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Common Health Insurance Terms
- Accessibility of Services: Your ability to get medical care and services when you need them.
- Accredited (Accreditation): A "seal of approval." 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.
- Actual Charge: The amount of money a doctor or hospital charges for a certain medical service or supply.
- Admitting Physician: The doctor responsible for admitting you to a hospital or other inpatient health facility.
- Advance Directives: Written ahead of time, this is your statement of how you want to get health care, in case you can't say how. Such care could include routine treatments and life-saving methods. You also can choose someone to make medical decisions in case you can't. Advance directives are also called a living will.
- Adverse Selection: The problem of attracting members who are sicker than the general population, specifically members who are sicker than was anticipated when developing the rates of reimbursement for medical costs.
- Affiliated Provider: A health care provider or facility that is part of the managed care organization's network, usually having formal arrangements to provide services to the MCO's member.
- Advocate: A person who gives you support or protects your rights.
- Affiliated Provider: A health care provider or facility that is paid by a health plan to give services to plan members.
- Agent: Licensed salesperson who represents one or more health insurance companies and presents their products to consumers.
- Ambulatory Care: All types of health services that do not require an overnight hospital stay.
- Ambulatory Surgical Center: A separate part of a hospital or a free-standing building that does outpatient surgery.
- Ancillary Services: Professional services by a hospital or other inpatient health program. These may include X-ray, drug, laboratory or other services.
- Anesthesia: Drugs that a person is given before and during surgery so he or she will not feel pain. Anesthesia should always be given by a doctor or a specially trained nurse.
- Assisted Living Facility (ALF): A homelike place with staff who give help to residents, including: help with dressing, bathing, feeding and housekeeping. Assisted living facilities usually give a less skilled level of care than you would get in skilled nursing facilities.
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- Benefits: The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.
- Board-Certified: This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.
- Broker: Licensed insurance salesperson who obtains quotes and plans from multiple sources of information for clients.
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- Capitation: A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.
- Case Management: A process used by a doctor, nurse or other health professional to manage your health care.]
- Case Manager: 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.
- Catastrophic Illness: 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.
- Catastrophic Limit: The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges.
- Certified (Certification): This means a hospital has passed a survey done by a state government agency. Being certified is not the same as being accredited.
- Claim: A claim is a request for payment for services and benefits you received under the insurance policy.
- Cobra: The Consolidated Omnibus Budget Reconciliation Act (COBRA) is federal law that extends your current group health insurance when you experience a qualifying event, most commonly termination of employment or reduction of hours to part-time status. The extension period is 18 months and some people with special qualifying events may be eligible for a longer extension. To be eligible for COBRA, your group policy must be in force with 20 or more employees covered on more than 50 percent of its typical business days in the previous calendar year. Cal-COBRA is California law that has similar provisions to federal COBRA. With Cal-COBRA the group policy must be in force with two to 19 employees covered on at least 50 percent of its working days during: · the preceding calendar year, or · the preceding calendar quarter, if the employer was not in business during any part of the preceding calendar year. The extension period for Cal-COBRA is 36 months. California Insurance Code (CIC) Section 10128.59 provides an extension under Cal-COBRA for those who have exhausted their 18 months on federal COBRA (or longer in special circumstances) for a total extension that cannot exceed 36 months. For the special Cal-COBRA extension to apply, the employer's master policy must be issued in California. If the group master policy is not issued in California, then the employer must employ 51% or more of its employees in California and have its principal place of business in California for their California employees to take advantage of Cal-COBRA.
- Coinsurance: You and the insurance company share the cost of medical procedures in a specified proportion. For example: 80 percent (company) and 20 percent (you).
- Comprehensive Outpatient Rehabilitation Facility (CORF): A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services and outpatient rehabilitation.
- Confidentiality: Your right to talk with your health care provider without anyone else finding out what you have said.
- Consumer driven health care (CDHC): Refers to health insurance plans that allow members to use personal Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) or similar medical payment products to pay routine health care expenses directly, while a high-deductible health insurance policy protects them from catastrophic medical expenses.
Coordination of Benefits Clause: A written statement that tells which health plan or insurance policy pays first if two health plans or insurance policies cover the same benefits. If one of the plans is Medicare, federal law may decide who pays first.
- Co-payment: The amount you pay for each medical service, such as a doctor visit. A co-payment is usually a set amount you pay for a service. For example, this could be $15 or $20 for a doctor visit. Co-payments are also used for some hospital outpatient services.
Cost Sharing: The cost for medical care that you pay yourself, such as a co-payment, coinsurance or deductible.
- Covered Benefit: A health service or item that is included in your health plan and that is paid for either partially or fully.
- Covered Charges: Services or benefits for which a health plan makes either partial or full payment.
- Custodial Care: Personal care, such as bathing, cooking and shopping.
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- Deductible: The amount you must pay for health care before the plan begins to pay. This amount can change every year.
- Denial of Claim: Refusal by an 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.
- Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured person.
- Diagnosis: The name for the health problem that you have.
- Discharge Planning: A process used to decide what a patient needs for a smooth move from one level of care to another, such as from the hospital to a nursing home. This is done by a social worker or other health care professional.
- Disenroll: Ending your health care coverage with a health plan.
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- Emergency Care: Care given for a medical emergency when you believe that your health is in serious danger.
- Employee Assistance Programs (EAP): 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.
- Employer Group Health Plan (GHP): A GHP is a health plan that gives health coverage to employees, former employees and their families and is from an employer or employee organization.
- Enroll: To join a health plan.
- Exclusive Provider Organization (EPO): A term derived from the phrase preferred provider organization (PPO); however, where a PPO generally extends coverage for non-preferred provider services as well as preferred provider services, an EPO provides coverage only for contracted providers -- hence, the term “exclusive.” Technically, many HMOs can also be described as EPOs.
- Exclusion Period: A period of time when an insurance company can delay coverage of a pre-existing condition. Sometimes called a pre-existing condition waiting period.
- Explanation of Benefits (EOB): The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed.
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- Fee-For-Service (FFS): A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as identified by a claim for payment.
- Fee Schedule: A complete listing of fees used by health plans to pay doctors or other providers.
- Formulary: A list of certain drugs and their proper dosages. In some health plans, doctors must order or use only drugs listed on the health plan's formulary.
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- Gatekeeper: In a managed care plan (HMO), this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.
- Group Health Plan: A health plan that provides health coverage to employees, former employees and their families and is supported by an employer or employee organization.
- Group or Network HMO: A health plan that contracts with group practices of doctors to give services in one or more places.
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- Health Insurance Portability & Accountability Act (HIPAA): A law passed in 1996 that is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job or if you move from one job to another. HIPAA protects you and your family if you have: pre-existing medical conditions and/or problems getting health coverage and you think it is based on past or present health.
- Health Maintenance Organization (HMO): A group of doctors, hospitals and other health care providers who agree to give health care to beneficiaries for a set amount of money every month. In an HMO, you usually must get all your care from the providers that are part of the plan.
- HMO with a Point of Service (POS) Option: A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost.
- Health Reimbursement Account (HRA): IRS-sanctioned arrangements that allow an employer, as agreed to in the HRA plan document, to reimburse for medical expenses paid by participating employees. HRAs reimburse only those items (co-pays, co-insurance, deductibles and services) agreed to by the employer that are not covered by the company's selected standard insurance plan.
- Health Savings Account (HSA): A health savings account allows individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. To be eligible for a health savings account, an individual must be covered by a high-deductible health plan (HDHP), must not be covered by other health insurance, is not eligible for Medicare and can't be claimed as a dependent on someone else's tax return.
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- Identification Card: A card given to you that identifies you as being eligible for benefits. This card must be presented when seeking treatment.
- Indemnity Health Plan: Indemnity health insurance plans are also called “fee for service.” With indemnity plans, individuals pay a pre-determined percentage of the cost of health care services, and the insurance company pays the other percentage.
- Independent Practice Association (IPA): An IPA is similar to an HMO, except that individuals receive care in a physician’s own office, rather than in an HMO facility.
- Individual Health Insurance: Health insurance coverage on an individual, not group, basis.
- Inpatient Care: Health care that you get when you stay overnight in a hospital.
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- Lifetime Maximum Benefit (or Maximum Lifetime Benefit): The maximum amount a health plan will pay in benefits to an insured individual during the individual’s lifetime.
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- Medicaid: A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
- Medically Necessary: Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; used for the diagnosis, direct care and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor.
- Medicare: The federal health insurance program for: people 65 years of age or older; certain younger people with disabilities; and people with end-stage renal disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).
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- Network: A group of doctors, hospitals, pharmacies and other health care experts hired by a health plan to take care of its members.
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- Open Enrollment Period: A period during which subscribers in a health benefit program have an opportunity to select among health plans being offered to them, usually without evidence of insurability or waiting periods.
- Organization Determination: A health plan's decision on whether to pay all or part of a bill or to give medical services after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process.
- Out-of-Pocket Costs: The total you pay out of your pocket for a policy year. These costs include the deductible, co-insurance and amounts considered by the insurance company to be above the usual and customary charges.
- Outpatient Services: A service you get in one day (24 hours or less) at a hospital outpatient department or community mental health center.
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- Pre-existing Condition: A medical condition that required treatment during a fixed period of time, usually 3 or 6 months before you purchased your insurance policy.
- Preferred Provider Organization (PPO): A managed care plan in which you use doctors, hospitals and providers that belong to the network. You can use doctors, hospitals and providers outside of the network for an additional cost.
- Premium: Money paid out in advance for insurance coverage.
- Preventive Health Care: Health care that seeks to prevent or foster early detection of disease and morbidity and focuses on keeping patients well in addition to healing them when they are sick.
- Primary Care Doctor: A doctor who is trained to give basic care. Your primary care doctor (PCP) is the doctor you see first for most health problems. He or she may talk with other doctors and health care providers about your care and refer you to them for more specialized care (specialists). In many managed care plans, you must see your primary care doctor before you see any other health care provider.
- Primary Payer: An insurance policy, plan or program that pays first on a claim for medical care.
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- Referral: An okay from your primary care doctor for you to see a specialist or get certain services. In many managed care plans, you need to get a referral before you get care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for your care.
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- Second Opinion: When another doctor gives his or her view about a diagnosis and how it should be treated.
- Service Area: The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
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- Urgently Needed Care: Care that you get for a sudden illness or injury that needs medical care right away but is not life threatening. Your primary care doctor generally provides urgently needed care.
- Usual and Customary Charges (UCR): (Also called Reasonable and Customary charges). The routine charge for a medical service by similar professional medical providers in the same geographical area. You may pay an amount above the usual and customary charge if a doctor or hospital charges more than others for the same service.
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- Waiting Period: A period of time when you are not covered by insurance for a particular problem.
- Workers' Compensation: Insurance that employers are required to have to cover employees who get sick or injured on the job.
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Adapted from the U.S. Department of Health and Human Services. | |
