kicks in and begins to pay at full.

Student Health Insurance

Health insurance coverage that can range from family policies, school-sponsored health plans, employer’s plan, or individual health insurance.

Subsidies

See Individual Subsidies.

T

Travel Insurance

Insurance

coverage people can receive while traveling to another country.

U

Underwriter

A person who concludes the amount for premiums and issue policies.

Universal Health Insurance

Health insurance that covers an entire population.

Usual and Customary Reimbursement (UCR)

Any necessary medical service or supplies needed for treatment are charged a common amount.

Utilization Review (UR)

A review of current patients on efficiency, quality and cost-effectiveness.

V

Vision Care Insurance -

Insurance which covers vision plans to help with co-pays or routine visits to optometrist or ophthalmologist.

W

Waiting Periods

Associated with specific health care costs, this is the time period a policy holder will not be insured.

Waiver of Premium

If regular payments cannot be made due to an unforeseen disability, the insured can purchase this policy which waives the premium for a period of time.

Women's Health and Cancer Rights Act (WHCRA)

Women with breast cancer and who elect to have breast reconstruction along with a mastectomy will have the right for coverage and protection.