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Individual/Family Welcome to our Glossary, for your Convenience...
Beneficiary (Also eligible; enrollee; member)
Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
Claims Made Policy
A form of insurance that pays claims presented to the insurer during the term of the policy or within a specific term after its expiration. It limits liability insurers' exposure to unknown future liabilities.
Cobra
Short for Consolidated Omnibus Budget Reconciliation Act. A federal law under which group health plans sponsored by employers with 20 or more employees must offer continuation of coverage to employees who leave their jobs and their dependents. The employee must pay the entire premium. Coverage can be extended up to 18 months. Surviving dependents can received longer coverage.
Coinsurance
For Health Insurance, it is a percentage of each claim above the deductible paid by the policyholder. For a 20 percent health insurance coinsurance clause, the policyholder pays for the deductible plus 20 percent of his covered losses. A predetermined percentage of the Eligible Charges for covered Services that a paricipant must pay directly to the provider for certain Health Care Services after the Deductible has been met within the Calendar year.
Co-payment
A charge you pay for medical services. Your health care plan covers the remaining medical charges. As an example, you may pay $10.00 for an office visit or a prescription.
Deductible
The amount of money you must pay each year for coverage to your medical care expenses, before your insurance policy begins to pay.
Exclusions
Specific conditions or circumstances in which the policy will not cover.
Elective Surgical Procedure
An elective surger is a planned, non-emergency surgical procedure. It may be either medically required (e.g., cataract surgery) or optional (e.g., breast augmentation or implant) surgery. Some elective procedures are necessary to prolong life, such as an angioplasty. However, unlike emergency surgery (e.g., appendectomy), which must be performed immediately, a required elective procedure can be scheduled at the patient's and surgeon's convenience.
Fee- for- Service
A health insurance plan that allows the holder to make almost all health care decisions independently. The plan holder pays for a service, submits a claim to the insurance company, and, if the service is covered in the policy, receives reimbursement. Fee-for-service plans often have higher deductibles or copay than managed care plans.
HDHP (High Deductible Health Plan)
Usually associated with an HSA. A high deductible health insurance plan, specially designed according to guidelines established by HSA legislation. You can compare benefits information among HDHPs such as deductibles, catastrophic limits, coinsurance, copayments, and preventive services provided before the deuctible with your Health Insurance Independent Representative.
HIPPA
Health Insurance Portability and Accountability Act of 1996. It is designed to protect heatlh insurance coverage for workers and their families when they change or lose their jobs. [click here for further details on HIPPA] (This will open a new window, please close it to come back to this page.)
HMO (Health Maintenance Organization)
Offer prepaid, comprehensive health coverage for both hospital and physician services. An HMO contracts with health care providers, eg., physicians, hospitals, and other health professionals, and members are required to use participating providers for all health services. Members are enrolled for a specified period of time. Model types include staff, group practice, network, and IPA.
HSA (Health Savings Account)
Is a personal savings account set up to be exclusively used for medical expenses and is paired with a high deductible health insurance policy. The health savings account (HSA) is a tax advantaged savings plan ( a financial account with various restrictions) available to taxpayers in the United States to cover current and future medical expenses. It allows money to be put in before tax is pain on it and then to withdraw the money tax free for qualified medical expenses. [Click here for more HSA Information] (This will open a new window, please close it to come back to this page.)
IPA
A means of organizing a health maintenance organization (HMO) in which the participating physicians maintain their own separate offices. Such physicians usually treat both private patients and HMO members.
Lifetime Maximum
The maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime.
Managed Care Plan
A health plan that uses managed care arrangements and has a defined system of selected providers that contract with the plan. Enrollees have a financial incentive to use participating providers that agree to provide a broad range of services to them. Providers may be paid on a pre-negotiated basis. (See also HMO, Point Of Service Plan (POS), and Preferred Provider Organization.)
Out-Of-Pocket Maximum
The highest amount of money you will pay in a year for deductibles and coinsurance plus regular premiums.
Part A Medicare
Refers to the inpatient portion of benefits under the Medicare Program, covering beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and copayments. Part A services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments. Part B, on the other hand, refers to outpatient coverage.
Part B Medicare
Refers to the outpatient benefits of Medicare. Medicare Supplementary Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, copayments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues.
Participating Physician
A primary care physician in practice in the payer's managed care service area who has entered into a contract.
Participating Provider
Any provider licensed in the state of provision and contracted with an insurer. Usually this refers to providers who are a part of a network. That network would be a panel of participating providers. Payers assemble their own provider panels.
Point-of-Service Plan (POS)
A point-of-service plan (POS) is a type of managed care plan that is a hybrid of HMO and PPO plans. Like and HMO, participants designate an in-network physician to be their primary care provider. But like a PPO, patients may go outside of the provider network for health care services. When the patients venture out of the network, they'll have to pay most of the cost, unless the primary care provider has made a referral to the out-of-network provider. Then the medical plan will pay.
Preexisting Conditions
A preexisting condition is defined as an illness or injury for which the Covered Person has consulted with a physician, or for which advice, treatment (including prescription drugs), or diagnosis was received or recommended, within the three-month period immediately preceding the effective date of his/her coverage und the plan.
PPO (Preferred Provider Organization)
A health care organization composed of physicians, hospitals, or other providers which offer health care services at a reduced fee. PPO's may also offer more flexibility by allowing for visits to out-of-network professionals at a greater expense to the policy holder. Visits within the network require only the payment of a small fee. A policy holder will have a primary physician within the network who will handle referrals to specialists that will be covered by the PPO. After any visit, the policy holder must submit a claim, and will be reimbursed for the visit minus his/her co-payment.
Premium
Amount paid to a carrier for providing coverage under a contract. Money paid out in advance for insurance coverage.
Preventative Care
Health care that emphasizes prevention, early detection and early treatment, thereby reducing the costs of healthcare in the long run. Health care that seeks to prevent or foster early detection of disease and morbidity and focuses on keeping patients well in addition to help them while they're sick.
Primary Care Physician, (PCP)
A "generalist" such as a family practitioner, pdiatrician, internist, or obstetrician. In a managed care organization, a primary care physician is accountable for the total health services of enrollees including referrals, procedures and hospitalization. Also see Primary Care Provider.
Primary Care Provider (PCP)
The provider that serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan.
Traditional Care
A phrase used to describe all forms of health care delivery except traditional fee-for-service, private practice. The term includes HMOs, PPOs, IPA's. Fee-For-Service (FFS) - Traditional method of payment for health care services where specific payment is made for specific services rendered.
Waiting Periods
The length of time an individual must wait to become eligible for benefits for a specific condition after overall coverage has begun.
Well-Child Care
Well-Child exams and routine immunizations and lab tests through 2 years of age. Deductible doesn't apply.
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